benefits guide 2013 - polk county public schools · desea una copia de su guía de beneficios e...
TRANSCRIPT
Benefits Guide 2013
Welcome to the School Board of Polk County! The Polk County School Board
(PCSB) strives to balance quality coverage and affordability in the benefits offered to you. The District is pleased to provide an affordable comprehensive benefits program to help meet the needs of you and your family. Your New Hire Benefits Guide is intended to provide a summary of the main features of the School Board of Polk County benefits package. It is much shorter and less technical than the legal documents and contracts that govern our benefits. The District has made every effort to make sure the information in this summary is accurate; however, in the case of any discrepancy, the provisions of the legal plan documents and insurance certificates will govern. You are encouraged to read your New Hire Guide and any individual plan materials before you make your elections. The more you understand the various elements of the School Board of Polk County benefits, the better prepared you will be to take full advantage of the benefits we provide for you and your family.
This Benefits Guide is a resource that will answer questions most employees have. If you have any questions concerning your benefits or need assistance, the Risk Management and Employee Benefits staff is here to assist you at 863-519-3858 or by email at [email protected]
Benefits and operational procedures may be updated as required by the PATIENT PROTECTION AND AFFORDABLE CARE ACT (health care reform). Check the Risk Management website at www.polk-fl.net/staff/employeeinfo/riskmanagement/default.htm periodically for any required changes that may result from health care reform guidance.
Atención Personas que hablan español: Si usted
desea una copia de su Guía de Beneficios e información sobre sus derechos en español, favor de comunicarse con el Departamento de Gestión de Riesgos y Beneficios al Empleado (Risk Management Department/ Employee Benefits) al 863-519-3858 ó por correo electrónico a: [email protected]
Actualmente nuestro Departamento cuenta con dos empleados de habla en español. A continuación esta la información de contacto.
863-519-3858 Ext.2221
1
Revised 2/15/12
New
Hire
En
rollm
en
t Y
ou were recently identified as a new
ly hired employee. A
s a result enclosed is a N
ew H
ire Benefits G
uide. Your N
ew H
ire Benefits G
uide is intended to provide a sum
mary of the m
ain features of the School Board of Polk C
ounty benefits package. R
eview the N
ew H
ire Benefits G
uide to ensure you have the following item
s in your guide:
• N
ew H
ire Enrollment Form
•
Risk M
anagement &
Employee B
enefits Staff contact list
If you are missing any of the item
s listed above, please contact Risk M
anagement
and Employee B
enefits at (863)519-3858 or by email at:
RiskM
anagement-A
Failure to return an enrollment form
will result in autom
atic enrollment for the
following plans:
• T
he PCSB
Health Plan for em
ployee only coverage. The PCSB
Health Plan is governed by Section 125 of the IRS code w
hich allows em
ployees to use pre-tax dollars to pay the premium
s. Benefit elections, including au
tomatic e
nrollment m
ust remain in e
ffect until the ne
xt annual O
pen Enrollm
ent Period un
less a qualifying e
vent is
experienced. Examples of qualifying events are m
arriage, divorce, birth, death, adoption, gain or loss of coverage, etc.
• $20,000 of G
roup Term L
ife and $10,000 of Accidental D
eath and D
ismem
berment coverage. This is provided by The B
oard, at no cost to the em
ployee. It is provided to each benefit eligible employee.
Important n
ote: If you are an A
FSCME em
ployee failure to waive the P
CSB
Health P
lan will result in autom
atic enrollment in the E
mployee O
nly coverage tier at the current Em
ployee Only m
onthly contribution level which is $15.00 per
month.
If you are covered by another health plan and do not wish to be enrolled in the
PCSB
Health Plan check the box to w
aive coverage for health insurance and return it to the Risk M
anagement and Em
ployee Benefits D
epartment.
Important n
ote: If you are covered under another group health plan failure to w
aive the PC
SB Health P
lan means that the P
CSB H
ealth Plan is considered
your primary insurance and your other plan now
becomes your secondary.
Continued on the next page
Background
information
What is required?
What happens if I
do not return the enrollm
ent form?
What if I w
ant to w
aive the health insurance offered?
2
2 02/21/2012
New
Hire Enrollm
ent Forms are due 15 days
from the date you receive this
guide. Please com
plete the beneficiary information on the Enrollm
ent form, even if you
do not wish to return the form
for any other enrollment. This coverage is
provided by The Board to each benefit eligible em
ployee at no cost to the em
ployee. The Flexible Spending am
ount indicated on your enrollment form
is the total am
ount that will be deducted from
your paychecks over the course of the Plan Y
ear.
Important note: FSA E
lections do not roll over from plan year to plan year. A
ll eligible expenses m
ust be incurred between your effective date of coverage in
2013 and Decem
ber 31, 2013.
Before returning your enrollm
ent form ensure that all dem
ographic information
has been provided for your dependent(s). The following inform
ation is required along w
ith the application for enrollment of an eligible dependent:
• A
valid social security number and date of birth for the dependent(s)
• D
ocumentation verifying dependent eligibility
(for requirements see page 6 of your N
ew H
ire Benefits Guide)
Failure to supply valid social secu
rity num
bers or dependent documentation
may result in suspension or term
ination of coverage. R
eturn all completed form
s to the Risk M
anagement and Em
ployee Benefits
Departm
ent by mail at: Polk C
ounty School Board A
TTN: Em
ployee Benefits D
epartment
P.O. B
ox 391 B
artow, FL 33881
or by courier at: Em
ployee Benefits D
epartment
District O
ffice, Route E
Please contact Risk M
anagement and Em
ployee Benefits at (863)519-3858 or by
email at: R
iskManagem
ent-AllStaff@
polk-fl.net
Deadline for
enrollment
Beneficiary
Designation
FSA E
nrollment
What if I am
enrolling dependents on m
y plan(s)?
How
do I return the com
pleted form?
Questions?
3
Important Information CHANGE OF STATUS
QUALIFYING EVENT
EXAMPLES
Marriage Divorce
Death Birth
Adoption Stepchild
Legal Guardianship
Gain or Loss of Coverage If you need to make a change to your coverage due to a Qualifying Event, you must submit the Change of Status Form along with required documentation no more than 31 days after the qualifying event has taken place. Change of Status Forms are available on the Risk Management and Employee Benefits page of the School Board of Polk County website: www.polk-fl.net/staff/employeeinfo/riskmanagement/default.htm or by contacting Risk Management at: [email protected].
Section 125
Section 125 of the IRS code allows employees to use pretax dollars to pay the premiums on certain group insurance products. These deductions are taken prior to Social Security and Federal Income Taxes being deducted from your paycheck, which can lead to significant savings. Benefits elections must remain in effect until the next Open Enrollment Period unless you experience a qualifying event. A qualifying event is a change in status to your life that meets IRS
approved definitions.
PRE-EXISTING CONDITION EXCLUSIONARY PERIOD Generally, there is no coverage under the Group Health Plans to treat a Pre-existing Condition, or Conditions arising from a Pre-existing Condition. The 12-month Pre-existing Condition exclusionary period begins on the first day of the Waiting Period for benefits if you are an initial enrollee; or 12 months from your Effective Date of coverage under the plan if you are a special or late enrollee. The Pre-existing Condition exclusionary period does not apply to any of the following:
1. Pregnancy. 2. Children under age 19 (Effective 01/01/2011
with Health Care Reform). 3. Routine follow up for breast cancer after the
member was determined to be free of breast cancer.
4. Conditions arising from domestic violence. 5. Inherited diseases of amino acid, organic acid,
carbohydrate or fat metabolism as well as malabsorption originating from congenital defects present at birth or acquired during the neonatal period.
Payroll Deductions Premiums are due in advance; therefore deductions begin one month before coverage is effective.
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The School Board of Polk County Contributions
The Board contributes $6,043.32 per year ($503.61 per month)* for health insurance for each eligible employee. Health insurance includes medical coverage currently through BCBS of Florida and prescription coverage through Express Scripts, formerly Medco. The Board also provides, at no cost, each benefit eligible employee with $20,000 of Group Term Life and $10,000 of Accidental Death and Dismemberment Insurance.
*Minus the $15 copay for AFSCME represented positions
Enrollment Basics
When will your Insurance End:
10 or 11 Month Employees If you resign prior to the end of the school year your benefits will end the last day of the month in which you resign.
12 Month Employees
Your benefits will end the last day of the month in which you resign.
IMPORTANT NOTE: The PCSB is pleased to announce a health plan designed for dual employee households. Board Spouse is offered at no cost for either employee. The Board will contribute the premium for both employees. Enrollment will be simple. As a married couple, one employee will elect coverage as the Board Spouse on their spouse’s Form. If you and your spouse who is already employed with PCSB elect to have you (the New Hire) be the Board Spouse on their plan you will do the following: On your New Hire Form you will:
Check the box next to “Please enroll me as a dependent (Board Spouse) on my
spouse’s health coverage”.
Enter your spouse’s SAP# on the line provided.
Have your Spouse sign on the line provided.
If you and your spouse who is already employed with PCSB elect to have your spouse be the Board Spouse on your (the New Hire’s) plan you will do the following: On your New Hire Form you will:
Check the box next to “Please enroll my spouse as a dependent (Board Spouse)
on my health coverage”.
Enter your spouse’s SAP# on the line provided.
Have your Spouse sign on the line provided.
A copy of your marriage license or last year’s Tax Return will need to accompany your enrollment form in order for dependent verification to be completed. Without this documentation, the Employee Benefits Department will be unable to process this request.
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Eligibility Requirements for Covered Employees To be an Eligible Employee, a person must be a bona fide employee of the School Board of Polk County and must meet each of the following requirements:
1. The Eligible Employee’s job must fall within an eligible job classification; 2. The Eligible Employee must have completed any applicable Waiting Period set forth by the Plan; and 3. The Eligible Employee must have completed any applicable eligibility requirement (s) set forth by the Plan.
The School Board of Polk County’s Covered Employee’s eligibility classification may be modified, and may be expanded to include:
1. Retired employees; 2. Additional job classifications; 3. Employees of affiliated or subsidiary companies of the School Board of Polk County, provided such companies and the
School Board of Polk County are under common control; and 4. Other individuals as determined by the School Board of Polk County (e.g., members of associations or labor unions).
Any expansion of the Covered Employee eligibility class must be approved in writing by the School Board of Polk County prior to such expansion.
Eligibility Requirements for Covered Dependent(s):
Important Notice Regarding Dependent Eligibility Verification
Employees will need to provide the following documentation to the Risk Management & Employee Benefits Department for any dependents being added during any Enrollment Period: Documentation to verify eligibility of:
Spouse - Copy of Marriage License
Child - Copy of Birth Certificate; Adoption Certificate; Court Order establishing legal guardianship.
Grandchild* - Copy of Birth Certificate. (*If a grandchild is the child of an employee’s currently covered dependent. A grandchild can only remain on the employee’s coverage for 18 months.)
Employee has legal custody of a minor child - Court Order establishing legal guardianship.
The previous year’s U.S. Tax Return showing the dependent being claimed by you can also be used to establish eligibility. NOTE: Knowingly covering an ineligible dependent
constitutes insurance fraud. If you are currently
covering a dependent who does not meet the eligibility
criteria defined in items 1-4 it is STRONGLY
recommended that you remove them from your
coverage during this Open Enrollment period.
It is solely the Covered Employee’s responsibility to establish that a dependent meets the applicable requirements for eligibility and to notify the Employee Benefits Department when eligibility ceases. Eligibility will terminate on the last day of the month in which the dependent no longer meets the eligibility criteria. The tier chosen will remain in effect for the plan year whether or not dependent verification is received; however dependents that have not been verified will not be covered under the plan.
Enrollment Basics
An individual who meets the eligibility criteria specified below is an Eligible Dependent and is eligible to apply for coverage under the PCSB Group Health Plan:
1. The Covered Employee’s present spouse (if spouse is a benefits eligible employee of the School Board of Polk County see
Board Spouse option). Note: an ex-spouse does not meet eligibility criteria even if insurance coverage is specified by a judge
in a divorce decree.
2. The Covered Employee’s natural, newborn, adopted, foster, or step child(ren) (or a child for whom the Covered Employee has
been court-appointed as legal guardian or legal custodian) until the end of the Calendar Month, in which the child reaches age
26.
3. The newborn child of a Covered Plan Participant other than the Covered Employee or the newborn child of a Covered Plan
Participant other than the Covered Employee’s spouse. Coverage for such newborn child will automatically terminate 18
months after the birth of the newborn child.
4. Handicapped Children
a. A handicapped dependent child is eligible to continue coverage, beyond the limiting age of 26, as a Covered
Dependent if such child is otherwise eligible for coverage under the Group Health Plan, incapable of self-sustaining
employment by reason of mental retardation or physical handicap, and chiefly dependent upon the Covered
Employee for support and maintenance provided that the symptoms or causes of such child’s handicap existed prior
to such child’s 26th birthday. This eligibility shall terminate on the last day of the month in which the child does not
meet the requirements for extended eligibility as a handicapped child.
6
HEALTH INSURANCE COVERAGE Customer Service 800-664-5295
Website http://www.bcbsfl.com
Monthly Premium Deductions
TIER PEA & non-union represented positions AFSCME represented positions
Employee $ 0.00* $ 15.00*
Spouse $418.00* $418.00*
1 Child $ 95.00* $ 95.00*
2 Children $190.00* $190.00*
3 or More Children $215.00* $215.00*
These premiums include medical coverage administered by BCBS FL and prescription coverage through Medco. Please make sure you have a card from both companies! If you are
missing a card, please call the company directly to request one.
IN NETWORK You have the freedom to receive care from an extensive network of BCBSF doctors, hospitals and other health care providers, or you can seek treatment from any licensed doctor or hospital as you see fit. If you choose a network provider for covered services, (NetworkBlue), you can receive greater cost savings through higher percentages of medical coverage. In some cases there are even lower up-front deductibles and maximum out-of-pocket expenses.
When using in-network providers there are no claim forms to file and you’ll never be responsible for any balance billing by a Blue Cross Blue Shield provider other than your deductible, coinsurance or any applicable co-pay. The plan does allow you to self-refer to specialists. You won’t be required to select a Primary Care Physician although, for your good health, it is always a good idea to allow your Primary Care Physician to help you coordinate your health care. Many specialties require a referral from your regular physician as part of their medical practice policy.
NetworkBlue members have access to Blue Cross and Blue Shield of Florida's statewide networks of participating providers. In addition, if you are traveling or reside outside the state of Florida, you will have access to the BCBS BlueCard PPO network.
OUT OF NETWORK You also have benefits when you go out of the network, but if the provider you see is not contracted with Blue Cross Blue Shield; they are not obligated to accept BCBSFL’s payment as payment-in full, and may bill you for any unpaid balance. This balance generally exceeds your coinsurance by a substantial amount.
If you choose to use a non-network medical provider, the out-of-pocket expenses could be higher than the in-network benefits.
AFSCME represented positions include: Bus Driver Bus Attendant Courier Custodian Food Service Maintenance
*Monthly premiums set based on negotiations
Once the benefits eligibility waiting period has been met, each eligible employee, (including each member or employee or member covered under the AFSCME CBA), shall be enrolled in the PCSB Health Plan with the applicable monthly employee contribution based on the coverage tier elected. Failure to waive the PCSB Health Plan will result in automatic enrollment in the Employee Only coverage tier at the current Employee Only monthly contribution level. The Group Health plan is considered Section 125 of the IRS code which allows employees to use pre-tax dollars to pay the premiums. Benefit elections, including automatic enrollment must remain in effect until the next annual Open Enrollment Period unless a qualifying event is experienced. Examples of qualifying events are marriage, divorce, birth, death, adoption, gain or loss of coverage, etc.
7
SCHEDULE OF BENEFITS
Medical Benefit PCSB Health Plan
Lifetime Maximum Unlimited
In-Network / YOU PAY Out-of-Network*/ YOU PAY
Calendar Year Deductible (CYD)
Individual Family
$750 $1,500
$1,500 $3,000
Calendar Year Out-of-Pocket Maximum Individual Family
Includes CYD, Copays & Coinsurance
$5,000
$9,000
Unlimited
Hospital Services Inpatient or Outpatient
Option 1** - CYD +20% Coinsurance Option 2** –CYD + 25% Coinsurance
CYD + 40% Coinsurance
Emergency Room
CYD + 20% Coinsurance CYD + 20% Coinsurance
Urgent Care $40 Copay CYD + 40% Coinsurance
Outpatient Surgery Ambulatory Surgical Center Facility Services Hospital Facility Services
CYD + 20% Coinsurance
Option 1** - CYD + 20% Coinsurance Option 2** – CYD + 25% Coinsurance
CYD + 40% Coinsurance
CYD + 40% Coinsurance
Family Physician Office Visit (Includes General Practice, Family Practice, Internal Medicine & Pediatrics)
$40 Copay CYD + 40% Coinsurance
Specialist Physician Office Visit (Includes all other physician specialties)
$40 Copay CYD + 40% Coinsurance
Maternity Care OB Specialist Hospital Services
$40 (Initial OB Visit Only)
Option 1** - CYD +20% Coinsurance Option 2** –CYD + 25% Coinsurance
CYD + 40% Coinsurance
8
Outpatient Therapy (Includes Cardiac, Occupational, Physical, Speech & Massage Therapies and Chiropractic Visits) Benefit Period Maximum
Option 1** - CYD + 20% Coinsurance
Option 2** – CYD + 25% Coinsurance 35 Visits (Includes up to 26 Spinal Manipulations)
CYD + 40% Coinsurance
35 Visits (Includes up to 26 Spinal Manipulations)
Independent Clinical Lab (outside the office visit setting) Independent Diagnostic Testing Facility (IDTF) (includes physician services)
Advanced Imaging (MRI, MRA, PET, CT, Nuclear Medicine)
CYD
CYD + 20% Coinsurance
CYD + 40% Coinsurance
CYD + 40% Coinsurance
Routine Preventive Health & Screening Services (includes well-woman exam) Family Physician/PCP or Specialist
No Maximum
$0
No Maximum
CYD + 40% Coinsurance
Preventive or Diagnostic Mammogram $0 $0
Colonoscopy (Routine) $0 CYD + 40% Coinsurance
Colonoscopy (Diagnostic) Ambulatory Surgical Center Outpatient Hospital
$0
Option 1** – 20% Coinsurance (CYD Waived) Option 2** – 25% Coinsurance (CYD Waived)
CYD + 40% Coinsurance
Mental Health & Substance Abuse Inpatient/Outpatient Provider Services at Hospital and ER
CYD + 20% Coinsurance
CYD + 20% Coinsurance
CYD + 40% Coinsurance
CYD + 20% Coinsurance
Skilled Nursing Facility CYD + 20% Coinsurance
Limited to 60 days per Benefit Period
CYD + 40% Coinsurance
Limited to 60 days per Benefit Period
* Diabetic Supplies are not covered as the Rx benefit is carved out. Diabetic Equipment (insulin pumps, tubing) are covered under the medical benefit. ** Q. What is the difference between an Option 1 and Option 2 hospital?
A. Option 1 hospitals are generally community-type hospitals while option 2 hospitals are more specialized teaching hospitals, usually with higher costs. In general, for services at an Option 1 hospital, you will be responsible for 20% coinsurance after your deductible is met. For Option 2 hospitals, you will be responsible for 25% coinsurance after your deductible is met. A hospital is classified as Option 1 or Option 2 strictly based on their contract status with BCBSF. The BCBSF online provider directory shows the option level of each hospital. All of the hospitals in Polk County are Option 1 hospitals. This is not an insurance contract or Benefit Booklet. The above Benefit Summary is only a partial description of the many benefits and services covered by your Health Plan. For a complete description of benefits and exclusions, please refer to the Summary Plan Description (SPD). The written terms of the SPD prevail.
SCHEDULE OF BENEFITS
Availability of Summary Health Information Understanding the benefits offered through the PCSB Health Plan is very important. To help guide you through the items covered, your plan makes available a Summary Plan Description (SPD), which summarizes important information about health coverage in a standard format. The SPD is available on the web at: http://www.polk-fl.net/staff/employeeinfo/riskmanagement/insurance.htm A paper copy is also available, free of charge, by calling 863-519-3858 (a toll-free number).
9
Questions Resources How to Access
Planning surgery or have questions about a condition?
Health Care Advocate
Florida Blue provides an on-site Health Care Advocate to assist members with Clinical Issues including treatment choices, cost saving options, community resources and more.
Located at the Polk County School Board Employee Health Clinic (863) 519-8044
Have a complex health condition?
Nurse Case Manager
Florida Blue provides a dedicated Nurse Case Manager who can answer questions about your treatment plan and help you coordinate with your physicians and other service providers.
Tammie Thompson, RN
Toll Free: 800-262-2166 ext 59264 Direct Line: 850-505-9264 [email protected]
Why pay more?
Know Before You Go
Use our online Medical Cost Comparison Tool to shop around for health care services. You can save money and still get the quality care you deserve.
Go to www.floridablue.com and log into your Member Account - select Tools and Medical Care Comparison
Questions about your treatment options?
Care Consultants
Our team of Care Consultants is standing by to answer questions about your benefits, treatment choices and cost saving options.
Toll Free at 1-888-476-2227
Monday through Friday, 8 AM to 9 PM
Want help face-to-face?
Florida Blue Center
The new Florida Blue Center in Winter Haven provides great customer service, in person.
385 Cypress Gardens Blvd Winter Haven Open 10am - 8pm, Mon. – Sat. No appointment needed. 1-877-352-5830
BlueCross BlueShield of Florida – Enhanced Benefits The health and wellness of our employees and their family members is very important to the Polk County School Board. The goal of the District’s health and wellness
programs is to motivate our members with chronic conditions to take an active part developing their treatment plans to increase their quality of life. The District in
partnership with Blue Cross Blue Shield of Florida provides our members’ access to various resources to assist members with every aspect of their health care needs.
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ER or doctor’s office?
Health Dialog 24-hour Nurse Line
Questions about health can come up at anytime, including times when doctors’ offices are closed. Our 24-hour nurse line can help you make informed health care choices.
Toll Free at 1-877-789-2583
Plan benefits or claim question?
On-Site Customer Service
The Florida Blue on-site Customer Service Representative is available to assist members with Benefit Issues including plan design questions and claim inquiries.
Connie Ashley Located in Bartow at the District Office
(863) 519-8799 [email protected]
Need help with a claim or have other questions?
Customer Service
Ask your customer service representative how to: Find out what’s covered and how much
you’ll pay Shop for the best value on upcoming
medical procedures. Maximize your health plan benefits to
save money. Access online tools and resources to help
you better manage your health. Receive support for a health condition
(like diabetes or asthma).
Toll Free at 1-855-600-6701
Monday – Thursday 8 a.m. – 8 p.m. Friday 9 a.m. – 8 p.m. Saturday 10 a.m. – 8 p.m.
Prefer online help?
www.floridablue.com Register your online Member Account to:
Review your plan benefits See your deductible Find a participating doctor or hospital View claim activity, status and history Use your personalized WebMD site Understand your upfront medical costs Find tools to improve your health Access our exclusive discount program
Go to www.floridablue.com and register. All you need to register is a valid email address, your SSN and your Member Number (located on your BCBSF Member ID card).
11
In Network Pharmacies Albertsons Bi-Lo Costco CVS Eckerd Kash n’ Karry K Mart Kroger Publix Rite Aid Sam’s Club Target Walgreens Wal-Mart Winn-Dixie These are examples of in network
pharmacies. Visit http://www.medco.com
for more information.
MEMBER COPAYS:
Generic Preferred Brand Non-Preferred Brand
Retail 30 $8 $30 + 10%* (max $60)
$50 + 10%* (max $100)
Retail 90 $8 $90 + 10%* (max $180)
$150 + 10%* (max $300)
Mail 90 $8 $75 $125
PHARMACY BENEFITS 1-800-476-6819 www.medco.com
*10% of the cost of the prescription minus the deductible.
$25.00 per person annual deductible for brand name
medications only.
If you purchase a brand-name medication when a
generic medication is available or when your doctor
requests a brand-name medication when a generic
medication is available, you will pay the generic co-
payment, plus the difference in cost between the brand
and the generic.
MAIL SERVICE PHARMACY
Through the Prescription Drug Program, you can take advantage of convenient delivery of your covered maintenance medications to your home or other specified address. Be sure to ask your physician for a 90-day prescription in order to take advantage of this benefit. Order online anytime, or call 1 800 4REFILL (1 800 473-3455) and use the automated telephone system. You can also mail in your refill orders by using the special mail-order pharmacy envelope. If you order by phone or via www.medco.com, you will need to provide your member number and the 12 -digit prescription number shown on the medication container and the refill slip. A website designed just for you: After a one-time registration at www.medco.com, you can login anytime to order refills, check the status of an order, price and compare medication costs, review prescription history, obtain Medco By Mail order forms and much more. You will pay your copays for prescriptions ordered through Medco’s mail order service directly to Medco.
12
Benefits and operational procedures may be updated as required by the PATIENT PROTECTION AND AFFORDABLE CARE ACT (health care reform). Check the Risk Management website at http://www.polk-fl.net/staff/employeeinfo/riskmanagement/default.htm periodically for any required changes that may result from health care reform guidance.
Go Generic! Did you know that the United States Food and Drug Administration (FDA) requires generic drugs to be as safe and effective as their brand-name counterparts? That means you can save money without compromising quality. A generic must contain identical amounts of the same active ingredients—in the same dosage form and strength—as its brand-name counterpart and be shown to work the same way in the body. There are many new generics available for conditions such as high cholesterol, allergies and depression. We suggest you take the preferred prescriptions member guide with you whenever you visit your doctor to discuss whether a generic medication is appropriate for you. Preferred Prescriptions Member Guide For an updated and complete listing of your prescription benefit, you can visit the “Benefit Highlights” section of the Medco website—www.medco.com—and click on the View your preferred drug list link. Not all medications listed here are covered by every prescription drug plan. Updates are made quarterly for additions and once a year in January for deletions.
Vacation Overrides If you need to refill your prescription prior to the allowed refill date because you will be going away on vacation, please contact the Risk Management & Employee Benefits Department at: 863-519-3858.
Utilization Management Medco’s comprehensive utilization management programs ensure that members get the right drug in the right dosage at the right time. They also encourage appropriate drug use and drug selection, and utilization management programs increase member safety. If you submit a prescription for a drug that has coverage limits; for example, prescription drugs used for cosmetic purposes may not be covered, or a medication might be limited to a certain amount (such as the number of pills or total dosage) within a specific time period, your pharmacist will tell you that approval is needed before the prescription can be filled. The pharmacist will give you or your doctor a toll-free number to call. If you use Medco By Mail, your doctor will be contacted directly. When a coverage limit is triggered, more information is needed to determine whether your use of the medication meets the plan's coverage conditions. Medco will notify you and your doctor in writing of the decision. If coverage is approved, the letter will indicate the amount of time for which coverage is valid. If coverage is denied, an explanation will be provided, along with instructions on how to submit an appeal.
13
Claims Review and Appeals Procedures
The Prescription Drug Program has a specific amount of time, by law, to evaluate and respond to benefit claims. The period of time permitted to evaluate and respond to a claim begins on the date the claim is first filed. In addition, there are specific timelines and information requirements that you must comply with when filing a claim, or the claim may be denied and the rights you might otherwise have may be forfeited.
Claims Appeal Process
In the event you receive an adverse benefit determination following an initial request for coverage of a prescription benefit claim, you have the right to appeal the adverse benefit determination in writing
within 180 days of receipt of notice of the initial coverage decision. An appeal may be initiated by you or your authorized representative (such as your physician). To initiate an appeal for coverage, provide
in writing your name, member ID, phone number, the prescription drug for which benefit coverage has been denied, the diagnosis code and treatment codes to which the prescription relates (together with
the corresponding explanation for those codes) and any additional information that may be relevant to your appeal. This information should be mailed to:
Medco Health Solutions, Inc.
PO Box 631850
Irving, TX 75063-0030
Attn: Appeals
If you are not satisfied with the coverage decision made on appeal, you may request in writing, within 90 days of the receipt of notice of the decision, a second level appeal. A second level appeal may be
initiated by you or your authorized representative (such as your physician). To initiate a second level appeal, provide in writing your name, member ID, phone number, the prescription drug for which benefit
coverage has been denied the diagnosis code and treatment codes to which the prescription relates (and the corresponding explanation for those codes) and any additional information that may be relevant
to your appeal. This information should be mailed to:
Medco Health Solutions, Inc.
PO Box 631850
Irving, TX 75063-0030
Attn: Appeals
If your second level appeal is denied and you are not satisfied with the decision of the second level appeal, you also may have the right to obtain an independent external review. Details about the process
to initiate an external review will be described in any notice of an adverse benefit determination. External reviews are not available for decisions relating to eligibility.
The right to an independent external review is only available for claims involving medical judgment or rescission. For example, claims based purely on the terms of the plan (e.g., plan only covers a quantity
of 30 tablets with no exceptions), generally would not qualify as a medical judgment claim. You can request an external review by an Independent Review Organization (IRO) as an additional level of appeal
prior to, or instead of, filing a civil action with respect to your claim under the Patient Protection and Affordable Care Act.
To file for an independent external review, your external review request must be received within 4 months of the date of the adverse benefit determination (If the date that is four months from that date is a
Saturday, Sunday or holiday, the deadline is the next business day). Your request should be mailed or faxed to: Medco Health Solutions, Inc. Attn: External Review Requests P.O. Box 631850
Irving TX 75063-0030
The Patient Protection and Affordable Care Act also allows for urgent care appeals. Urgent appeals may only be requested for clinical based appeals and can only be requested by your physician. Urgent
appeals are reviewed within 72 hours.
Appeal Review Time Frame
Appeal processing time frames:
• First level appeals are reviewed within 15 days
• Second level appeals are reviewed within 30 days
• External Reviews are reviewed within 5 business days to determine if it is eligible to be forwarded to an Independent Review Organization (IRO) and you will be notified of eligibility within 1
business day. If eligible for external review, you will be notified within 45 business days of the decision.
14
Basic Life Additional Group Term Life
How to Calculate the Premium: _______________ ÷ $1,000 x $ ____________ = $ ________________ (elected amount) (rate from chart) (monthly cost) The Pre-tax benefit for Group Term Life is available for amounts up to $50,000 in coverage. This total includes the $20,000 paid for by the School Board of Polk County for each benefit-eligible employee. Employees may elect additional coverage; however deductions for amounts over the total of $50,000 will be taken
on a post-tax basis
TERM LIFE INSURANCE Customer Service: 800-325-5757 ext. 0283
Website: http://www3.standard.com/net/public/Individuals
The District provides each benefit-eligible employee with $20,000 of life insurance coverage. This coverage includes $10,000 of Accidental Death and Dismemberment (AD&D).
You have the ability to purchase additional amounts of Group Term Life and Accidental Death & Dismemberment coverage. You may elect coverage in increments of 1 to 5 times your Annual Earnings up to a maximum of $300,000.
There is a Guarantee Issue up to the amount of $150,000 for new hires. If you did not elect additional life insurance the first time it was available to
you and you choose to enroll at a later date, you will be considered a late entrant and be subject to medical underwriting. Medical underwriting is also required for amounts in excess of $150,000. Rates for Additional Life include AD&D coverage.
Age Reductions Under this plan, Additional Life coverage reduces: 35% at age 65; 50% at age 70; and 65% at age 75.
AGE as of 01/01/13 RATE: PER $1,000
<=29 .069
30-34 .079
35-39 .099
40-44 .134
45-49 .185
50-54 .248
55-59 .261
60-64 .281
65+ .316
Additional AD&D Coverage Features ⇒ Seat Belt Benefit: This provision provides an additional benefit in the event of a covered automobile accident.
⇒ Air Bag Benefit: Provides an additional benefit in the event an air bag is deployed in an automobile accident.
⇒ Family Benefits Package: Eligible family members may be entitled to receive additional financial help for child care, college or career
training.
⇒ Occupational Assault: Provides an additional benefit if you suffer death or dismemberment as a result of an act of workplace physical
violence that is punishable by law.
⇒ Public Transportation: Provides an additional benefit in the event of death as a result of an accident that occurs while you are riding
as a fare-paying passenger on public transportation.
Dependent Life Any eligible employee may purchase Life Insurance for eligible dependents. The amount of coverage is $10,000 for the spouse and $5,000 for dependent children up to age 20; or 25 if child is a full time student. The entire amount of coverage is guarantee issue for new hires. Medical underwriting is required for all late entrants. Monthly Premium Rate: $6.06
15
While disability can be caused by an accident, most often it is caused by illness such as the following:
Diabetes
Heart Disease
Back Problems
Depression
Why should you purchase Disability Coverage?
You have purchased home, auto, health and life insurance to protect yourself, but what steps have you taken to
protect yourself and those who count on you from an unexpected loss of income? Could you meet your financial
obligations if you became disabled and unable to work?
What about Social Security and Pension Plan disability payments? Won’t those cover me if I become disabled?
The truth is Social Security’s disability definitions are extremely strict. The benefit waiting period is 6 months, and many times applications are denied the first time, causing the process to be years long. Pension Plan disability can be reduced when Social Security and Workers’ Comp are
integrated, as is often the case. Total and permanent disability is usually what Pension Plan disability is based on.
If you elect Short-Term and/or Long-Term
Disability during this year’s Open Enrollment you
will have the ability to enroll without Evidence of
Insurability. This is your opportunity to get a
guarantee issue for these benefits.
16
Short Term Disability Insurance
Short Term Disability Rate Table
Age as of 01/01/13
Option A (7 day waiting period)
Option B (14 day waiting period)
Option C (30 day waiting period)
<=29 30-34 35-39 40-44 45-49 50-54 55-59 60+
$1.31 $1.45 $0.94 $0.70 $0.76 $0.80 $1.03 $1.31
$0.92 $1.00 $0.62 $0.44 $0.47 $0.50 $0.64 $0.81
$0.64 $0.70 $0.43 $0.29 $0.31 $0.33 $0.42 $0.53
Customer Service 800-325-5757 ext. 0283 Website: http://www3.standard.com/net/public/Individuals
Benefit Waiting Period and Maximum Benefit Period The benefit waiting period is the period of time that you must be continuously disabled before benefits become payable. You must exhaust all of your accumulated sick leave before benefits become payable. Please choose one of the following Benefit Waiting Periods
that best meets your needs:
Option A
Accidental Injury
7 days
Other disabilities
7 days
up to 25 weeks
Option B
Accidental Injury
14 days
Other disabilities
14 days
up to 24 weeks
Option C
Accidental Injury
30 days
Other disabilities
30 days
up to 22 weeks
Step 1: Determine your average weekly income, not to exceed $2,917. $ Step 2: Multiply your weekly earnings by .60. $ Step 3: Select your rate from the rate table. $ Step 4: Multiply the results from Step 2 by the rate. $ Step 5: Divide the amount from Step 4 by 10. $
This is your estimated monthly payroll deduction. $ Example: An Employee age 30, earning a monthly salary of $2,492, selecting Option C would have a monthly payroll deduction of $24.15.
If you become disabled, benefits may continue during disability up to the maximum stated. If you are eligible to receive benefits under a long term disability plan issued by The Standard, STD benefits cease to be payable when LTD benefits begin.
How is the STD Benefit amount calculated? The weekly STD benefit amount is determined by multiplying your insured weekly predisability earnings by the specified benefit percentage. This amount is then reduced by other income you receive or are eligible to receive while STD benefits are payable. This other income is referred to as *deductible income.
In the example below, the STD benefit amount is 60 percent of insured predisability earnings. If your weekly earnings before becoming disabled were $500 and you now receive a weekly state disability benefit of $50, your weekly STD benefit would be calculated as follows:
Insured predisability earnings $500 STD benefit percentage x 60%
$300 Less state disability benefit -50 Amount of STD benefit $250
*Deductible income is income you receive or are eligible to receive while STD benefits are payable. It includes but is not limited to the following:
Benefits under any state disability income benefit law or similar law. Earnings from work activity while you are disabled. Any amount you receive by compromise, settlement or other method as a result of a claim for any of the above.
If you choose to enroll as a New Hire this will be considered your initial enrollment opportunity and you will not be subject to Medical Underwriting. 17
Long Term Disability Insurance
How is the LTD benefit amount calculated?
The LTD benefit level is 60% of predisability earnings. After 180 days of continuous disability the LTD benefit amount is determined by multiplying your insured monthly predisability earnings by 60%. This amount is then reduced by other income you receive or are eligible to receive while LTD benefits are payable. This other income is referred to as deductible income. In the following example, the LTD benefit amount is 60 percent of insured predisability earnings. If your monthly earnings (or predisability earnings) before becoming disabled were $2,000 and you now receive a monthly Social Security disability benefit of $600 and a monthly state disability benefit of $200, your monthly LTD benefit would be calculated as follows:
Insured predisability earnings $2,000 LTD benefit percentage x 60% $1,200 Less Social Security disability benefit -600 Less state disability income benefit -200 Amount of LTD benefit $400
Plan Maximum Monthly Benefit: $7,500 Plan Minimum Monthly Benefit: $ 100
Group Long Term Disability (LTD) insurance is designed to pay a monthly benefit to you in the event you cannot work because of a covered illness or injury. This benefit replaces a portion of your income, thus helping you to meet your financial commitments in a time of need.
Benefit Waiting Period and Maximum Benefit Period If your claim for Long Term Disability benefits is approved by The Standard, benefits become payable after you have been continuously disabled for 180 days and remain continuously disabled. Benefits are
not payable during the benefit waiting period. You must exhaust all of your accumulated sick leave. If you become disabled
before age 62, LTD benefits may continue during disability until you reach age 65. If you become disabled at age 62 or older, the benefit duration is determined by your age when disability begins.
Long Term Disability Rate Table
Age as of 01/01/13
Rate
<=29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
$0.19 $0.22 $0.28 $0.39 $0.59 $0.88 $1.11 $1.14 $1.27 $1.37 $2.15
To calculate your monthly payroll deduction, use the following formula: Enter your average monthly income, not to exceed $12,500 $ __________ Select your rate from the rate table and divide this number by 100. $ __________ Multiply Line 1 by the amount shown on Line 2. $ __________ This is your estimated monthly payroll deduction $ __________ Example: An Employee age 30, earning a monthly salary of $5,000
would have a monthly payroll deduction of $11.00.
For Features, Exclusions and Limitations for Short and Long Term Disability products through The Standard, please visit the Disability section of the Employee Benefits webpage.
If you choose to enroll as a New Hire this will be considered your initial enrollment opportunity and you will not be subject to Medical Underwriting.
18
Level of Coverage LOW PLAN MIDDLE PLAN HIGH PLAN
Employee Only $12.58 $21.63 $36.84
Employee & Spouse $24.86 $43.23 $71.33
Employee & Child(ren) $30.88 $54.51 $86.45
Employee, Spouse & Child(ren) $37.39 $74.85 $114.94
DENTAL INSURANCE Customer Service 800-521-2651 Website www.deltadentalins.com
Low Plan Middle Plan High Plan
Coverage Type PDP** In-Network:
Out-of-Network:
PDP** In-Network:
Out-of-Network:
PDP** In-Network:
Out-of-Network:
Type A – cleanings, oral examinations, fluoride, X-Rays
Schedule Schedule 100% of PPO fee
100% of PPO fee
80% of PPO fee
80% of MPA*
Type B – fillings, simple extractions, Endodontics, General Anesthesia, Oral Surgery, Periodontal Maintenance, sealants
Schedule Schedule 80% of PPO fee
80% of PPO fee
80% of PPO fee
80% of MPA*
Type C –bridges, dentures, Crowns, Periodontal surgery
Schedule Schedule
50% of PPO fee
50% of PPO fee
80% of PPO fee
80% of MPA*
Deductible†:
Individual $50 $50 $50 $50 $50 $50
Family $150 $150 $150 $150 $150 $150
Annual Maximum Benefit: In-Network Out-of-Network
In-Network Out-of-Network
In-Network Out-of-Network
Per Person $1000 $1000 $1000 $1000 $2000 $2000
Orthodontia Lifetime Maximum (child ortho only – to age 19):
N/A N/A In-Network Out-of-Network
In-Network Out-of-Network
Per Person N/A N/A $1000 $1000 $1000 $1000
† Deductible applies to Type B&C services only – waived on Type A services. *MPA = Maximum Plan Allowance **Preferred Dental Provider This is only a brief summary of the plans. Benefits are subject to limitations and exclusions of the plan. The dental health plan contract must be consulted to determine the exact terms and conditions of coverage.
MONTHLY PREMIUM DEDUCTIONS
Most potential savings with Delta Dental PPO dentists • Delta Dental PPO dentists agree to fees as full payment. • You’ll usually pay less when you visit a Delta Dental PPO dentist. • When you visit your dentist, you should ask specifically if he or she is a contracted Delta Dental PPO dentist.
Some savings with Delta Dental Premier dentists • Premier dentists’ contracted fees are usually slightly higher than PPO dentists’ contracted fees. • Premier dentists will not bill you above their contracted fees, so you still receive some cost protections not available with a non-Delta Dental dentist.
No savings with non-Delta Dental dentists • Non-Delta Dental dentists have no fee agreements with Delta Dental, so you will usually have the highest out-of- pocket costs when you visit a non- Delta Dental dentist. • You are responsible for the difference between
what Delta Dental pays and the dentist’s fee.
19
You do not need a claim form or an ID
card to use this benefit, however, ID
cards are now available to download
and print on UnitedHealthcare’s
website at: www.myuhcvision.com Login and look for the
blue box to pop up over your name on the right
of the screen.
If you visit an out-of-network provider, you will need to send your itemized receipts, with the primary-insured’s unique identification number and the patient’s name and date of birth, to:
UnitedHealthcare Vision Claims Department
P.O. Box 30978, Salt Lake City, UT 84130
VISION INSURANCE Customer Service 800-638-3120
Website www.myuhcvision.com
Monthly Premium Deductions
Employee $5.94
Employee + Spouse $10.75
Employee + Child(ren) $11.16
Employee + Family $17.20
In-network Services With UnitedHealthcare Vision, you are able to visit any provider you choose, but you maximize your savings when you visit a network
provider.
Copays for in-network services Comprehensive Exam $ 10.00
Materials $ 20.00
Vision Benefit Exam once every calendar year Lenses once every calendar year Frames once every 2 calendar years Contacts* once every calendar year
Out-of-Network Benefits
If you choose an out-of-network provider, you will be reimbursed up to:
Exam $40.00 Frames $45.00
Lenses Single vision $40.00 Bifocal $60.00 Trifocal $80.00
Lenticular $80.00
Contact Lenses in Lieu of Eyeglasses (lenses & frame) Elective $105.00*
Necessary** $210.00
* Less any network fitting/evaluation fee. ** Necessary contact lenses are determined at the provider’s discretion for one or more of the following conditions: Following cataract surgery without intraocular lens implant; To correct extreme vision problems that cannot be corrected with spectacle lenses; With certain conditions of anisometropia; With certain conditions of keratoconus. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare Vision concerning the reimbursement that UnitedHealthcare Vision would make before you purchase such contacts.
20
Use it or Lose It: The amount of money you save in taxes depends in part on your childcare and unreimbursed medical elections. Care must be taken when making those estimates. After expenses are estimated and elections are made, money will be held on account to pay these costs. Under the “Use it or Lose it” rule, any monies taken pre-tax must be used to pay for qualified, elected benefits or they will be forfeited. A Medical Expense Reimbursement Worksheet to help you estimate your expenses for this plan year has been provided This will assist you in making an “informed” decision about the amount of money you choose to set aside in one of these accounts. The Plan Year ends December 31st. You have three months from the end of the Plan Year to turn in any outstanding receipts for reimbursement of claims for dates of service during that Plan Year.
FLEXIBLE SPENDING ACCOUNT Customer Service 1-800-422-4661 Website www.tasconline.com
WHAT IS A FLEXPLAN? A FlexPlan is a Flexible Spending Account (FSA) Plan that is offered through your employer and administered by TASC. A FlexPlan is one of the most valuable benefits your employer can offer. A FlexPlan provides you with the opportunity to withhold pretax dollars from your paycheck to pay for qualified, non-reimbursable health related and dependent care expenses.
HOW THE PLAN WORKS Participating in the FlexPlan is easy. You decide how much to contribute and whether to participate in the Medical FSA, Child Care FSA, or both. A worksheet has been provided for you to help you estimate your expenses. Your election amount should conservatively match your estimated expenses for the year. Refer to the examples on the following page to see how quickly the out-of-pocket expenses can add up. You can always find out more information by calling one of TASC team members at 800-422-4661, Option 1; or visit the TASC website at www.tasconline.com
Please remember deduction amounts
requested for the current Plan Year can only
be used during the current Plan Year!
As a New Hire your Plan Year will begin the
1st day your benefits become effective & end
on December 31st of the same calendar year.
Plan Years following this will run January
1-December 31
Childcare Reimbursement Account A FlexPlan Child Care Reimbursement Account gives you the opportunity to pay for the first $5,000 of employment-related Child care expenses tax-free. The rules for eligibility are the same as those for Child Care Credit outlined in IRS Publication 503. This includes children under 13 as well as adults incapable of self-care that are claimed as dependents.
Eligible Child Care Expenses Include: Payments made for services provided in your
home as long as services are not provided by
someone you also claim as a dependent, or
your other children under age 19.
Payments made for child care services
outside your home.
If a child care center (caring for six or more
children) is used, it must be in compliance
with state and local law.
21
Remember to keep your receipts! You may be asked at any time to provide receipts for your purchases.
Flexible Spending Account
MEDICAL CARE REIMBURSEMENT ACCOUNT
Having a Medical Care Flexible Spending Account gives you the opportunity through payroll deduction to be reimbursed tax-free, up to the annual maximum for health care expenses not covered or not fully paid by medical or dental plans. These expenses may include deductibles, co-insurance payments, dental services, eyeglasses, contact lenses and solutions. A listing of these expenses is included for your review. While not intended to be complete, this list illustrates health care expenses that may be claimed as part of the plan.
QUALIFYING MEDICAL CARE EXPENSES Under the Plan, you will be reimbursed only for medical expenses. They include, for example, expenses you have incurred for:
Medicine, prescription drugs, birth control pills and vaccines.
Medical doctors, dentists, eye doctors, chiropractors, osteopaths, podiatrists, psychiatrists, psychologists, physical therapists, acupuncturists and psychoanalysts (medical care only).
Medical examination, X ray and laboratory service, insulin treatment and whirlpool baths the doctor prescribed.
Nursing help. If you pay someone to do both nursing and housework, you can be reimbursed only for the cost of the nursing help.
Hospital care (including meals and lodging), clinic cost and lab fees.
Medical treatment at a center for Substance abuse.
Medical aids such as hearing aids (and batteries), false teeth, eyeglasses, contact lenses, braces, orthopedic shoes, crutches, wheelchairs, guide dogs and the cost of maintaining them.
Ambulance service and other travel costs to get medical care. If you used your own car, you can claim what you spent for gas and oil to go to and from the place you received the care; or you can claim 24 cents a mile. Add parking and tolls to the amount you claim under either method.
Qualifying Medical expenses include only those expenses incurred for: Yourself.
Your spouse.
All dependents you list on your federal tax return.
You cannot obtain reimbursement for:
The basic cost of Medicare insurance (Medicare A).
Life insurance or income protection policies.
Accident or health insurance for you or members of your family.
The hospital insurance benefits tax withheld from your pay as part of the Social Security tax or paid as part of Social Security self employment tax.
Nursing care for a healthy baby.
Illegal operations or drugs.
Travel your doctor told you to take for a rest or change.
Cosmetic Surgery.
Long-term care expenses
Annual Maximum Contributions for
Medical FSA: $ 2,500
Annual Minimum Contributions for
Medical FSA: $ 300
Under the Patient
Protection and Affordable Care Act (PPACA) or
health care reform, the amount of contributions to
a medical FSA will be limited to $2,500 annually.
22
The School Board of Polk County offers you an Employee Assistance Program through Horizon Health.
The EAP is a free, confidential service that helps you and your family deal with personal problems that may affect your quality of life.
Experienced professionals are available to provide confidential counseling for a variety of life’s challenges. Your EAP is available 24 hours a day, 365 days a year. You can, at any time of the day, talk to a qualified counselor by calling toll-free 1-800-272-7252.
Remember, the EAP is not just for people in crisis situations, but also to help with the everyday problems that we all face in life including:
Stress management Financial issues Marital and relationship issues Legal issues Alcohol and drug abuse problems
EMPLOYEE ASSISTANCE PROGRAM Customer Service 800-272-7252
Website http://www.horizoncarelink.com/login.aspx
Learn more about Horizon EAP on their
website at: www.horizoncarelink.com
Immediate access to EAP benefits.
Free, confidential diagnostic
interview, plus up to 6 counseling
sessions for each eligible
household member.
800-272-7252
Username: PCS Password: PCS
TAX SHELTERED ANNUITIES AND BENCOR Website http://www.polkfl.net/staff/employeeinfo/riskmanagement/default.htm
Tax Sheltered Annuities The District currently supports a 403(b) retirement savings plan. Commonly referred to as Tax Sheltered Annuities or TSAs, these plans are available only to employees of school systems and certain other non-profit organizations. This District also offers 457(b) deferred compensation plans in addition to the 403(b) plans Employees may elect to contribute a limited portion of their salary, pre-tax, to one of the authorized plans. For information on the contribution limits, please talk to an authorized agent from the School Board of Polk County’s list of Authorized Annuity Companies found on the Risk Management page of the School Board of Polk County website at: http://www.polk-fl.net/staff/employeeinfo/riskmanagement/default.htm Authorized Providers of 403(b)/403(b)(7) Accounts and 457(b) Deferred Compensation Plans
Vendors for 403(b)/403(b)(7) Accounts Company Phone Number
Allen & Company 863-688-9000 American Century Services, LLC 800-345-3533 Ameriprise Financial 863-682-6134 AXA Equitable Life 800-628-6673 CPS Investment Advisors 877-564-6277 Great American Life 800-854-3649 Horace Mann 800-999-1030 ING Retirement Plans 877-884-5050 Life Insurance of the SouthWest 800-579-2878 Plan Member Services 800-874-6910 VALIC 800-369-0314 Waddell & Reed 727-573-7711
Vendors for 457(b) Deferred Compensation Plans Company Phone Number
AXA Equitable 800-628-6673 Great American Life 800-854-3649 Horace Mann 800-999-1030 ING Retirement Plans 877-884-5050 Life Insurance of the SouthWest 800-579-2878 Plan Member Services 800-874-6910 VALIC 800-369-0314
BENCOR 1-888-258-3422 www.bencor.com BENCOR Special Pay Plan is an IRC Section 401(a) qualified retirement plan. This plan permits employees of Polk County Schools to defer Federal withholding taxes and permanently avoid Social Security and Medicare Taxes on eligible accumulated sick and annual leave at the time of their retirement.
23
PCSB WELLNESS PROGRAM 3425 New Jersey Road, Lakeland, FL 33803 • Phone 863-648-3057
• Fax 863-648-3060 Website http://www.polk-Fl.net/staff/employeeinfo/wellness/default.htm
Babies and You/Healthy Addition®—
Receive $200 by completing both programs.
Babies & You and Healthy Addition® Prenatal Programs are offered at no cost to all employees enrolled with PCSB health insurance. Babies and You is a March of Dimes preconception program designed to promote healthy pregnancies and prevent birth defects with education and free prenatal vitamins. Topics include pregnancy preparation, genetics, stress, exercise, eating, and how to care for your newborn baby. NOTE: To be eligible for the $100 reimbursement, the program MUST be completed NO LATER than the end of your first trimester.
To register for Babies and You classes visit www.surveymonkey.com/s/babiesandyou
Call 648-3057 for any questions
Healthy Addition® provides:
FREE prenatal vitamins, prenatal information and $100 after your baby
arrives! To be eligible for the $100 you must join prior to 21 weeks of
gestation.
Pregnancy risk screening and monitoring
Emotional support and reinforcement of physician's plan of care
FREE Healthy Addition® nurse hotline 8:00 am - 5:00 pm, 800-955-7635
(option 6)
FREE 24/7 Health Dialog nurse hotline, 877-789-2583
Tobacco Cessation A FREE 5-week program to help you be Tobacco-Free! Includes Nicotine Replacement Therapy (patches) See the Tobacco Cessation webpage for dates and locations of classes.
How It Works: Participants can choose to join the ABCs of Diabetes program by contacting Allison Sullins at the Wellness Program 863-648-3057. In order to remain in good standing in the ABCs of Diabetes program and continue to receive program benefits, participants must fulfill all requirements as described in the Program Details within the specified time frame. Participants will be enrolled in the Diabetes Prescription Benefit after completing the following:
Diabetic Screening Saturday or required tests performed by his/her personal
physician;
One-on-one goal-setting session
Four (4) educational classes
Sign the “Notice of Understanding” outlining the terms and conditions of the
ABCs of Diabetes program requirements. Failure to sign the “Notice of
Understanding” will result in removal from the ABCs of Diabetes program.
Polk County School Board reserves the right to modify the ABCs of Diabetes program at any time. ABCs of Diabetes Medication Benefit List Visit www.polk-fl.net (keyword: Wellness) ABCs of Diabetes webpage for complete details
24
KNOW YOUR RIGHTS
HIPAA Notice of Privacy Practices
The School Board of Polk County is concerned about your privacy, and maintains a strict privacy policy. Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the School Board of Polk County has implemented procedures to ensure full compliance with all federal privacy protection laws and regulations. What is HIPAA? A comprehensive federal legislation regarding health insurance which is comprised of four key areas:
1. Portability protects health insurance coverage for workers and their families when they change or lose their jobs. It also prevents discrimination against an employee and their families due to preexisting medical conditions.
2. Privacy provides the first comprehensive federal protection for the privacy of an individual’s health information (PHI*). This gives individuals more control over their health information, and it sets boundaries on the use and disclosure of their health information.
3. Security establishes safeguards that must be achieved to protect the privacy of protected health information and holds violators accountable with civil and
criminal penalties that can be imposed if they violate an individual’s privacy rights.
4. Standardize electronic health care transactions
*PHI -Protected Health Information – Information that relates to the past, present, or future physical or mental health of the individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care. This includes information that can be used to identify the individual. You have the following rights regarding your health information under HIPAA:
1. The right to request restrictions.
2. The right to receive confidential communications.
3. The right to inspect and copy.
4. The right to amend your health information.
5. The right to receive an accounting of disclosures.
6. The right to obtain a paper copy of the Notice of Privacy Practices at any time
A copy of the Privacy Policy can be found on the Risk Management & Employee Benefits page of the School Board of Polk County website at: http://www.polk-fl.net/staff/employeeinfo/riskmanagement/default.htm A copy of this policy can also be obtained by contacting your Risk Management & Employee Benefits Department.
Si usted necesita tener una copia de esta información en español, por favor contacte al Risk Management
Department al 863-519-3858 o por correo electrónico a: [email protected].
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COBRA Rights Notice Insurance coverage terminates on the last day of the month in which the employee separates from service with the School Board of Polk County. An information packet, including written notice explaining the terminated employee’s rights under COBRA will be sent by the School Board of Polk County COBRA administrator, Ceridian. This information will be sent to the address on file in SAP, so it is very important to update your contact information anytime you have an address change. The Consolidated Omnibus Budget Reconciliation Act of 1993 (COBRA) allows you to continue the coverage you had as an active employee if you elect to continue the coverage by paying the full amount of the premium plus an administrative charge of 2 percent. Each qualified beneficiary must be offered the option to continue coverage following a qualifying event. Qualifying beneficiaries include any eligible dependent that is covered on the insurance coverage at the time of the employee’s separation of service that is eligible and that continues to be eligible for coverage. Any qualifying beneficiary that experiences a qualifying event separate from the employee separating from service, i.e. a spouse in the
case of a divorce, must also be offered the option to continue coverage.
REASON FOR LOSS OF COVERAGE
EMPLOYEE
SPOUSE
CHILD(REN)
Employee separation from service
18 MONTHS 18 MONTHS 18 MONTHS
Employee reduction of hours (no longer eligible for coverage through employer)
18 MONTHS 18 MONTHS 18 MONTHS
Employee, spouse or dependent become legally disabled
29 MONTHS 29 MONTHS 29 MONTHS
Death of Employee
36 MONTHS 36 MONTHS
Divorce or Legal Separation
36 MONTHS 36 MONTHS
Entitled to Medicare
36 MONTHS 36 MONTHS
Child no longer qualifies
36 MONTHS
Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free Or Low-Cost Health Coverage To Children And Families
If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance.
You may be eligible for assistance paying your employer health plan premiums. Contact the Florida Medicaid / SCHIP office at www.fdhc.state.fl.us/Medicaid/index.shtml or by phone: 1-866-762-2237 To see if any more States have added a premium assistance program since January 22, 2010, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565
26
MEDICARE PRESCRIPTION DRUG COVERAGE (PART D) CREDITABLE COVERAGE NOTICE
Important Notice from School Board of Polk County about Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with School Board of Polk County and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to
everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. School Board of Polk County has determined that the prescription drug coverage offered by School Board of Polk County’s medical plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15th through December 31st. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
Your current School Board of Polk County coverage pays for other health expenses, in addition to prescription drugs, and If you decide to join a Medicare drug plan, please keep in mind that you cannot also be enrolled in the School Board of Polk County Medical Plan.
The School Board of Polk County plan provides comprehensive prescription drug coverage through retail and mail providers. There is a $25 per year per individual deductible for Brand Name drugs in addition to the follow copayments:
Generic Preferred Brand Non‐Preferred Brand Retail 30 Days $ 8.00 $30.00+10%* $50.00 +10%* (max $60.00) (max $100.00) Retail 90 Days $8.00 $90.00 +10%* $150.00 +10%* (max $180.00) (max $300) Mail 90 Days $8.00 $75.00 $125.00
*10% of the cost of the prescription minus the deductible.
IMPORTANT NOTE: If you purchase a brand-name medication when a generic medication is available or when your doctor requests a brand-name medication when a generic medication is available, you will pay the generic co-payment, plus the difference in cost between the brand and the generic.
27
When Will You Pay a Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your coverage with School Board of Polk County and don’t enroll in a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the Risk Management & Employee Benefits Department for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through School Board of Polk County changes. You also may request a copy of this notice at any time.
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at: www.socialsecurity.gov, or call them at
800‐772‐1213 (TTY 800‐325‐0778).
Remember: Keep this Creditable Coverage Notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: August 1, 2012 Name of Entity/Sender: School Board of Polk County Contact: Kathy Faulkner, Retiree Clerk Address: 1915 Floral Avenue, Bartow, FL 33830 Phone Number: 863‐519‐3858
For More Information About Your Options Under Medicare Prescription DrugCoverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help
Call 800‐MEDICARE (800‐633‐4227). TTY users should call
877‐486‐2048
If you join a non-School Board of Polk County Medicare drug plan and drop your current School Board of Polk County health plan, be advised that you and your dependents will no longer be eligible for the School Board of Polk County Retiree Health Plan.
28
Women’s Health and Cancer Rights Act of 1998 (WHCRA) Annual Notice
Do you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998,
provides benefits for mastectomy‐related services including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses,
and complications resulting from a mastectomy, including lymphedemas? Call your Plan
Administrator, Blue Cross Blue Shield of Florida, at 800‐810‐2583 for more information.
Social Security Number Collection Policy This statement serves as notification of the purpose and usage of social security numbers in compliance with Chapter 119 of the Florida Statutes. The School Board of Polk County Risk Management & Employee Benefits Department acknowledges that a social security number is a unique identifier and can be used to obtain sensitive information; however, social security numbers must be collected under certain circumstances for the department to properly and accurately perform its duties as part of an educational institution.
The Risk Management & Employee Benefits Department of the School Board of Polk County, Florida collects beneficiary social security numbers for specific purposes, including life insurance claims processing. A copy of this notice should be given to all parties you have listed as beneficiaries for your life insurance through the Employee Group-Term Life Insurance policy with the School Board of Polk County, Florida. The full written policy is available on the Risk Management & Employee Benefits page of the School Board of Polk County Website at: http://www.polk-
fl.net/staff/employeeinfo/riskmanagement/default.htm
Newborn and Mothers Health Protection Act The Newborn and Mothers Health Protection Act has set rules for group health plans and insurance issuers regarding restrictions to coverage for hospital stays in connection with childbirth.
The length of stay may not be limited to less than: 48 hours following a vaginal delivery
OR 96 hours following a cesarean section
Determination of when the hospital stay begins is based on the following: For an in the hospital delivery:
o The stay begins at the time of the delivery. For multiple births, the stay begins at the time of the last delivery.
For a delivery outside the hospital (i.e. birthing center): o The stay begins at the time of admission to the hospital.
Requiring authorization for the stay is prohibited. If the attending provider and mother are both in agreement, then an early discharge is permitted. Group Health Plans may not: Deny eligibility or continued eligibility to enroll or renew coverage to avoid these requirements.
Try to encourage the mother to take less by providing payments or rebates.
Penalize a provider or provide incentives to a provider in an attempt to induce them to furnish care that is not consistent with these rules.
These rules do not mandate hospital stay benefits on a plan that does not provide that coverage. The group plan is not prohibited from imposing deductibles, coinsurance, or other cost-sharing related to the benefits.
29
While you are out on a Leave of Absence, it is your responsibility to contact the Risk
Management & Employee Benefits Department at 863-519-3858 regarding the
continuation of your insurance benefits provided by the Board, and any other
voluntary insurance benefits in which you are enrolled. If the necessary arrangements
are not made to continue your benefits, interruption or cancellation of the benefits
may result.
FAMILY AND MEDICAL LEAVE ACT & LEAVE OF ABSENCE
FAMILY & MEDICAL LEAVE ACT According to the Family and Medical Leave Act of 1993 eligible employees must be granted up to 12 work weeks of unpaid leave by their employer for any of the following reasons occurring during a 12 month period:
Birth of employee’s child Adoption or placement of a foster child Caring for ill or injured immediate family member (spouse, child, parent) Serious illness or Injury of employee (employee unable to work)
Effective January 16, 2009 the FMLA regulations have been updated to include implementation of new military family leave entitlements enacted under the National Defense Authorization Act for FY 2008. This change permits any of the following family members to take up to 26 work weeks of leave to care for a member of any of the Armed Forces; Active, Reserve or National Guard, undergoing medical treatment or recuperation (including therapy), for serious injury or illness:
Spouse Parent
Child Next of kin
LEAVE OF ABSENCE Unless otherwise specified by law, leave is granted at the discretion of the School Board. Policies regarding leave are designed to protect school operation from unnecessary interruption due to absences. When employees apply for leave, they must complete the appropriate form and include the reason for requesting the leave in writing. The School Board may cancel the leave if it is used for a different purpose or cause. Leave is generally granted in advance, not retroactively. However, emergencies that cannot be anticipated are considered “granted” in advance if they are promptly reported. Except for military leave, leave cannot be granted beyond July 1 of the next fiscal year. However, a new application may be filed at the expiration of leave, with new leave granted at the discretion of the School Board. The person on leave is responsible for requesting a renewal; it is not automatic. If a renewal is not requested, employment will be terminated.
Types of Leave • Professional • Charter School • Military • Jury Duty • Family Medical Leave • Medical Leave • Illness-in-the-Line-of-Duty
• Temporary Duty Assignment
UNPAID LEAVE AND EMPLOYEE BENEFITS If you go on official unpaid leave, you are entitled to any and all of your benefits. However, for as long as you are on leave, to the extent permitted by law, the Board does not contribute to your health or life insurance coverage. You will be responsible for payroll deductions that you would have paid if you were still on active status, plus the amount the Board would have contributed. If you fail to pay your premium, the Insurance Department may cancel the coverage. Employees on leave are entitled to the same annual enrollment that active employees have.
30
ST
AN
DA
RD
INSU
RA
NC
E C
OM
PA
NY
A S
tock L
ife In
su
ran
ce C
om
pan
y
900 S
W F
ifth A
ven
ue
Portla
nd, O
regon
97204-1
282
(503) 3
21-7
000
CE
RT
IFIC
AT
E
GR
OU
P L
IFE
INSU
RA
NC
E
Polic
yh
old
er: Th
e Sch
ool B
oard
of P
olk
Cou
nty
, Flo
rida
Polic
y N
um
ber:
625950-D
Effectiv
e Date:
Octo
be r 1
, 2004
A G
rou
p P
olic
y h
as b
een
issu
ed to
the P
olicy
hold
er. We certify
that y
ou
will b
e insu
red a
s pro
vided
by
the term
s o
f the G
rou
p P
olic
y. If y
ou
r covera
ge is ch
an
ged b
y a
n a
men
dm
ent to
the G
rou
p P
olic
y, w
e
will p
rovid
e the P
olic
yh
old
er with
a re
vised C
ertificate o
r oth
er notic
e to b
e giv
en
to y
ou
.
This
polic
y in
clu
des a
n A
ccele
rate
d B
en
efit. D
eath
benefits
will b
e re
duced if a
n A
ccele
rate
d
Benefit is
paid
. Th
e re
ceip
t of th
is b
en
efit m
ay b
e ta
xable
an
d m
ay a
ffect y
our e
ligib
ility fo
r M
edic
aid
or o
ther g
overn
ment b
enefits
or e
ntitle
ments
. How
ever, if y
ou m
eet th
e d
efin
ition o
f "te
rmin
ally
ill
indiv
idual"
accord
ing
to
the
Inte
rnal
Revenue
Code
Sectio
n
101,
your
Accele
rate
d B
en
efit
may be non-ta
xable
. Y
ou should
con
sult
your
pers
on
al
tax an
d/or
legal
advis
or b
efo
re y
ou a
pply
for a
n A
ccele
rate
d B
enefit.
Poss
essio
n o
f this C
ertificate d
oes n
ot n
ece
ssa
rily m
ean
you
are in
su
red. Y
ou
are in
sured
on
ly if y
ou
m
eet th
e requ
iremen
ts set o
ut in
this C
ertificate. If th
e terms o
f the C
ertificate d
iffer from
the G
rou
p
Polic
y, th
e terms sta
ted in
the G
rou
p P
olic
y w
ill govern
.
"We", "u
s" an
d "o
ur" m
ean
Sta
ndard
Insu
ran
ce C
om
pan
y. "Y
ou
" an
d "y
ou
r" mean
the M
ember. A
ll oth
er defin
ed term
s appea
r w
ith th
e in
itial
letter capita
lized.
S
ectio
n h
eadin
gs,
an
d refere
nces
to
them
, appear in
bold
face ty
pe.
Th
is c
ertific
ate
pro
vid
es life
insu
ran
ce fo
r em
plo
yees a
nd
dep
en
den
ts, if a
pplic
able
, of T
he S
ch
ool B
oa
rd
of P
olk
Cou
nty
, Flo
rida
, 19
15
Sou
th F
lora
l Ave, B
arto
w F
L, 3
38
31
, un
der 6
25950-D
. Th
e e
mplo
yee s
ha
ll be giv
en
a
cop
y o
f the g
rou
p e
nro
llmen
t a
pplic
atio
n. T
he b
en
efits
are
pa
ya
ble
to th
e b
en
efic
iarie
s o
f re
cord
desig
na
ted
by th
e e
mplo
yee.
G
C190-L
IFE
/S399
31
Glossary of H
ealth Coverage and M
edical Term
s Page 1 of 4
Glossary of H
ealth Coverage and M
edical Terms
• T
his glossary has many com
monly used term
s, but isn’t a full list. These glossary term
s and definitions are intended to be educational and m
ay be different from the term
s and definitions in your plan. Some of these term
s also m
ight not have exactly the same m
eaning when used in your policy or plan, and in any such case, the policy or plan
governs. (See your Summ
ary of Benefits and Coverage for inform
ation on how to get a copy of your policy or plan
document.)
• Bold blue text indicates a term
defined in this Glossary.
• See page 4 for an exam
ple showing how
deductibles, co-insurance and out-of-pocket limits w
ork together in a real life situation.
Allow
ed Am
ount M
aximum
amount on w
hich payment is based for
covered health care services. This m
ay be called “eligible expense,” “paym
ent allowance" or "negotiated rate." If
your provider charges more than the allow
ed amount, you
may have to pay the difference. (See Balance Billing.)
Appeal
A request for your health insurer or plan to review
a decision or a grievance again.
Balance Billing W
hen a provider bills you for the difference between the
provider’s charge and the allowed am
ount. For example,
if the provider’s charge is $100 and the allowed am
ount is $70, the provider m
ay bill you for the remaining $30.
A preferred provider m
ay not balance bill you for covered services.
Co-insurance
Your share of the costs
of a covered health care service, calculated as a percent (for exam
ple, 20%
) of the allowed
amount for the service.
You pay co-insurance
plus any deductibles you ow
e. For example,
if the health insurance or plan’s allowed am
ount for an office visit is $100 and you’ve m
et your deductible, your co-insurance paym
ent of 20% w
ould be $20. The health
insurance or plan pays the rest of the allowed am
ount.
Com
plications of Pregnancy C
onditions due to pregnancy, labor and delivery that require m
edical care to prevent serious harm to the health
of the mother or the fetus. M
orning sickness and a non-em
ergency caesarean section aren’t complications of
pregnancy.
Co-paym
ent A
fixed amount (for exam
ple, $15) you pay for a covered health care service, usually w
hen you receive the service. T
he amount can vary by the type of covered health care
service.
Deductible
The am
ount you owe for
health care services your health insurance or plan covers before your health insurance or plan begins to pay. For exam
ple, if your deductible is $1000, your plan w
on’t pay anything until you’ve m
et your $1000 deductible for covered health care services subject to the deductible. T
he deductible may not apply
to all services.
Durable M
edical Equipment (D
ME)
Equipment and supplies ordered by a health care provider
for everyday or extended use. Coverage for D
ME m
ay include: oxygen equipm
ent, wheelchairs, crutches or
blood testing strips for diabetics.
Emergency M
edical Condition
An illness, injury, sym
ptom or condition so serious that a
reasonable person would seek care right aw
ay to avoid severe harm
.
Emergency M
edical Transportation
Am
bulance services for an emergency m
edical condition.
Emergency R
oom C
are Em
ergency services you get in an emergency room
.
Emergency Services
Evaluation of an emergency m
edical condition and treatm
ent to keep the condition from getting w
orse.
(See page 4 for a detailed example.)
Jane pays 20%
H
er plan pays 80%
(See page 4 for a detailed example.)
Jane pays 100%
H
er plan pays 0%
OM
B C
ontrol Num
bers 1545-2229, 1210-0147, and 0938-1146
32
Glossary of H
ealth Coverage and M
edical Term
s Page 2 of 4
Excluded Services H
ealth care services that your health insurance or plan doesn’t pay for or cover.
Grievance
A com
plaint that you comm
unicate to your health insurer or plan.
Habilitation Services
Health care services that help a person keep, learn or
improve skills and functioning for daily living. Exam
ples include therapy for a child w
ho isn’t walking or talking at
the expected age. These services m
ay include physical and occupational therapy, speech-language pathology and other services for people w
ith disabilities in a variety of inpatient and/or outpatient settings.
Health Insurance
A contract that requires your health insurer to pay som
e or all of your health care costs in exchange for a prem
ium.
Hom
e Health C
are H
ealth care services a person receives at home.
Hospice Services
Services to provide comfort and support for persons in
the last stages of a terminal illness and their fam
ilies.
Hospitalization
Care in a hospital that requires adm
ission as an inpatient and usually requires an overnight stay. A
n overnight stay for observation could be outpatient care.
Hospital O
utpatient Care
Care in a hospital that usually doesn’t require an
overnight stay.
In-network C
o-insurance T
he percent (for example, 20%
) you pay of the allowed
amount for covered health care services to providers w
ho contract w
ith your health insurance or plan. In-network
co-insurance usually costs you less than out-of-network
co-insurance.
In-network C
o-payment
A fixed am
ount (for example, $15) you pay for covered
health care services to providers who contract w
ith your health insurance or plan. In-netw
ork co-payments usually
are less than out-of-network co-paym
ents.
Medically N
ecessary H
ealth care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its sym
ptoms and that m
eet accepted standards of m
edicine.
Netw
ork T
he facilities, providers and suppliers your health insurer or plan has contracted w
ith to provide health care services.
Non-Preferred Provider
A provider w
ho doesn’t have a contract with your health
insurer or plan to provide services to you. You’ll pay
more to see a non-preferred provider. C
heck your policy to see if you can go to all providers w
ho have contracted w
ith your health insurance or plan, or if your health insurance or plan has a “tiered” netw
ork and you must
pay extra to see some providers.
Out-of-netw
ork Co-insurance
The percent (for exam
ple, 40%) you pay of the allow
ed am
ount for covered health care services to providers who
do not contract with your health insurance or plan. O
ut-of-netw
ork co-insurance usually costs you more than in-
network co-insurance.
Out-of-netw
ork Co-paym
ent A
fixed amount (for exam
ple, $30) you pay for covered health care services from
providers who do not contract
with your health insurance or plan. O
ut-of-network co-
payments usually are m
ore than in-network co-paym
ents.
Out-of-Pocket Lim
it T
he most you pay during a
policy period (usually a year) before your health insurance or plan begins to pay 100%
of the allowed
amount. T
his limit never
includes your premium
, balance-billed charges or health care your health insurance or plan doesn’t cover. Som
e health insurance or plans don’t count all of your co-paym
ents, deductibles, co-insurance paym
ents, out-of-network paym
ents or other expenses tow
ard this limit.
Physician Services H
ealth care services a licensed medical physician (M
.D. –
Medical D
octor or D.O
. – Doctor of O
steopathic M
edicine) provides or coordinates.
(See page 4 for a detailed example.)
Jane pays 0%
H
er plan pays 100%
33
Glossary of H
ealth Coverage and M
edical Term
s Page 3 of 4
Plan A
benefit your employer, union or other group sponsor
provides to you to pay for your health care services.
Preauthorization A
decision by your health insurer or plan that a health care service, treatm
ent plan, prescription drug or durable m
edical equipment is m
edically necessary. Sometim
es called prior authorization, prior approval or precertification. Y
our health insurance or plan may
require preauthorization for certain services before you receive them
, except in an emergency. Preauthorization
isn’t a promise your health insurance or plan w
ill cover the cost.
Preferred Provider A
provider who has a contract w
ith your health insurer or plan to provide services to you at a discount. C
heck your policy to see if you can see all preferred providers or if your health insurance or plan has a “tiered” netw
ork and you m
ust pay extra to see some providers. Y
our health insurance or plan m
ay have preferred providers who are
also “participating” providers. Participating providers also contract w
ith your health insurer or plan, but the discount m
ay not be as great, and you may have to pay
more.
Premium
T
he amount that m
ust be paid for your health insurance or plan. Y
ou and/or your employer usually pay it
monthly, quarterly or yearly.
Prescription Drug C
overage H
ealth insurance or plan that helps pay for prescription drugs and m
edications.
Prescription Drugs
Drugs and m
edications that by law require a prescription.
Primary C
are Physician A
physician (M.D
. – Medical D
octor or D.O
. – Doctor
of Osteopathic M
edicine) who directly provides or
coordinates a range of health care services for a patient.
Primary C
are Provider A
physician (M.D
. – Medical D
octor or D.O
. – Doctor
of Osteopathic M
edicine), nurse practitioner, clinical nurse specialist or physician assistant, as allow
ed under state law
, who provides, coordinates or helps a patient
access a range of health care services.
Provider A
physician (M.D
. – Medical D
octor or D.O
. – Doctor
of Osteopathic M
edicine), health care professional or health care facility licensed, certified or accredited as required by state law
.
Reconstructive Surgery
Surgery and follow-up treatm
ent needed to correct or im
prove a part of the body because of birth defects, accidents, injuries or m
edical conditions.
Rehabilitation Services
Health care services that help a person keep, get back or
improve skills and functioning for daily living that have
been lost or impaired because a person w
as sick, hurt or disabled. T
hese services may include physical and
occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.
Skilled Nursing C
are Services from
licensed nurses in your own hom
e or in a nursing hom
e. Skilled care services are from technicians
and therapists in your own hom
e or in a nursing home.
Specialist A
physician specialist focuses on a specific area of m
edicine or a group of patients to diagnose, manage,
prevent or treat certain types of symptom
s and conditions. A
non-physician specialist is a provider who
has more training in a specific area of health care.
UC
R (U
sual, Custom
ary and Reasonable)
The am
ount paid for a medical service in a geographic
area based on what providers in the area usually charge
for the same or sim
ilar medical service. T
he UC
R
amount som
etimes is used to determ
ine the allowed
amount.
Urgent C
are C
are for an illness, injury or condition serious enough that a reasonable person w
ould seek care right away, but
not so severe as to require emergency room
care.
34
Glossary of Health Coverage and Medical Terms Page 4 of 4
How You and Your Insurer Share Costs - Example Jane’s Plan Deductible: $1,500 Co-insurance: 20% Out-of-Pocket Limit: $5,000
Jane reaches her $1,500 deductible, co-insurance begins Jane has seen a doctor several times and paid $1,500 in total. Her plan pays some of the costs for her next visit.
Office visit costs: $75 Jane pays: 20% of $75 = $15 Her plan pays: 80% of $75 = $60
Jane pays 20%
Her plan pays 80%
Jane pays 100%
Her plan pays 0%
Jane hasn’t reached her $1,500 deductible yet Her plan doesn’t pay any of the costs.
Office visit costs: $125 Jane pays: $125 Her plan pays: $0
January 1st Beginning of Coverage Period
December 31st End of Coverage Period
more costs
more costs
Jane reaches her $5,000 out-of-pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year.
Office visit costs: $200 Jane pays: $0 Her plan pays: $200
Jane pays 0%
Her plan pays 100%
35
Area C
od
e: 863
Nam
e:
Title/Re
spo
nsib
ilities: P
ho
ne
:
Joy M
yers D
irector - R
isk Man
agemen
t 5
19
-38
58
ext. 22
30
Jean Fo
wler
Secretary III
Resp
on
sibilities: V
ehicle A
cciden
ts, Stud
ent In
juries an
d G
en
eral
Liability, W
orkers' C
om
pen
sation
51
9-3
85
8 ext. 2
23
1
Belin
da
Han
cock
Cle
rk Specialist
Resp
on
sibilities: W
orkers' C
om
pen
sation
(emp
loyee
inju
ries),
Veh
icle Accid
ents, Stu
den
t Inju
ries, Ge
neral Liab
ility
51
9-3
85
8 ext. 2
22
6
Jenn
ifer
Ho
op
er
Be
nefits &
Qu
ality Co
ntro
l Spe
cialist
Resp
on
sibilities: C
om
mu
nicatio
ns, Liab
ility Insu
rance, R
isk
Man
agemen
t & A
dm
inistratio
n Su
pp
ort
51
9-3
85
8 ext. 2
22
4
Bill G
ainer
An
alyst - Ben
efits and
Risk M
anage
me
nt
51
9-3
85
8 ext. 2
22
8
Tiffany
Co
mb
ee
Sup
ervisor - Em
plo
yee B
en
efits
Resp
on
sibilities: R
etiree H
ealth B
en
efits, Gro
up
Health
Be
nefits,
Ad
min
istration
Office Su
pp
ort
51
9-3
85
8 ext.22
27
Co
nn
ie Epp
s
Senio
r Tech
- Risk M
anagem
ent R
esp
on
sibilities: Leave o
f
Ab
sence &
FMLA
related
to In
suran
ce, Disab
ility, CO
BR
A, G
rou
p
Health
Ben
efits, Retiree
Health
Be
nefits, C
han
ge of Statu
s,
Ad
min
istration
Office Su
pp
ort
51
9-3
85
8 ext. 2
22
3
Nico
lle
Ro
drigu
ez
Cle
rk Specialist
Resp
on
sibilities: N
ew Em
plo
yee B
enefits, G
rou
p H
ealth B
en
efits,
CO
BR
A, C
ertificates o
f Cred
itable C
overage, Tax Sh
eltered
An
nu
ities, Ad
min
istration
Office Su
pp
ort
51
9-3
85
8 ext. 2
22
1
Kath
y Fau
lkner
Cle
rk Specialist
Resp
on
sibilities: R
etiree H
ealth B
en
efits, Gro
up
Health
Be
nefits,
Life Insu
rance C
laims, A
dm
inistratio
n O
ffice Sup
po
rt
51
9-3
85
8 ext. 2
22
5
Co
nn
ie Ash
ley B
lueC
ross B
lueSh
ield O
n-Site
Rep
resentative
51
9-8
79
9
Fax R
isk Man
ageme
nt
53
4-5
08
5
RISK
MA
NA
GEM
ENT A
ND
EMP
LOY
EE BEN
EFITS
DEP
AR
TMEN
T CO
NTA
CT LIST
36
PO
LK C
OU
NT
Y S
CH
OO
L BO
AR
D E
MP
LOY
EE
HE
ALT
H C
LINIC
A
ND
FLO
RID
A B
LUE
CE
NT
ER
S
upporting the personal health and wellness of our em
ployees, retirees and their families is an im
portant focus of the Polk
County S
chool Board. W
e are excited to let you know about three new
healthcare resources now available to you.
We are hopeful that this w
ill help remove m
any of the barriers to healthcare that a number of our m
embers have
experienced such as, the ability to get an appointment and the affo
rdability of the visit. E
mployees, retirees and covered dependents age 2 and up covered by the P
CS
B health plan can now
get primary
healthcare services from a physician
-led team at tw
o convenient locations: Th
e Po
lk Co
un
ty Sch
oo
l Bo
ard E
mp
loyee
Health
Clin
ic in Haines C
ity and the Better N
ow
Health
Cen
ter in Winter H
aven. T
he primary goal of the clinics is to provide high quality fam
ily practice health to mem
bers of the PC
SB
health plan. If you choose to use the services at either clinic there w
ill be no co-pay for your visit. In addition certain labs can be perform
ed at either location. A
dditionally, the clinics are able to dispense certain generic medications as prescribed by one of the clinic providers. Y
ou m
ay (depending on the prescription) be able to get your m
edication at no cost from the clinics. T
he clinics can only dispense prescriptions w
ritten by one of the clinic providers. Y
ou can also stop by the Flo
rida B
lue C
enter in W
inter Haven w
here you’ll be able to get in-person support for your health
and wellness goals, plus answ
ers to questions about claims or benefits.
If you are already established with a physician, you are not required to use the P
CS
B E
mployee H
ealth Clinic. Y
ou will
continue to receive the benefits of your health plan.
Sick w
aiting room
X-R
ay room available at the F
lorida Blue C
linic
Clinical C
are C
onsultant available for m
eetings and assistance at both clinics
641 US H
ighway
17-92 West,
#631B
Haines C
ity, FL 33844 Appointm
ents: 863-419-3322
395 Cypress G
ardens Blvd.
Winter H
aven, FL 33880 Appointm
ents: 863-837-5739
TO: and eligible dependents
FROM: Employee Benefits Route: E
