your health benefits guide · benefits guide your health your decision 2016 - 2017 plan year ....

Benefits Guide

Your Health

Your Decision

2016 - 2017

Plan Year

2 Overview

Table of Contents Page

Overview 2 - 3

Core Group Benefits 4

Medical 5 - 6

Dental 7

Basic Term Life Insurance & Supplemental Term Life 8

LTD 9

STD 10

Vision 11

Trustmark Voluntary Benefits 12 - 13

LifeLock Iden-ty The/ Protec-on 14

Important Contacts 15

Who is eligible?

Employees working at least 30 hours each work week and their eligible dependents.

When can I Enroll? New hire ini-al enrollment and annual open enrollment allows for employees of the Diocese to enroll or

make changes in any of the plans without a qualifying event.

In order to make changes outside of your ini-al or annual enrollment period, there would need to be a

qualifying event such as the birth of a child, change in marital status, death, or loss of coverage due to no

fault of your own. You must make your requested changes on the Benefits website and you must send the

required documenta-on to the Diocese Benefits Office within thirty-one (31) days of the qualifying event in

order for coverage to be effec-ve. No changes will be authorized un-l the suppor-ng documenta-on has

been provided to the Benefits Office. Ques-ons may be directed to the Benefits Office.

WELCOME TO ENROLLMENT

FOR YOUR 2016 - 2017 BENEFITS!

The Diocese of Palm Beach offers you and your eligible family members a comprehensive and valuable

benefits program. We encourage you to take the -me to educate yourself about your op-ons and choose

the best coverage for you and your family.

Annual Enrollment

Online Benefit Enrollment System open:

May 2nd - May 13th

DO I NEED TO ENROLL IN BENEFITS?

If you need to make changes to your benefits or if you would

like to review your current elec-ons you can log in to our

online benefits enrollment system from any computer,

tablet or smartphone:

Explainmybenefits.biz/diocese

If you have ques-ons regarding the enrollment system or benefits call the

Explain My Benefits Enrollment Center:

321– 296-8060; Op-on 1

Monday - Friday, 9:00am - 5:00pm

3 Overview

Who is Eligible? Employees working at least 30 hours each work week and their eligible dependents. Some benefits are restricted offer-

ings. Eligibility will be indicated for each benefit.

Dependents An individual who meets the eligibility criteria specified below is an Eligible Dependent and is eligible for coverage

under this Booklet:

1. The Covered Employee’s Spouse*.

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) who has not reached the end of the Cal-

endar Year in which he or she reaches age 26 (or in the case of a Foster Child, is no longer eligible under the Foster

Child Program), regardless of the dependent child’s student or marital status, financial dependency on the Covered

Employee, whether the dependent child resides with the Covered Employee, or whether the dependent child is

eligible for or enrolled in any other health plan.

3. The newborn child of a Covered Dependent child who has not reached the end of the Calendar Year in which he or

she becomes 26. Coverage for such newborn child will automa-cally terminate 18 months a/er the birth of the

newborn child.

Note: If a Covered Dependent child who has reached the end of the Calendar year in which he or she becomes 26 obtains a

dependent of their own (e.g., through birth or adop�on) such newborn child will not be eligible for this coverage and the Covered

Dependent child will also lose his or her eligibility for this coverage. It is the Covered Employee’s sole responsibility to establish that

a child meets the applicable requirements for eligibility.

*SPOUSE shall mean for all purposes of the Trust and each Plan of the Trust, the individual to whom the Member Par-

-cipant is civilly married under a marriage covenant between a man and a woman as described in Canon 1055 of the

Code of Canon Law (Codex Iuris Canonici) for the La-n Rite of the Catholic Church.

Medical and Vision - Dependent children up to age 26 regardless of financial dependency, residency, student status,

employment or marital status. Coverage ends the last day of the year the child turns 26.**

**A Covered Dependent child may con-nue coverage beyond the age of 26 (Medical & Vision ONLY), provided he or

she is:

1. unmarried and does not have a dependent;

2. a Florida resident or a full--me or part--me student;

3. not enrolled in any other health coverage policy or plan; and

4. not en-tled to benefits under Title XVIII of the Social Security Act unless the child is a

Handicapped dependent child.

This eligibility shall terminate on the last day of the Calendar Year in which the dependent child reaches age 30.

Dental & Supplemental Term Life- Dependent children up to age 19 or 25, if a full-5me student. Coverage ends the

last day of the year the child turns 19 or 25.

4 Overview of Core Group Benefits

Plans BCBS Standard BCBS Premium

In Network Out-of-Network In Network Out-of-Network

Deduc5ble

Individual $400 $600 $300 Combined w/ In-Network

Family $1,200 $1,800 $900 Combined w/ In-Network

Coinsurance 20% 50% 10% 30%

Out of Pocket Maximum (Includes Deduc5ble, Coinsurance, Co-pays, PAD and Rx)

Individual $3,500 Combined w/ In-Network $2,500 Combined w/ In-Network

Family $7,000 Combined w/ In-Network $7,500 Combined w/ In-Network

Preven5ve Care

Office Visit Covered 100% 50% Coinsurance Covered 100% 30% Coinsurance

Mammograms Covered 100% Covered 100% Covered 100% Covered 100%

Colonoscopy Covered 100% 50% Coinsurance Covered 100% 30% Coinsurance

Physician Office Visit

Primary Care $25 Co-pay 50% a/er Ded. $25 Co-pay 30% a/er Ded.

Specialist $50 Co-pay 50% a/er Ded. $50 Co-pay 30% a/er Ded.

Diagnos-c Labs 20% Coinsurance 50% a/er Ded. 10% Coinsurance 30% a/er Ded.

Complex Imaging $50 Co-pay 50% a/er Ded. $50 Co-pay 30% a/er Ded.

Hospital Services, Urgent Care & Walk-In Clinics

In-Pa-ent Hospital

Services (Out of Network

PAD Applies)

20% a/er Ded. 50% a/er Ded. +

$500 PAD 10% a/er Ded.

30% a/er Ded. +

$300 PAD

Outpa-ent Surgery 20% a/er Ded. 50% a/er Ded. 10% a/er Ded. 30% a/er Ded.

Emergency Room

(PVD Applies)

20% a/er Ded. +

$100 PVD

20% a/er Ded. +

$100 PVD

10% a/er Ded. +

$50 PVD

10% a/er Ded. +

$50 PVD

Urgent Care $25 Co-pay 50% a/er Ded. $25 Co-pay 30% a/er Ded.

Prescrip5ons

Pharmacy Deduc-ble

Per Rx Max Out of Pocket

$100

$50 per Rx Full cost at purchase and

must file a claim for

reimbursement

$100

$50 per Rx

Generic

Preferred Brand

Non-Preferred Brand

Rx Ded. + Greater of $5 or 30%

Rx Ded + Greater of $35 or 30%

Rx Ded + Greater of $50 or 50%




Specialty Drugs 20%

$375 Max per Rx Not Covered

Rx Ded. + 10%

$225 Max per Rx Not Covered

Full cost at purchase and

must file a claim for

reimbursement

5 Group Benefits - Medical

Go to www.floridablue.com to locate a network provider. Please note that your out-of-pocket costs will be more if you

choose to go to an out-of-network provider.

Coverage Tier BCBS Standard Plan BCBS Premium Plan

Employee Only $9.00 $28.00

Employee & Spouse $260.50 $299.50

Employee & Child (1 Child) $260.50 $299.50

Employee & Children $357.00 $400.50

Family $357.00 $400.50

Semi-Monthly (24 Pay Period) Rates

Coverage Tier BCBS Standard Plan BCBS Premium Plan



Employee & Child (1 Child) $312.60 $359.40


Family $428.40 $480.60

20 Pay Period Rates

6 Group Benefits - Medical Rates

Go to www.floridablue.com to locate a network provider. Please note that your out-of-pocket costs will be more if you

choose to go to an out-of-network provider.

Good oral care enhances overall physical health, appearance and mental well-being. Problems with the teeth and

gums are common and easily treated health problems. Keep your teeth healthy and your smile bright with the Diocese

of Palm Beach dental benefit plan.

Go to www.deltadentalins.com to locate a network PPO provider. Please note that your out-of-pocket costs may be

more if you choose to go to an out-of-network provider.

*When you receive services from an Out of Network Den-st, the percentages in this column indicate the por-on of Delta Dental’s

Out of Network Den-st Fee that will be paid for those services. The Out of Network Den-st Fee may be less than what your den-st

charges and you are responsible for the difference.

***Dependents ages 19 and under can be covered with no requirements and age 25 if a full �me student. Coverage terminates

at the end of the calendar year in which the dependent turns 19 or 25.

7 Group Benefits - Dental

Plan Delta Dental PPO

In-Network

Delta Dental PPO

Out of Network*

Calendar Year Deduc5ble $100 per person $100 per person

Annual Maximum $1,500 per person $1,500 per person

Preventa5ve Services

Oral examina-ons, rou-ne cleanings, x-rays,

fluoride treatment, space maintainers

Plan pays 100%

Deduc-ble waived

Plan pays 100%

Deduc-ble waived

Basic Services

Fillings, sealants, denture repairs,

endodon-cs, periodon-cs, oral surgery

80% Covered 80% Covered

Major Services

Crowns, inlays, onlays, cast restora-ons,

bridges, dentures

50% Covered 50% Covered

Deduc5ble Applies

Coverage Tier Semi-Monthly (24 Pay Period) Rates 20 Pay Period Rates



Employee & Child (1 child) $46.00 $55.20


Family $59.00 $70.80

** Coverage reduces by 50% at age 70

8 Group Benefits - Term Life Insurance

COSTS FOR VOLUNTARY SUPPLEMENTAL LIFE AND

ACCIDENTAL DEATH & DISMEMBERMENT

Age Band Employee & Spouse Life

Monthly Rate per $1,000 Age Band

Employee & Spouse Life

Monthly Rate per $1,000

00-29 $0.070 50-54 $0.410

30-34 $0.080 55-59 $0.700

35-39 $0.110 60-64 $1.010

40-44 $0.170 65-69 $1.540

45-49 $0.230 70-100 $2.900

$2,000 $0.24

$4,000 $0.48

$6,000 $0.72

$8,000 $0.96

$10,000 $1.20

CHILD LIFE

MONTHLY RATES

Coverage Amount

$50,000

# of Units/$1,000

(Coverage Amt./1,000)

50


from rate table above

.110

Total Monthly Premium

$ 5.50

Example: A 36 year old employee wants to

purchase $50,000 of term life insurance.

Coverage Amount

_______________

# of Units/$1,000

(Coverage Amt./1,000)

_______________


from rate table above

_______________

Total Monthly Premium

_______________

Employee Worksheet

Basic Term Life and AD&D The Diocese of Palm Beach provides Basic Life and AD&D Insurance for all eligible employees at no cost to the

employee. The Basic Life benefit is $25,000 and AD&D insurance benefit is $25,000.

Voluntary Supplemental Term Life You also have the opportunity to purchase supplemental Term Life coverage for yourself, spouse and dependent

children. Please note that dependent children include unmarried adopted, natural or stepchildren age 14 days to age

19 (25 if full--me student).

You may elect Voluntary Life Insurance in increments of $10,000 to a maximum of $100,000. You may elect Voluntary

Life Insurance on your dependents: spouse in increments of $10,000 to a maximum of $50,000, not to exceed 100% of

your Op-onal Term Life coverage amount and children in increments of $2,000 to a maximum of $10,000, not to

exceed 50% of your Op-onal Term Life coverage.

Guaranteed Issue Amount

$50,000 employee / $20,000 spouse / $10,000 children

Guaranteed Issue is only for employees enrolling within the ini5al eligibility enrollment period.

EOI is required for enrollment / changes a/er the ini-al enrollment period.

Available to Laity employees

Laity employees of the Diocese of Palm Beach are provided, at no cost to you, Long Term Disability (LTD) coverage,

aGer one full year of employment with the Diocese. LTD coverage supplements your lost wages should you be

unable to work due to an illness or injury. LTD coverage begins a/er missing the specific elimina-on period below due

to a medically cer-fied reason. Benefits are payable up to the specific benefit dura-on period below. Benefits may be

offset by deduc-ble sources of income - please see your policy for details.

Elimina5on Period for sickness, accident or pregnancy: 90 Days

Monthly Benefit: 60% of your monthly earnings to a maximum benefit of $3,000

Maximum Benefit Period: Under age 61 to normal re-rement age*, but not less than 60 months

Age 61 to normal re-rement age*, but not less than 48 months




Age 65 24 months

Age 66 21 months

Age 67 18 months

Age 68 15 months

Age 69 and over 12 months

*Your normal re�rement age is your re�rement age under the Social Security Act where re�rement age depends on

your year of birth.

Pre-Exis5ng Condi5on: LTD benefits will not be paid for a disability that begins within 12 months of your coverage

effec-ve date and due to a pre-exis-ng condi-on.

LONG TERM DISABILITY

9 Group Benefits - Disability Insurance

As an employee of the Diocese of Palm Beach, you are able to enroll in Short Term Disability (STD) coverage at your

own expense. STD coverage supplements your lost wages should you be unable to work due to an illness, injury or

pregnancy. STD coverage begins a/er missing the specific elimina-on period below due to a medically cer-fied reason.

Benefits are payable up to the specific benefit dura-on period below.

Elimina5on Period for sickness, accident or pregnancy: 14 Days

Maximum Benefit Period: 11 weeks

Weekly Benefit: 60% of your weekly earnings to a maximum benefit of $1,500

Cost per unit of weekly benefit: $.017

Pre-Exis5ng Condi5on: STD benefits will not be paid for a disability that begins within 12 months of your coverage

effec-ve date and due to a pre-exis-ng condi-on.

SHORT TERM DISABILITY

Step 1 Indicate your weekly earnings $1,000.00

Step 2 Mul-ply your weekly earnings by 60% $600.00

Step 3 If the amount in Step 2 is greater than $1,500, indicate

$1,500. Otherwise, indicate the amount from step 2. $600.00

Step 4 Mul-ply the amount in Step 3 by the rate of $0.017 to

obtain your total STD monthly cost. $10.20

Calcula5on for Total Monthly STD Cost

Example: Employee has a $52,000 annual salary and wants to purchase short

term disability.

10 Group Benefits - Disability Insurance

Available to Laity only. Available only for those in their ini5al eligibility period.

Regular eye examina-ons cannot only determine your need for correc-ve eyewear, but also may detect

general health problems in their earliest stages. Protec-on for your eyes should be a major concern to

everyone.

*Dependent eligibility rules for

the Vision Plan are on Page 4.

Go to www.vsp.com to locate a network provider. Please note that your out-of-pocket costs may be more if

you choose to go to an out-of-network provider.

11 Group Benefits - Vision Insurance

Available to all employees

WellVision Exam � Focuses on your eyes and overall wellness $10 Every plan year**

Prescrip5on Glasses $25 See frames and lenses

Frame

� $150 allowance for a wide selec-on of frames

� $170 allowance for featured frame brands

� 20% off amount over your allowance

Included in

Prescrip-on

Glasses

Every other plan year

Lenses � Single vision, lines bifocal, and lined trifocal lenses

� Polycarbonate lenses for dependent children

Included in

Prescrip-on

Glasses

Every plan year

Lens Op5ons

� Standard progressive lenses

� Premium progressive lenses

� Custom progressive lenses

� Average 20-25% off other lens op-ons

$55

$95 - $105

$150 - $175

Every plan year

Contacts

(instead of glasses)

� $150 allowance for contacts; copay does not apply

� Contact lens exam (fiUng and evalua-on) Up to $60 Every plan year

Diabe5c Eyecare Plus

Program

� Services related to diabe-c eye disease, glaucoma and age-

related macular degenera-on (AMD). Re-nal screening for

eligible members with diabetes. Limita-ons and coordina-on

with medical coverage may apply. Ask your VSP doctor for

details.

$20 As needed

Extra Savings and

Discounts

Glasses and Sunglasses: 20% off addi-onal glasses and sunglasses, including lens op-ons, from any VSP

doctor within 12 months of your last WellVision Exam.

Re5nal Screening: Guaranteed pricing on re-nal screening as an enhancement to your WellVision Exam.

Laser Vision Correc5on: Average 15% off the regular price or 5% off the promo-onal price; discounts only

available from contracted facili-es.

Your Coverage with Other Providers

Visit vsp.com for details, if you plan to see a provider other than a VSP doctor.

Exam……….up to $45 Single Vision Lenses……..up to $30 Lined Trifocal Lenses……..up to $65 Contacts……..up to $105

Frame……..up to $70 Lined Bifocal Lenses……..up to $50 Progressive Lenses……....up to $50

*Coverage with a retail chain affiliate may be different. Once your benefit is effec5ve, visit vsp.com for details. **Plan year begins in August





Family $9.60 $11.52

TRUSTMARK ACCIDENT PLAN A plan that helps pay for the unexpected expenses that can result from an accident.

• On and off-the-job coverage = 24 hours per day, 7 days a week

• Family coverage available

• Sports related injuries covered also

Money is paid directly to you for (please see brochure for a complete list of benefits and details):

• Ini-al Doctor’s Office Visit: $200 • Fractures: up to $15,000

• Hospitaliza-on: $3,200 admission, $500 per day • Disloca-ons: up to $12,000

Wellness Benefit Included: A wellness benefit is paid for all rou-ne physicals, vaccines, and health screen-

ing tests for each covered person. There is a 60-day wai-ng period, a/er ini-al enrollment, for this benefit.

This benefit pays $50 per test per person, twice each year (maximum of $100 annually per insured).

Examples of Health Screenings include:

• Low-dose Mammogram • Pap Smear

• Serum Cholesterol • Fas-ng blood glucose test

• Prostate Specific An-gen (PSA)

• Stress Test on a bicycle or treadmill

*Dependents up to age 26

can be covered regardless

of student status.

What are Voluntary Benefits? Voluntary Benefits are offered to strengthen your overall benefits package. You customize the benefit based

on your needs and affordability. Available to all employees.

• Ownership – Policies are fully portable and belong to you if you leave the Diocese, price and plan benefits

remain the same

• Benefits are payroll deducted

• Cash benefits are paid directly to you, not to a hospital or to a doctor

• Benefits are paid regardless of any other coverage you may have

• Level premiums—Rates do not increase with age

• Guaranteed Renewable

• Designed to provide addi-onal cash flow to assist with out of pocket medical costs and other bills

The Voluntary Benefits offered are Accident and Universal Life with Long Term Care through Trustmark.

12 Voluntary Individual Benefits





Family $18.78 $22.54

Trustmark Universal Life with Long Term Care

Universal Life with Long Term Care includes both a death benefit and a living benefit.

• Trustmark Universal Life with Long Term Care is a permanent life insurance policy that is designed to

match your needs throughout your life-me. It pays a higher death benefit during your working years

when expenses are high and you need maximum protec-on.

• The Universal Life with Long Term Care policy is priced to remain the same cost to you un-l age 100.

• The death benefit reduces at age 70 when the need for life insurance typically decreases.

• The Living Benefit, Long Term Care never reduces and is 4% of the original death benefit per month for up

to 25 months.

• If you use the Long Term Care benefit, your death benefit amount does not reduce due to the Benefit

Restora5on feature included.

• Coverage available for spouse and children as well.

Special Underwri�ng at Ini�al Offering

Guaranteed Issue (Employee Only)

The lesser of the face amount purchased by $18 per week or $200,000

Rates

This benefit is customized by each employee so rates vary, but can start as liYle as a few dollars a week.

13 Voluntary Individual Benefits

Iden-ty the/ in the United States is a major problem that con-nues to be on the rise. Professional

protec-on and assistance have become important tools in figh-ng the iden-ty the/ epidemic.

Thieves today can get a hold of your personal informa-on from trash cans, dumpsters, stolen mail, and even

shoulder surfing. Once thieves have your informa-on, it’s a simple maYer to open new fraudulent accounts

and make purchases in your name.

When you enroll in LifeLock, you can be confident knowing that they are available 24 hours a day, 7 days a

week, and commiYed 100% to helping protect your informa-on as if it were their own.

LifeLock offers Proac5ve Protec5on:

• LifeLock Iden-ty Alert System

• eRecon

• TrueAddress

• WalletLock

• Reduc-on in Pre-Approved Credit Card offers

• 24-Hour Customer Service

• Offered through payroll deduc5on at a 15% discount off retail rates

$1 Million Total Service Guarantee

LifeLock’s proac-ve approach works to help stop iden-ty the/ before it happens.

As a LifeLock member, if you become a vic-m of iden-ty the/ because of a failure

in their service, they will help fix it at their expense, up to $1,000,000.

*Employee & Children and Family Tiers: You may enroll up to 8 children with 4 of those children between the ages of 18 and 26.

14 LifeLock Iden-ty The/ Protec-on




*Employee & Children $7.44 $8.93

*Family $11.69 $14.03

Vendor Phone Website

Medical

Florida Blue 800-352-2583 www.floridablue.com

Pharmacy

RxEDO Pharmacy Benefits 888-879-7339 www.rxedo.com

Dental

Delta 800-521-2651 www.deltadentalins.com

Life / STD / LTD

Pruden-al

Contact the Benefits office at the

Diocese:

Sandy Maulden: 561-995-9574

Ana Jarosz: 561-995-9525

[email protected]

[email protected]

Vision

VSP 800-877-7195 www.vsp.com

Voluntary Benefits

Trustmark 800-918-8877 www.trustmarksolu-ons.com

Iden5ty TheG Protec5on

LifeLock 800-543-3562 www.lifelock.com

Trustmark Claims Help

Explain My Benefits 321-296-8060, Op-on 2 [email protected]

Sandy Maulden

561-775-9574

[email protected]

Ana Jarosz

561-775-9525

[email protected]

Fax: 561-775-9575

For other ques5ons please contact the Diocesan Benefits Office:

Or go to the website at:

hYp://www.explainmybenefits.biz/diocese

15 Important Contacts

Benefit Guide Descrip5on

Please Note: This Employee Benefit Brochure is designed to provide a brief overview of the benefit plans that are provided for and made

available to employees of the Diocese of Palm Beach and their families. Please refer to the Diocesan Benefits website and your plan

booklets for full details.

your health benefits guide · benefits guide your health your decision 2016 - 2017 plan year ....

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