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Summary of Benefits and Coverage
Medical
Medical Summary Plan Document - Consumer Choice
Medical Summary Plan Document - New Value & Premier
Prescription Drug Benefit
Flexible Spending Accounts
Dental
Vision
Life Insurance
Accidental Death & Dismemberment
Short-Term Disability
Long-Term Disability

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ICMA-RC
Nationwide

 

Plan Information

Medical
For 2014, employees can enroll in one of three (3) Preferred Provider Organization (PPO) health plan options administered by UnitedHealthcare. With the Consumer Choice, New Value, and Premier health plans, you have the ability to see any physician or other health care professional from the UnitedHealthcare network, including specialists, without a referral. In addition, the coverage is the same for all of the plans; however, the amount you pay out-of-pocket varies from plan to plan.
In-network preventive care services are covered at 100% for all three (3) plans.

Below is a a brief overview of each plan. A detailed, side-by-side comparison of each plan can be found on page four (4) of the 2014 Civilian Benefit Matters guide.

Consumer Choice (Consumer-Driven Health Plan) PPO
No co-pays, deductible must be met before the health plan pays, lowest premium contribution

In-Network Benefits - Employees who choose in-network providers pay:

  • Annual deductible of $1,250 for individual ($2,500 for family coverage) for plan year 2014 
  • With this plan, there are no co-pays. You are responsible for 100% of the cost of health care services (ex: prescription medications, office visits, x-rays) until the deductible is satisfied.
  • Once the deductible is satisfied, you pay 20% of discounted eligible expenses up to a maximum of $4,000 for an individual or $8,000 for family coverage per year, excluding the deductible. Amounts above this annual maximum are paid by the City at 100% of eligible expense.
  • Consumer Choice allows you to save for future and pay for current qualified health care expenses with a Health Savings Account (HSA). In 2014, the City will contribute $500 ($1,000 for a family) into your HSA. Unlike a Flexible Spending Account, you own the funds in an HSA and they roll over from year to year, including interest.

More information about Consumer Choice and HSAs is available on pages five (5) and six (6) of the 2014 Civilian Benefit Matters guide.

NEW VALUE PPO
Mid-level out-of-pocket expense, mid-level premium contribution

In-Network Benefits - Employees who choose in-network providers pay:

  • Annual deductible of $1,250 for individual ($2,500 for family coverage) for plan year 2014
  • Office visit co-pays: Primary Care - $30 Premium Designation Specialist - $35 Urgent Care - $50 Specialist - $55 These payments are not subject to the deductible or co-insurance, but they do count toward your out-of-pocket maximum.
  • Once the deductible is satisfied, you pay 20% of discounted eligible expenses up to a maximum of $3,000 for an individual or $6,000 for family coverage per year, excluding the deductible. Amounts above this annual maximum are paid by the City at 100% of eligible expense.

PREMIER PPO
Lower out-of-pocket expenses, higher premium contribution

In-Network Benefits - Employees who choose in-network providers pay:

  • Annual deductible of $600 for individual ($1,500 for family coverage) for plan year 2014
  • Office visit co-pays: Primary Care - $30 Premium Designation Specialist - $35 Urgent Care - $50 Specialist - $55 These payments are not subject to the deductible or co-insurance, but they do count toward your out-of-pocket maximum.
  • Once the deductible is satisfied, you pay 20% of discounted eligible expenses up to a maximum of $2,200 for an individual or $4,400 for family coverage per year, excluding the deductible. Amounts above this annual maximum are paid by the City at 100% of eligible expense.

Prescription Drug Benefit

The City’s prescription drug benefit, administered by UnitedHealthcare, provides you with access to a wide variety of drugs while helping to make the medications you need more affordable. You also have access to more than 60,000 in-network pharmacies to fill your next prescription.

The 2014 prescription drug co-pays are below. For additional details, including information about the Automatic Generics and Value-Based Co-pays Programs and the convenience of the OptumRx Mail Service Pharmacy Program, see page seven (7) of the 2014 Civilian Benefit Matters guide.

2013 Prescription Drug Plan


New Value and Premier Co-pays

Value-Based Co-pays (Diabetes Medications)

                                                                            30-day Retail

Tier 1 (generics)

$10

$0

Tier 2 (preferred brand formulary)

$35

$10

Tier 3 (non-preferred brand)

$65

$20

Tier 4 (specialty)

$100

N / A

                                                                            90-day Mail Order

Tier 1 (generics)

$20

$0

Tier 2 (preferred brand formulary)

$70

$20

Tier 3 (non-preferred brand)

$130

$40

Tier 4 (specialty)

$200

N / A

Remember, Consumer Choice does not have co-pays. You are responsible for 100% of the cost of your medication until you reach your deductible. For IRS-approved maintenance medications you only pay 20% of the cost since these medications are not subject to the deductible. Click here for a complete list of these medications.


Flexible Spending Accounts
A Flexible Spending Account (FSA) is just that – a flexible way to help you pay for expenses that are not usually covered by your benefit plan – and it saves you money.

Here are a couple of important points to bring to your attention about FSAs.

1. The “Use it or Lose it” Rule
Whatever you decide to contribute to an FSA, make sure you use all of it by the end of the plan year – or else any remaining money will be forfeited. All claims for reimbursement must be filed by March of the following calendar year. Any remaining money will be lost.

2. There are FSA limits on what you can contribute
For 2014, the contribution limit for a Health Care FSA is a maximum of $2,500 and $5,000 for a Child/Elder (Dependent) Care FSA. When you elect to defer money into an account, the amount is divided by 24 (number of payroll deductions throughout the year) to determine the payroll deduction for each pay period.

You can view a complete list of eligible services on www.myuhc.com. You can also visit www.irs.gov or call 1-800-TAX-FORM (1-800-829-3676).

Use the online FSA Savings Calculator to help calculate your potential savings.

  • Go to www.myuhc.com.
  • Under the Information Center, click on “Flexible Spending Account.”
  • Click on “Calculate FSA Savings.”

Flexible Spending Accounts

Health Care FSA
A Health Care FSA is used to help pay for health care expenses that are typically not paid for by your health plan. Expenses for all immediate family members living in household are eligible. If you enroll in the Consumer Choice plan, you cannot have a Health Care FSA. However, you will be able to pay for your qualified health care expenses with your Health Savings Account.

With a Health Care FSA, it is important to:
1. Consider the type of services you may need during the year.
2. Estimate the cost of the services.
3. Determine your pre-tax contributions to help meet those costs.

Sample expenses:

  • Co-pays for health care and drugs
  • Co-insurance amounts that you pay
  • Medical, dental, and prescription drug co-pays
  • Dental expenses not covered by insurance

How it Works:

  • UnitedHealthcare provides you with an Consumer Account Card to use at the pharmacy or the doctor’s office.
  • For expenses that are paid with the Consumer Accounts Card, the merchant or health care provider will be reimbursed directly.
  • If expenses are not paid using the Consumer Accounts Card you will need to submit a claim reimbursement form and receipt to UnitedHealthcare via email, fax, or mail, and you will be sent a check.

Child/Elder (Dependent) Care FSA
You can use the Child/Elder Care FSA to pay for eligible day care expenses related to the care of or services provided to children under the age of 13, or tax dependents who are mentally or physically incapable of caring for themselves. Like the FSA, each paycheck you set aside some of your pay, before taxes, to use for eligible expenses. Child/Elder Care claims are submitted using an FSA claim form. Please allow four (4) to six (6) weeks to receive your reimbursement payment. Funds will be available to you as they are deposited into your Child/Elder Care FSA.

Eligible care includes expenses subject to taxation for:

  • Day care for children up to age 13, including nursery or pre-school fees
  • Adult care center
  • Babysitter
  • Expenses to allow both spouses to work

Dental
Through the dental benefits plans administered by Delta Dental, employees have access to a network of dental providers. For detailed plan information, including a brief video, claim forms, plan highlights, and more, visit www.deltadentalins.com/cityofsanantonio. You can also call 1-800-521-2651 (CitiDent PPO) or 1-800-422-4234
(DeltaCare DHMO) for assistance.

CitiDent PPO administered by Delta Dental
The CitiDent PPO is a dental PPO plan that allows you to obtain preventive, basic, major, and orthodontic care from the dentist of your choice. Obtaining services from an in-network will lower your out-of-pocket costs.

Annual Deductibles
Individual:  $50
Family:       $150

Dental Expenses
Preventive / Diagnostic:   100%
Basic Services:                80%
Major Services:                50%
Orthodontics:                   50%

Maximum Benefits
Annual per person:             $1,200
Lifetime TMJ:                      $500
Lifetime orthodontia:           $1,500
(per child)

DeltaCare Dental HMO administered by Delta Dental

The DeltaCare Dental HMO is a dental plan that provides comprehensive dental care when services are obtained from an
in-network primary dentist. During open enrollment, select a dentist within a 35-mile radius of your zip code from the DeltaCare network to serve as your primary dentist.

With this plan, you are only responsible for the co-pays for any covered services you receive from your selected dentist. There are no deductibles, yearly maximums, or paperwork claims to file. Examples of common services and co-pays are listed below.

Description

Procedure Code

Co-Pay

Office Visit

D0999

$5

Oral exam, x-rays, and fluoride treatment

N/A

No cost

Prophylaxis (teeth cleaning twice a year)

D1110

No cost

Periodontal scaling and root planning, per quadrant

D4341

$40

Fillings (amalgam or resin) for one surface, anterior

D2140

$5

Surgical extraction, erupted tooth

D7210

$45

Root canal – molar (excluding final restoration)

N/A

$280

Crown– porcelain fused to predominantly base metal

D2750

$295

Orthodontics for children and adults

D8070 (children) / D8090 (adults)

$1,700 / $1,900



Vision
The City's vision plan benefit, administered by Davis Vision, provides you and your dependents with access to a national network of doctors and retail providers to help you care for your eyes. Eye exams, eyeglasses, and contacts are available to you at only the cost of applicable co-pays. To locate a vision provider near you or for additional information, log onto www.davisvision.com, click on the Members tab, and enter the 2471 (City's Client Code) in the Open Enrollment section. You can also call Davis Vision at 1-800-448-9372. View page nine (9) of the 2014 Civilian Benefit Matters for additional vision plan details.

Contact Lens and Frame Benefits
Contact lenses selected (in lieu of eyeglasses) from Davis Vision's Contact Lens Collection are covered in full. With Davis Vision's Frame Collection, you have access to several designer and brand name frames (in lieu of contacts) at only the cost of applicable co-pays. Plan eyewear includes a one-year eyeglass breakage warranty at no cost to you.

Davis Vision Collection
To maximize your vision plan benefit, consider purchasing frames or contact lenses from the Davis Vision Collection. The Collection is available at most participating independent provider locations. Independent providers do not include retail stores such as Visionworks or Walmart. To locate a participating independent provider near you, visit www.davisvision.com.

Benefit Summary

Comprehensive Eye Exam - $10 co-pay, one exam per year

Frames (in lieu of contacts)

Contacts (in lieu of eyeglasses)

Once per calendar year beginning January 1.

Once per calendar year beginning January 1.

$130 retail allowance toward any frame from provider, plus 20% off balance³.

$150 retail allowance toward Non Collection Contact lenses, plus 15% off balance².

                                          OR                                           OR

Any Fashion or Designer frame from Davis Vision’s Collection¹ (value up to $175).

Any contact lenses from Davis Vision’s Contact Lens Collection¹.

One year eyeglass breakage warranty included at no additional cost.

Contact Lens Evaluation, Fitting & Follow Up
Care - Once per calendar year beginning January 1. Collection contact lenses covered in full, including fitting fee. Fitting fee is an additional charge minus 15% discount if Non Collection contact lenses².

Spectacle Lenses - Once per calendar year beginning January 1. For standard single-vision, lined bifocal, or trifocal lenses.

 

¹The Davis Vision Collection is available at most participating independent provider locations.
²For dependent children, monocular patients, and patients with prescriptions of 6.00 diopters or greater.
³Additional discounts not applicable at Walmart or Sam’s Club locations.


Life Insurance
The City of San Antonio provides Basic Life and Accidental Death & Dismemberment Insurance to you through Dearborn National Life Insurance Company to help protect your family in the event of your death. In addition to this insurance, you can also buy additional voluntary life insurance for yourself and your dependents.

Dependent Life Insurance
Optional Dependent Life Insurance is available at a fixed bi-weekly premium cost of $2.00 regardless of the number of covered dependents. In the event of the death of an insured dependent at any time and from any cause, the plan will pay $25,000 for a spouse and $10,000 for each dependent child through age 20 (or age 25 if a full-time student).

Supplemental Life Insurance
Voluntary Supplemental Life Insurance of up to five (5) times an employee’s annual base salary or $900,000 - whichever is less - is also available. The cost of the coverage varies by the employee’s age and the amount of coverage. Benefits are reduced at age 70. See plan certificate of coverage for more details. New employees may enroll in up to two (2) times their annual salary or $200,000 Supplemental Life Insurance without answering any medical questions during the first 31 days of employment. Enrollment after that time may be requested during the annual open enrollment period upon successful completion and approval of an Evidence of Insurability (EOI) Questionnaire. Coverage requested after the first 31 days of employment cannot be guaranteed.

To calculate bi-weekly premium:

1. Round annual salary up to next highest $1,000
2. Multiply by number of units of coverage requested (1-5 times annual salary)
3. Divide total life insurance coverage amount by $1,000
4. Multiply age banded rate by total coverage requested

Supplemental Life Insurance Rate Table

Amount of total life coverage
(Annual salary x level of coverage)

Total life coverage divided by $1,000

Employee Age

Premium Multiplier

Bi-Weekly Premium

 

 

Under 30

$.022

 

 

 

30-34

$.032

 

 

 

35-39

$.037

 

 

 

40-44

$.050

 

 

 

45-49

$.087

 

 

 

50-54

$.135

 

 

 

55-59

$.234

 

 

 

60-64

$.388

 

 

 

65-69

$.592

 

 

 

70-74

$1.076

 

Example: 48 year old employee with an annual salary of $34, 240

1. Round annual salary up to $35,000
2. $35,000 x 3 times life= $105,000
3. $105,000 divided by $1,000= $105
4. $105 x $0.087= $9.14 biweekly premium


Accidental Death & Dismemberment
All full-time employees are automatically covered under the Dearborn National Life Insurance Company's Basic Term Life Insurance plan.  The City pays the entire cost of this coverage. If you die while covered under the basic life insurance plan, your beneficiary will receive a tax-free lump sum benefit equal to your annual base salary. You also have Accidental Death and Dismemberment (AD&D) coverage which pays one time your annual salary to your beneficiary in the event of your accidental death, in addition to the basic life insurance amount.


Short-Term Disability
The City of San Antonio offers, at no cost to eligible, full-time City employees, a disability program with extended sick leave benefits for non-job-related illnesses or injuries. This program provides employees with a percentage of their salary based on years of service for a maximum of 26 weeks if unable to work as a result of a non-work related disability.

Eligibility

  • Any full-time civilian employee who suffers an off-the-job injury or illness
  • Employee must be off work for 5 consecutive working days and be under the care of a licensed physician
  • Employee must have completed their six month probationary period
  • Employee must submit a complete application within 30 days of onset of disability for benefits under the
  • program, along with an attending physician’s statement

The benefits are granted according to the following schedule:

Years of Service 100% 80% 60% 50% 40%
           

6 months, but less than 1 year

0

0

6

7

13

1 year, but less than 5 years

0

4

9

13

0

5 years, but less than 10 years

2

4

8

12

0

10 years, but less than 15 years

4

9

13

0

0

15 years or more

6

7

13

0

0



Long-Term Disability
To supplement your long-term disability coverage, the City offers employees the option to purchase additional long-term disability coverage.  If you purchase additional voluntary coverage, you will be eligible to receive an additional 20% of your salary in long-term disability protection. Total benefits with the purchase of additional long term disability are calculated at 60% of salary minus offsets (i.e. Social Security, other coverage, etc.).

Program Features

  • Total benefits paid with the purchase of supplemental coverage increase to 60% of salary minus all offsets (i.e. Social Security, other coverage, etc.)
  • All long-term disability payments paid for by the employer are taxable income  

If you are on short-term or long-term disability at the time you enroll in additional long-term disability coverage, the additional 20% coverage will be delayed until you return to active duty.