2020 CPS Benefits Guide - Chesapeake City Public Schoolscpschools.com/employee-benefits-risk...the...

1

INSPIRE ENGAGE EMPOWER ChesapeakePUBLIC SCHOOLS

2020 BENEFITS GUIDE

Welcome Chesapeake Public Schools (CPS) is excited to offer you and your family comprehensive benefts options designed to help you grow personally fnancially and professionally

This benefts guide contains an overview of the benefts package available to you through CPS You will fnd helpful information herein to assist you in understanding all benefts offered Please read your materials carefully to choose the options that best meet the needs of you and your family

As you prepare to enroll for benefts or make changes to your coverage consider the needs of you and your family throughout the entire year Keep this guide as reference to use throughout the year If you have any questions contact Employee Benefts and Risk Management or carrier directly

Availability of Summary Health Plan Information As an employee the health benefts available to you represent a signifcant component of your compensation package They also provide important protection for you and your family in the case of illness or injury

Your plan offers a series of health coverage options Choosing a health coverage option is an important decision To help you make an informed choice your plan makes available a Summary of Benefts and Coverage (SBC) which summarizes important information about any health coverage option in a standard format to help you compare across options

Disclaimer This document is an outline of the coverage proposed by the carrier(s) based on information provided by your company It does not include all of the terms coverage exclusions limitations and conditions of the actual contract language

The intent of this document is to provide you with general information regarding the status of andor potential concerns related to your current employee benefts environment It does not necessarily fully address all of your specifc issues It should not be construed as nor is it intended to provide legal advice

Medicare Part D mdash Prescription Drug Information If you are covered by Medicare or will become eligible for Medicare in the next 12 months a Federal law gives you more choices about your prescription drug coverage Please see page 23 for more details

2

Contents Benefts Glossary 4

Eligibility 5

Enrollment 6

Health and Wellness7-8

Medical 9-11

Telehealth 12

Flexible Spending Accounts 13

Health Savings Account 14

Dental Plan 15

Long Term Care 16

Life and ADampD Insurance 17

Voluntary Life Beneft Term Insurance 18

Whole Life 18

Short Term Disability 19

Critical Illness 19

Accident 20

Hospital Indemnity 21

Legal Plan 22

Creditable Coverage Notice 23

Legal Notices 24-26

Resources 27

3

Benefts Glossary

Co-insurance ndash A percentage of a health care costmdashsuch as 20 percentmdashthat the covered member pays after meeting the deductible

Co-payment ndash The fxed dollar amountmdashsuch as $25 for each doctor visitmdashthat the covered member pays for medical services or prescriptions

Deductible ndash A fxed dollar amount that the covered member must pay out-of-pocket each calendar year before the plan will begin to pay There is typically an Individual and a Family deductible An ldquoembeddedrdquo deductible means that a single member of a family does not have to meet the full family deductible for after-deductible benefts to take effect Instead the memberrsquos after-deductible benefts will take effect as soon as heshe has met the individual deductible Non-embedded deductible plans are different because after-deductible benefts do not begin to pay for medical expenses until the entire family deductible has been met

Formulary ndash A list of prescription drugs covered by the health plan often structured in tiers that subsidize low-cost generics at a higher percentage than more expensive brand-name or specialty drugs

Flexible Spending Accounts (FSA) ndash FSAs let you set aside money from your paycheck on a pre-tax basis to use for eligible out-of-pocket expenses Employees must elect to participate in these plans annually There are three types of FSAs

bull Health Care FSA ndash You can use this account to pay for eligible medical dental vision hearing and prescription drug expenses for you your spouse and your eligible tax dependents

bull Dependent Care FSA ndash You can use this account to pay for eligible child and adult care expenses like day care before and after school care nursery school preschool and summer day camp

bull Limited Purpose FSA ndash You can only elect this account if you have a Health Savings Account (HSA) and use it to pay for eligible dental and vision expenses

Health savings account (HSA) ndash HSAs may be opened by employees who enroll in a high-deductible health plan Employees can put money in an HSA up to an annual limit set by the government (for 2020 the limit is $3550 for employee-only coverage and $7100 for family coverage) using pre-tax dollars HSA funds may be used to pay for medical expenses before or after the deductible has been met and no tax is owed on funds withdrawn from an HSA to pay for eligible medical expenses HSAs are individually owned and the account remains with an employee after employment ends

High-deductible health plan (HDHP) ndash An HDHP features higher annual deductibles ($1500 Individual and $3000 for family coverage in 2020) than traditional health plans such as a preferred provider organization (PPO) or health maintenance organization (HMO) plan With the exception of preventive care covered members must meet the annual deductible before the plan pays benefts HDHPs however typically have lower premiums than a PPO or HMO plan

In-network ndash Doctors clinics hospitals and other providers with whom the health plan has an agreement to care for its members Health plans cover a greater share of the cost for in-network health providers than for providers who are out-of-network

Out-of-network ndash A health plan will cover treatment for doctors clinics hospitals and other providers who are out-of-network but covered employees will pay more out-of-pocket to use out-of-network providers than for in-network providers

Out-of-pocket limit ndash The most a member could pay during a coverage period (usually one year) for hisher share of the costs of covered services including co-payments and co-insurance

Premium ndash The amount that must be paid for a health insurance plan by covered employees and their employer shared by both A covered employeersquos share of the annual premium is generally paid per pay period and deducted from hisher paycheck

Preventive care ndash Preventive care includes screenings and other services for adults and children (Examples include certain immunizations screenings for high blood pressure cholesterol Type 2 diabetes and certain types of cancer) Preventive care services are covered with no deductible copayments or coinsurance when you use an in-network provider Please note certain benefts for members who have current symptoms or a diagnosed health problem may be covered under the ldquoDiagnostic Testsrdquo beneft instead of preventive services

4

Eligibility

All full-time employees are eligible to enroll for benefts described in this guide Benefts for all newly-hired employees begin on the frst of the month following date of hire

Coverage for Dependents A dependent is your

bull Legal Spouse bull Natural born child or stepchild bull Legally adopted child

You may cover a dependent child on the Chesapeake Public Schools health plans as follows bull Medical and Dental Plans Through the last day of the year in which the child reaches age

26 A dependent child who is either mentally or physically handicapped and incapable of self-support may continue to be covered regardless of age if the condition exists and coverage is in effect when the child reaches age 26

Required Documentation to Add Dependents to Medical andor Dental Coverage bull Spouse All of the below documents are required

1 CPS Affdavit of Spouse Health Care Coverage 2 A copy of your citycourt certifed marriage register certifcate (not the one from the

clergyman) 3 A copy of the front page of last yearrsquos federal 1040 tax return showing either married

fling joint or married fling separately (return must list your spousersquos name and SS) and One (1) fnancial document from a fnancial institution dated within the last 60 days which must list your name and your spousersquos name the date and the CPS employeersquos mailing address Examples checking savings credit card personal loan or mortgage statements only

bull Newborn children only 1 A copy of the proof of birth letter from the hospital within 31 calendar days of the

babyrsquos birthdate for a temporary enrollment 2 A copy of the state certifed birth certifcate and Social Security number within 45

calendar days of the babyrsquos birthdate to complete the enrollment bull Children and Disabled Children

1 A copy of the childrsquos birth certifcate or adoption certifcate naming you or your spouse as the childrsquos birthadoptive parent (If CPS employee is not the named birth adoptive parent all the above documentation for a spouse is also required) or

2 A copy of the court order naming you or your spouse as the childrsquos legal guardian (your tax return showing dependent is claimed is required if dependent is over age 18 AND if CPS employee is not the guardian all the above documentation for a spouse is also required)

3 Disabled children over 26 years old must also have an Anthem Handicapped Dependent Certifcation completed by a physician and submitted with enrollment paperwork

5

Enrollment

Open Enrollment Open Enrollment is your once-a-year opportunity to make changes to your beneft elections and choose the plans and coverage levels that are right for you and your family

You can change plans as well as add or drop coverage provided to you andor your dependent(s) that meet the eligibility requirements Any changes made during Open Enrollment must remain in effect until the following Open Enrollment period unless you experience a qualifying life event We encourage you to research your options evaluate the level of coverage you truly need and ultimately make choices that best meet your needs

Qualifying Events For Medical Dental and Flexible Benefts you may only make changes to your elections during the year if you experience a qualifying life event Qualifying life events include

bull Marriage divorce bull Gain or loss of an eligible dependent for reasons such as birth adoption court order

disability death marriage or reaching the dependent child age limit bull Changes in your spousersquos employment affecting beneft eligibility bull Changes in your spousersquos beneft coverage with another employer that affects beneft

eligibility bull Changes in employee work status

The change to your beneft elections must be consistent with the qualifying life event You have 31 calendar days from the date of the event to submit appropriate forms to the Department of Employee Benefts and Risk Management Specifc documentation is required to add dependents You will receive confrmation of when your changes will become effective

If you attempt to make beneft elections beyond the 31 calendar day from the event you must wait until the next Open Enrollment to make any changes to your coverage

Important Forms bull Affdavit of Spouse Healthcare Coverage bull Documentation to add spouse eligible dependents

For more information Department of Employee Benefts and Risk Management cpsbeneftscpschoolscom 757-547-1343

6

Health and Wellness

Chesapeake Public Schools (CPS) is committed to helping you CPS Health Centers lead a healthier life by providing you the tools and resources to

make healthier choices To help accomplish this CPS joined Locations forces with Marathon Health one of the leading providers of

onsite healthcare to operate two employee Health Centers Knells Ridge The Health Centers offer convenient and free healthcare 817 Botetourt Ct services to employees covered by CPS health plan In addition Chesapeake VA 23320 to the acute care employees can receive for common illnesses 757-389-7300 Marathon Health also offers health coaching to address lifestyle

health risks such as stress unhealthy eating inadequate sleep Washington Shoppes and physical inactivity Coaching for chronic conditions such 838 Old George Washington as diabetes asthma heart problems or high blood pressure Hwy Chesapeake VA 23323 757-389-7631 Health Coaching

Health coaching is an innovative way to help you manage your Hours health You can evaluate your health mdash where you are and Mon-Fri 7 am ndash 530 pm where you want to be The health coach will help you set goals Sat 9 am ndash 2 pm and will provide you the resources and support you need in Sun Closed order to achieve them A health coach is available to

employees after completing a Health History and Risk Assessment (HHRA) and a fasting Biometric Health Screening

To Schedule Appointments Health coaching is available to spouses and dependent Please call the location children (age 6 and older) for chronic conditions including directly or schedule online at asthma and diabetes MyMarathon-Healthcom

Condition Care Programs for Asthma and Diabetes Employees spouses and dependents (age 6 and older) with diabetes andor asthma covered by a CPS health insurance plan are encouraged to enroll in our Condition Care Program Enrollment begins at the Health Center with the completion of a HHRA Biometric Health Screening and a Comprehensive Health Review (CHR) Participants are assigned to a Health Coach that works with their physician to offer additional support in managing their condition As an incentive for meeting with a Health Coach on a regular basis copays for medications and supplies used to treat diabetes and or asthma will be covered 100 To enroll please contact one of our CPS Health Centers

Your Privacy is Important All care received from Marathon Health is completely confdential The rules that protect the privacy of your health information at your local medical offce also protect your health information at a Marathon Health practice For more information on the Marathon Health Privacy Policy visit Marathon-HealthcomPrivacy or call (802) 857-0400 and ask to speak with the Marathon Health privacy offce

7

Health and Wellness Mental amp Emotional Health Care Counseling is now available at the Washington Shoppes Health Center for employees covered by a CPS health plan There is no cost for these services For more details please call (757) 389-7631

Wellness Credits Employees will receive a $20 per pay period reduction in their health insurance premium if the employee completes both a biometric screening and an online questionnaire concerning their personal health history (HHRA) Participation is voluntary and not required

The following two (2) steps must be completed each year You must complete both steps each year for a premium reduction in the following year

Step 1 Complete an online Health History and Risk Assessment (HHRA) bull Login to MyMarathon-Healthcom and complete the HHRA found under the

ldquoQuestionnairesrdquo tab bull If you completed a HHRA before simply complete the Health Risk Assessment Annual

Update bull Need help logging on Call Marathon Health at 1-888-490-6077

Step 2 Complete a Fasting Biometric Health Screening There are two ways you can complete this step

1 Schedule a screening at the Health Center 2 Schedule a screening with your Primary Care Doctor (PCP) and complete the Physician

Screening Form found at cpschoolscomwellnesscredits

For more information wwwcpschoolscomwellness

8

9

Medical Plan Summary

To meet the diverse needs of Chesapeake Public Schools employees and their families we offer a robust medical plan through Anthem All plans allow you to receive care from participating and non-participating providers however you will be covered at a higher level when using in-network providers

Option 1 Health Keepers HMO Open Access Plan The HMO plan offers affordable health care for you and your family through a network of health care providers Most network services will have a copay that will go towards your out-of-pocket maximum For the services that donrsquot have copays you will pay full cost of the services until you reach your deductible and then coinsurance will apply Once you reach your out-of-pocket maximum (includes copays deductibles and coinsurance) all eligible services will be covered at 100 Preventive care services are covered at 100 in-network

Option 2 Keycare PPO Plan (Closed Plan) This plan is closed to any new enrollment If you are not currently enrolled in this plan you are not eligible for this plan The PPO plan allows you to visit any provider whether they are in-network or out-of-network however you will be covered at a higher level when using in-network providers You have an annual deductible that you must meet before coinsurance applies There are also copays for certain services that will apply to your out-of-pocket maximum Once the out-of-pocket maximum is met all eligible services will be covered at 100 Preventive care services are covered at 100 in-network

Option 3 Keycare HDHP with HSA The Keycare HDHP plan does not have any medical copays meaning you pay the full cost of all services until your deductible is met Once the deductible is met coinsurance will apply Just like the other plans once the out-of-pocket-maximum is met services will be covered at 100 Preventive care services are covered at 100 in-network The HDHP plan is also paired with a Health Savings Account (HSA) that will help offset a portion of your deductible Please see page 14 for more information on the HSA

Prescription Drug Plans You will have two options when flling prescriptions the frst is the Retail and Home Delivery Pharmacy through Anthem and the other is the CPS Wellness Center Pharmacy As an employee you and your family are encouraged to use the CPS Pharmacy whenever possible as it reduces your co-pays and deductibles An important note on the Retail and Home Delivery Pharmacy A pharmacy deductible will apply to the HMO and PPO plans on all Tier 23 and 4 drugs If you are enrolled in the HSA plan you will need to pay 100 of the cost of your prescriptions until your meet your plan deductible After the plan deductible is met you will be responsible for plan co-pays based on the drug tier

Potential Financial Responsibility When Using Out-of-Network Providers The amount the plan pays for covered services provided by non-network providers is based on a maximum allowable amount for the specifc service rendered Although your plan stipulates an out-of-pocket maximum for out-of-network services please note the maximum allowed amount for an eligible procedure may not be equal to the amount charged by your out-of-network provider Your out-of-network provider may bill you for the difference between the amount charged and the maximum allowed amount This is called balance billing and the amount billed to you can be substantial The out-of-pocket maximum outlined in your policy will not include amounts in excess of the allowable charge and other non-covered expenses as defned by your plan The maximum reimbursable amount for non-network providers can be based on a number of schedules such as a percentage of reasonable and customary or a percentage of Medicare The plan document or carrierrsquos master policy is the controlling document and this Beneft Highlight does not include all of the terms coverage exclusions limitations and conditions of the actual plan language Contact your claims payer or insurer for more information

For more information Anthem wwwanthemcom 1-800-451-1527

Medical Plans Plan Features Health Keepers HMO

In Network KeyCare PPO In Network

KeyCare HDHP with HSA

Calendar Year Deductible $200 Individual $400 Family

$200 Individual $400 Family


Out of Pocket Maximum $3500 Individual $7000 Family



Coverage

Preventive Care Visit No Charge No charge No charge

Doctor Visits $25 per visit to your

PCP $50 per visit to a specialist

$25 per visit to a PCP $50 per visit to a specialist

After deductible 20 of the amount the health care pro-

fessionals in the network have agreed to accept for

their services

Online Visits $15 for each visit $15 for each visit $49 per visit

Labs Diagnostic X-rays and Other Outpatient Diagnostic Tests

$25 per visit to your PCP $50 per visit to a

specialist

20 of the amount the health care professionals in our network have agreed to

accept for their services

After deductible 20 of the amount the

health care professionals in the network have agreed to


Outpatient Services in a Hospital or Facility

$250 per visit $200 plus 20 of the amount the health care

professionals in our network have agreed to accept for their services




Inpatient Stays in a Hospital or Facility

$300 per day (not to exceed $1500) for an

admission

$400 plus 20 of the amount the health care

professionals in the network have agreed to





Routine Vision $15 for each visit $15 for each visit $15 for each visit

Emergency Care Visits In or Out of the Service Area Waived if admitted directly to the hospital

$200 per visit to an emergency room







Waived if admitted directly to the hospital

Employee Cost Per Pay Period (20 pay periods)

Health Keepers HMO Open Access

KeyCare PPO HDHP with HSA

Employee Only $2900 $11200 $2100

Employee + Child(ren) $9500 $19100 $2200

Employee + Spouse $14300 $24900 $7100

Employee + Family $20300 $31900 $12900

Double Employee $4200 $14800 Not eligible

Double Employee + Family $10200 $21800 Not eligible


10 10

Prescription Plans Prescription Plan Features Retail PharmacyHome

Delivery Pharmacy

CPS Wellness Center

Tier 1 Retail (30 day supply) Home Delivery (90 day supply)

$20 copay $40 copay

$2 copay $4 copay

Tier 2 Retail (30 day supply) ($100 deductible)

$50 copay after $100 deductible

$20 copay

Home Delivery (90 day supply) $100 copay after $100 deductible

$40 copay

Tier 3 Retail (30 day supply) $100 copay after $100 $40 copay ($100 deductible) deductible


$80 copay


Specialty Drugs

10 coinsurance after $100 deductible $200 per

prescription maximum

10 coinsurance $200 per prescription maximum

Home Delivery (90 day supply) 10 coinsurance after $100 deductible $400 per



CPS Wellness Center Pharmacy The centers include full-service pharmacies operated by On-Site Rx Inc a company specializing in employer-sponsored pharmacies The pharmacies will save you and your family signifcant money on co-pays Furthermore these pharmacies have staff dedicated to your well-being They exclusively serve Chesapeake Public Schools (CPS) employees retirees and dependents on a CPS health insurance plan

Locations Knells Ridge 817 Botetourt Ct Chesapeake VA 23320 Phone (757) 410-2775 Fax (757) 410-2790

Washington Shoppes 838 Old George Washington Hwy Chesapeake VA 23323 Phone (757) 606-1956 Fax (757) 606-1970 Hours (both locations) M-F 900 am to 600 pm | Sa 9 am to 230 pm | Su Closed

11

Telehealth

With LiveHealth Online you can access a doctor from your home offce or on the go 247365 Board certifed doctors can visit with you by secure video to help treat many non-emergency medical conditions LiveHealth Onlinersquos doctors can diagnose your symptoms prescribe medication and send prescriptions to your pharmacy of choice

When Should You Use LiveHealth bull Instead of going to the ER or an urgent care center for a non-emergency issue bull During or after normal business hours nights weekends and even holidays bull If your primary care doctor is not available bull To request prescription reflls (when appropriate) bull If traveling and in need of medical care

Who is Eligible If you are enrolled in any of the medical plans then you and your dependents are eligible for this service Pediatricians are on call 247365 A parent or guardian must be present on each call for children 18 years of age or younger

Common Conditions Treated bull Allergies bull Asthma bull Bronchitis bull Cold amp Flu bull Diarrhea bull Ear Aches bull Fever bull Headache bull Infections

Pediatric Conditions bull Cold amp Flu bull Constipation bull Ear Aches bull Nausea bull Pink Eye bull And More

How Much Does it Cost

bull Insect Bites bull Joint Aches bull Rashes bull Respiratory Infections bull Sinus Infections bull Skin Infections bull Sore Throat bull Urinary Tract Infections bull And More

Signing up is free you only pay per visit You will pay $15 per visit for the HMO and PPO plans and you will pay $49 per visit for the HDHP plan

How to Sign Up You can easily sign up or activate your account by using one of the following methods

1 Go online and visit livehealthonlinecom 2 Call our toll free number 1-888-548-3432 3 Download the LiveHealth Online App

12

THE FLEXIBLE BENEFIT PLAN WORKS

Gross Month ly Income

Eligible Pre-Tax employer medical insurance Eligible Pre-Tax Medical Expenses Eligible Pre-Tax Dependent Child Care Expenses

Taxab1e Income

Federal Tax (15) Slate Tax (575) FICA Tax (765)

Alter-Tax employer medical insurance After-Tax medical Expenses After-Tax dependent child care ecpenses

Monlhly Spendable Income

Without Flex Benefits $ 250000

$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59

By taking advantage of the Flexible Benerit Plan this employee was able to inorease hisfher spendable income by S1 54 84 every month This means an annuaI tax savings of $1 85808 Remember with the FLE XIBLE BENEFIT PLA N the better vou plan the more vou save

FSA The Flexible Spending Account (FSA) plans administered by Flexible Beneft Administrators allow you to set aside pre-tax dollars to pay for your eligible out-of-pocket health care and dependent care expenses

Elections made to either plan cannot be changed unless you have a qualifying life event You must contact the Department of Employee Benefts and Risk Management within 31 calendar days of your qualifying event in order to make a change to your FSA contribution

There are three types of FSA accounts bull Health Care FSA - Covers qualifed health care expenses for you and your eligible family

members that are not reimbursed by any medical dental or vision care plan that you or your dependents have You may contribute up to $2700 for the 2020 plan year

bull Limited Purpose Health Care FSA - This account is for those who enrolled in the High Deductible Health Plan Under a Limited Purpose FSA eligible expenses are limited to qualifying dental and vision expenses for you your spouse and your eligible dependents

bull Dependent Care FSA - Reimburses your eligible expenses for child care andor elder care You may contribute up to $5000 per family per plan year ($2500 if married and fle separate on tax returns)

Important Notes About the FSA bull Enrollment for the FSA plans is required each year You do not need to be enrolled in a

Medical Plan to participate in the FSA Plan bull The IRS sets an annual maximum on each FSA plan The annual maximum for both health

care FSAs is $2700 for 2020 The dependent care FSA maximum is $5000 ($2500 if you are married but fling separately)

bull The FSA plan year runs from January 1 - December 31 bull You have until March 30 of the following plan year to submit claims for expenses incurred in

the current plan year (Example you have until March 30 2021 to submit claims for the 2020 plan year if still actively employed)

bull Unused FSA funds will be forfeited This is known as the ldquouse it or lose itrdquo rule Please plan your expenses carefully to avoid over-contributing to the FSA Set aside only enough money to cover the expenses you are reasonably certain you will incur

bull If your employment ends you only have 30 days from your termination date to submit claims incurred prior to your last day

For more information Flexible Beneft Administrators wwwfex-admincom 757-340-4567 13

HSA

If you enroll in the High Deductible Health Plan (HDHP) you will have the option to open a Health Savings Account (HSA)

What To Know About The HSA bull A Health Savings Account is a tax-advantaged savings account used to pay for eligible

medical expenses as well as deductibles coinsurance prescriptions vision and dental care incurred by employees and dependents

bull Contributions are made pre-tax from your paycheck reducing your federal income taxes bull Assets in your HSA account grow tax-free bull Funds can be withdrawn without IRS taxation if you use them for qualifed medical

expenses bull Account holders will be issued a debit card to pay for eligible expenses bull Your tax dependents are also eligible to use HSA funds bull Once enrolled in Medicare you are no longer eligible to contribute to an HSA However you

can continue to use the funds in your account bull There is NO ldquouse it or lose it penaltyrdquo Your account is portable and will remain yours if you

leave Chesapeake Public Schools bull Additional retirement savings Age 65+ HSA funds can be withdrawn for any purpose

without penalty bull Calendar Year Maximum contributions amounts are regulated by the IRS

To participate in the HSA you must bull Be enrolled in the HDHP bull Not be covered by any other plan such as a spousersquos medical plan or a Medical Flexible

Spending Account bull Not be enrolled in Medicare TRICARE or TRICARE for Life bull Not be claimed as a dependent on someone elsersquos tax return

How the HSA Works Money Goes In You can contribute pre-tax dollars through payroll deductions as long as you do not exceed the IRS maximums for 2020

bull $3550 for single coverage bull $7100 if you enroll your spouse andor children bull $1000 catch-up contributions at age 55+

Money Comes Out When you have an eligible expense you decide whether to use your tax-free HSA or pay for care with other resources

You pay the full cost of non-preventive care including non-preventive prescription drugs until you meet the deductible Remember you receive discounted rates in-network

Money Left Over Rolls Over Any money left in your account is yours to pay for eligible health care expenses in the future mdash tax-free

If you leave CPS or retire you take the money with you

For auditing purposes it is important to keep all of your receipts Using your HSA funds for anything other than qualifed medical expenses before age 65 could result in taxation on those amounts plus a 20 IRS penalty

A complete list of qualifed HSA expenses can be found in the IRS Publication 502 Medical and Dental Expenses available by visiting wwwirsgov


14

Dental Plan Plan Features In Network Out of Network

Annual Beneft Maximum $1250 $1250

Plan Year Deductible bull Individual bull Family

$50 $100

$50 $100

Annual Deductible ndash (Calendar Year) bull Per insured person bull Family maximum

$50 2x single member

deductible


deductible

Coverage Anthem Pays Anthem Pays

Diagnostic amp Preventive Care bull Periodic oral exam bull Teeth cleaning (prophylaxis) bull Bitewing X-rays 2x a year bull Intraoral X-rays

100 coinsurance 100 coinsurance

Basic Dental Care bull Fillings bull Root Canal bull Scaling and Root Planing


Major Dental Care bull Crowns bull Dentures bull Bridges bull Implants bull Prosthetic RepairsAdjustments


Orthodontic Services Not covered Not covered

Employee Cost Per Pay Period (10 months)

Employee Only $000

Employee + Family $1561


15

Long Term Care The caregiving needs of an aging loved one can take an emotional and fnancial toll on a family Long Term Care insurance is one way to help reduce the impact on family and loved ones

bull Most medical plans do not cover long term care services such as nursing home care or at-home care to assist with activities of daily living such as bathing eating etc

bull Anyone at any age may need these services the cost of which can quickly deplete savings or retirement income Under this program coverage to help pay for long term care may be more affordable than you think

bull VRS has contracted with Genworth Life Insurance Co as the insurer for the program This coverage is employee-paid and provides a monthly beneft allowance for covered long term care expenses

For More Information Genworth wwwgenworthcomCOV 1-866-859-6060

16

Life and ADampD Insurance This plan is offered through Anthem Life Insurance Company and is available for employees only You must enroll in this plan if you enroll in medical andor dental insurance It is also available if you are not enrolled in medical andor dental insurance You will receive $10000 of Basic Life and ADampD insurance at $096 per pay period

Anthem Life Resource Advisor Chesapeake Public Schools employees enrolled in the Anthem 10K Basic Life insurance policy have access to a resource advisor with Anthem Counselors are available to speak with you on various topics like money matters legal issues such as wills identity theft emotional problems travel assistance and more Please contact the Employee Benefts Department for informational fiers For assistance contact a Resource Advisor at 888-209-7840

Employee and Family Voluntary ADampD Insurance You have the option of choosing Accidental Death amp Dismemberment insurance for yourself your spouse andor your child(ren) This plan also offered through Anthem Life Insurance Company provides 24-hour coverage against any covered accident Coverage is shown below

Employee Only 100 for employee EmployeeSpouse 100 for employee60 for spouse EmployeeChildren 100 for employee20 for each child EmployeeFamily 100 for employee60 for spouse20 for each child

Dependent children up to age 24 Employees who are married to another Chesapeake Public Schools employee cannot be covered as a dependent under a spousersquos plan Only one employee can carry family coverage


17

Afac Group Voluntary Benefts

Voluntary Term Life Afac group term life insurance helps take care of your loved onesrsquo immediate and future needs if you should pass away Immediate needs can include burialfuneral expenses uninsured medical costs and current bills and debts Future needs could include income replacement education plans ongoing family obligations emergency funds and retirement expenses

Itrsquos Insurance for Daily Living Afac pays cash benefts directly to you unless you choose otherwise This means that your family will have added fnancial resources to help with ongoing living expenses Afac group term life insurance plans are designed to provide you with cash benefts such as the following

bull Up to $100000 of Term Life coverage bull Waiver of premium bull Accidental death

This is a brief product overview only Products and benefts vary by state and may not be available in some states Plan design and optional benefts are selected at the employer level The plan has limitations and exclusions that may affect benefts payable Refer to the plan for complete details limitations and exclusions

Whole Life Insurance Afac group whole life insurance helps take care of your loved onesrsquo immediate and future needs if you should pass away Immediate needs can include burialfuneral expenses uninsured medical costs and current bills and debts Future needs could include income replacement education plans ongoing family obligations emergency funds and retirement expenses This plan also builds cash value

Itrsquos Insurance for Daily Living Afac pays cash benefts directly to you unless otherwise assigned This means that your family will have added fnancial resources to help with ongoing living expenses Afac group whole life insurance plans are designed to provide you with cash benefts such as the following

bull Up to $300000 of Whole Life coverage bull Waiver of premium bull Accidental death


For more information wwwafaccom 1-800-992-3522

18


Short Term Disability No one plans on becoming disabled It not something we typically think about and yet it is something that can happen to anyone If you get sick or hurt and could not work how would you pay the mortgage Buy groceries Make your car payment And all of the other bills that wonrsquot go away just because your paycheck is gone

This is where the Afac group short-term disability insurance plan can help make the difference The difference that means you will have a portion of your income to help take care of your bills while yoursquore taking care of yourself

Itrsquos Insurance for Daily Living Afac pays cash benefts directly to you unless you choose otherwise This means that you will have added fnancial resources to help with medical costs or ongoing living expenses Afac group disability insurance plans can help with everyday living expenses like your rent or mortgage utility bills groceries and more by providing benefts such as the following

bull Total disability bull Partial disability bull Waiver of premium


Critical Illness Chances are you know someone who has been diagnosed with a critical illness such as cancer a heart attack (myocardial infarction) or stroke You cannot help but notice the strain itrsquos placed on the personrsquos life both physically and emotionally Whatrsquos not so obvious is the impact on that personrsquos personal fnances While the person is busy getting well the bills may continue to pile up

Would You Have The Money to Cover the Out-of-Pocket Expenses such as bull Transportation to a distant medical facility bull Specialized treatment costs bull Living expenses like rent mortgage and utility bills

Itrsquos Insurance for Daily Living Afac pays cash benefts directly to you unless you choose otherwise This means that you will have added fnancial resources to help with medical costs or ongoing living expenses Afac group critical illness insurance plans are designed to provide you with cash benefts such as the following

bull Pays a lump sum beneft for a covered critical illness cancer heart attack and stroke



19


Accident Accidents can happen in an instant affecting you or a loved one Afac is designed to help families plan for the health care bumps ahead and take some of the uncertainty and fnancial insecurity out of getting better

Protection for the unexpected thatrsquos the beneft of the Afac Group Accident Plan After an accident you may have expenses yoursquove never thought about Can your fnances handle them Itrsquos reassuring to know that an accident insurance plan can be there for you in your time of need to help cover expenses such as

bull Ambulance rides bull Emergency room visits bull Surgery and anesthesia bull Prescriptions bull Major Diagnostic Testing bull Burns

Plan Features bull Benefts are paid directly to you unless otherwise assigned bull Coverage is guaranteed-issue (which means you may qualify for coverage without having

to answer health questions) bull Benefts are paid regardless of any other medical insurance

What you need when you need it Group accident insurance pays cash benefts that you can use any way you see ft


20


Hospital Indemnity The average cost per inpatient day for a hospital stay is $21571

As health care costs continue to rise you are responsible for paying more and more out-of-pocket costs with every accident and illness Afac is designed to help families plan for the health care bumps ahead and take some of the uncertainty and fnancial insecurity out of getting better

How will you help protect your savings when you have a covered accident or sickness

If you are confned to the hospital major medical insurance will help with many medical expenses but you could be left with out-of-pocket expenses You could also lose pay while yoursquore out of work And you can be sure that the bills will keep coming Afac is here to help

Itrsquos Insurance for Daily Living Afac pays cash benefts directly to you unless you choose otherwise This means that you will have added fnancial resources to help with medical costs or ongoing living expenses Afac group hospital indemnity insurance plans2 are designed to provide you with cash benefts to help with the following

bull Hospital Confnement Beneft bull Hospital Admission Beneft bull Hospital Intensive Care Beneft bull Intermediate Intensive Care Step-Down Unit bull Everyday living expenses like your rent or mortgage utility bills groceries and more bull It even provides coverage for newborn children for 60 days from the date of birth3

1 State Health Facts Kaiser Family Foundation 2015 httpwwwstatehealthfactsorg 2 This is a brief product overview only Products and benefts vary by state and may not be

available in some states Plan design and optional benefts are selected at the employer level The plan has limitations and exclusions that may affect benefts payable Refer to the plan for complete details limitations and exclusions

3 Applies to newly adopted children as well Refer to the plan for complete details


21

Legal Plan Legal Resources covers 100 of the attorney fees for fully covered legal matters Whether your legal matter is for an everyday legal need or a result of an unexpected life event you and your family will have immediate and ongoing access to a network of top-rated law frms in your area Donrsquot see your legal need listed below Donrsquot worry the Legal Resources Plan offer a 25 discount on less common services such as Immigration Tax Law Small Business Matters Bankruptcy Felonies and more The plan may be used as often as needed however it may not be used against your employer Your cost is only $1020 per pay period and covers you your spouse and qualifed dependent children up to age 26

General Advice and Consultation Prep and Review of Routine Legal Documents

Family Law Domestic adoption uncontested Real Estate Divorce uncontested Purchase sale or refnance of primary

residence Criminal Matters Tenant-landlord matters Defense of misdemeanor Misdemeanor defense of juvenile Wills and Estate Matters Elder Law

Will preparation and periodic updates Consumer Relations and Credit Protection Financial powers of attorney Warranty and billing disputes Contingent trust for minor children

Power of attorneys for members parents Civil Actions Estate Advice Representation as a defendant or plaintiff Insurance matters Traffc Violations Small claims court advice Speeding and reckless driving

Driving under the infuence (1st offense)

This summary of coverage is intended to provide a broad overview of plan coverage For specifc coverage questions call Member Services at 8007285768 Members are responsible for all non-attorney costs such as fling fees court cost fnes etc The plan may not be used against the administrator of the plan

Identity Protection Plan and Insurance Rates as low as $597 per pay period

Identity theft is the fastest growing crime in the US with more than 167 million victims last year alone The need for identity theft protection and insurance is rising and will continue to grow as we further integrate our lives electronically

We insure our homes our health and our cars Now you can safeguard your personal identity credit and fnancial well-being Our ID protection plans includes

bull 247 fully managed do-it-for-you resolution by Certifed identity Restoration Specialists bull $1 Million of identity theft insurance bull Real-time advanced identity monitoring with instant alerts bull Monthly credit reports and scores bull Lost wallet assistance bull Emergency cash and travel services bull Online data protection tools and software bull Personal and secure Dashboard with unlimited account monitoring bull Family plans available

For more information Legal Resources wwwlegalresourcescom 1-800-728-5768 or 757-498-1220

22

Important Information from Anthem Blue Cross and Blue Shield about Your Prescription Drug Beneft Plan and Medicare Employers must provide information regarding creditable coverage to allow Medicare-eligible members to make informed decisions regarding Medicare Part D coverage Anthem Blue Cross and Blue Shield has determined that the following prescription drug coverage plan is creditable for the 2017 Medicare Part D standard prescription drug beneft

Your Prescription Drug Plan

Retail Pharmacy CPS Wellness Center

Tier 1 $20 $2

Tier 2 $50 copay after $100 deductible $20


Tier 4 10 after $100 deductible (max $200) 10 (max $200)

Why is creditable coverage important Most employers that provide prescription drug coverage to Medicare-eligible members ndash including active employees retirees and their dependents ndash must disclose to those members whether that coverage is creditable or not creditable toward the Medicare Part D prescription drug beneft Benefciaries who are not covered under a creditable prescription drug plan and who choose not to enroll during the annual open enrollment period for Part D will pay a late enrollment penalty if they subsequently do choose to enroll in Medicare Part D

What do I need to do Notice to benefciaries must occur at the following times

bull Prior to the Annual Coordinated Enrollment Period (ACEP) each year which begins Jan 1 bull Prior to the effective date of the personrsquos enrollment in the plan bull At the time of any change in the creditable coverage status of the prescription drug plan bull Upon request from the benefciary

Notice to the Centers for Medicare amp Medicaid Services (CMS) whether coverage is creditable or non-creditable must occur at the following times

bull Within 60 days after the beginning date of the plan year bull Within 30 days after the termination of the prescription drug plan bull Within 30 days after any change in the creditable coverage status of the prescription drug

plan

To learn more about Medicare Part D creditable coverage and your responsibilities as a plan sponsor please visit CMS on the World Wide Web at httpwwwcmshhsgov EmplUnionPlanSponsorInfo

Date January 1 2020 Name of EntitySender Chesapeake Public Schools Contact PositionOffce Employee BeneftsRisk Management Address 312 Cedar Road Chesapeake VA 23322 Phone Number (757) 547-1343

23

Legal Notices The Womenrsquos Health and Cancer Rights Act The Womenrsquos Health and Cancer Right Act requires group health plans that provide coverage for mastectomy to provide coverage for certain reconstructive services This law also requires that written notice of the availability of the coverage be delivered to all plan participants upon enrollment and annually thereafter This language serves to fulfll that requirement for this year

These services include bull Reconstruction of the breast upon which the mastectomy has been performed bull Surgeryreconstruction of the other breast to produce a symmetrical appearance bull Prostheses and bull Treatment for physical complications during all stages of mastectomy including

lymphedemas

In Addition The Plan May Not bull Interfere with a participantrsquos rights under the plan to avoid these requirement or bull Offer inducements to the healthcare provider or assess penalties against the provider in

an attempt to interfere with the requirements of the law

However the plan may apply deductibles coinsurance and co-pays consistent with other coverage provided by the Plan If you have any questions about the current plan coverage please contact Employee Benefts and Risk Management at 757-547-1343

Know Your Cobra Notifcation Responsibilities It is your responsibility to notify Financial Service and Risk Management when a dependent becomes eligible or ceases to be eligible for coverage under our beneft plans All eligibility changes should be reported within 31 days of the event Failure to report changes in a timely manner can impact your ability to add newly eligible dependents or discontinue pre-tax premium contributions on ineligible dependents

In addition failure to report a loss of eligibility due to legal separation or divorce or a dependent that has otherwise ceased to be eligible such as a child reaching the maximum dependent child age limit can impact your dependentrsquos rights for group health plan coverage under the federal law known as COBRA If you fail to report the loss of eligibility within 31 days of the event your dependents may be left with no continuation coverage under our plan Please see your COBRA notice or your group health plan summary plan description for additional information

Protecting Your Health Information Privacy Rights Chesapeake Public Schools is committed to the privacy of your health information The administrators of the Chesapeake Public Schools Health Care Plan (the ldquoPlanrdquo) use strict privacy standards to protect your health information from unauthorized use or disclosure The Planrsquos policies protecting your privacy rights and your rights under the law are described in the Planrsquos Notice of Privacy Practices You may receive a copy of the Notice of Privacy Practices by contacting Employee Benefts and Risk Management

Notice of Your HIPPA Special Enrollment Rights Loss of Other Coverage - If you are declining enrollment for yourself andor your dependents (including your spouse) because of other health insurance coverage or group health plan coverage you may be able to enroll yourself andor your dependents in this plan if you or your dependents lose eligibility for that other coverage or if the employer stops contributing towards your or your dependentrsquos coverage To be eligible for this special enrollment opportunity you must request enrollment within 31 days after your other coverage ends or after the employer stops contributing towards the other coverage

24

Legal Notices New Dependent as a Result of Marriage Birth Adoption or Placement for Adoption - If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself andor your dependent(s) To be eligible for this special enrollment opportunity you must request enrollment within 31 days after the marriage birth adoption or placement for adoption

Medicaid Coverage - The Chesapeake Public Schools group health plan will allow an employee or dependent who is eligible but not enrolled for coverage to enroll for coverage if either of the following events occur

bull Termination of Medicaid or CHIP Coverage - If the employee or dependent is covered under a Medicaid plan or under a State child health plan (SCHIP) and coverage of the employee or dependent under such a plan is terminated as a result of loss of eligibility

bull Eligibility for Premium Assistance Under Medicaid or CHIP - If the employee or dependent becomes eligible for premium assistance under Medicaid or SCHIP including under any waiver or demonstration project conducted under or in relation to such a plan This is usually a program where the state assists employed individuals with premium payment assistance for their employerrsquos group health plan rather than direct enrollment in a state Medicaid program

To be eligible for this special enrollment opportunity you must request coverage under the group health plan within 31 days after the date the employee or dependent becomes eligible for premium assistance under Medicaid or SCHIP or the date you or your dependentrsquos Medicaid or state-sponsored CHIP coverage ends

To request special enrollment or obtain more information please contact Employee Benefts and Risk Management at 757-547-1343

Premium Assistance Under Medicaid and the Childrenrsquos Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace For more information visit wwwhealthcaregov

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below contact your State Medicaid or CHIP offce to fnd 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 contact your State Medicaid or CHIP offce or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to fnd out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan

If you or your dependents are eligible for premium assistance under Medicaid or CHIP as well as eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 31 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at wwwaskebsadolgov or call 1-866-444-EBSA (3272)

25

Legal Notices Virginia - Medicaid

Medicaid Website wwwcovervaorg Medicaid Phone 1-800-432-5924 CHIP Website wwwcovervaorg CHIP Phone 1-855-242-8282

To see if any other states have added a premium assistance program since July 31 2018 or for more information on special enrollment rights contact either

US Department of Labor US Department of Health and Human Services Employee Benefts Security Administration Centers for Medicare amp Medicaid Services 1-866-444-EBSA (3272) 1-877-267-2323 Menu Option 4 Ext 61565

26

Resources

Beneft Carrier Phone Website

Medical Anthem 1-800-451-1527 wwwanthemcom

Telehealth LiveHealth Online 1-888-548-3432 wwwlivehealthonlinecom

FSA Flexible Beneft Administrators 1-757-340-4567 wwwfex-admincom

HSA Anthem 1-800-451-1527 wwwanthemcom

Dental Anthem 1-866-956-8607 wwwanthemcom

Life and ADampD Anthem 1-800-451-1527 wwwanthemcom

Short Term Disability Group Term Life Whole Life Accident Critical Illness Hospital Indemnity

Afac 1-800-992-3522 wwwafaccom

Legal Plan Legal Resources 1-800-728-5768 wwwlegalresourcescom

Department of Employee Benefts and Risk Management

1-757-547-1343 cpsbeneftscpschoolscom

wwwcpschoolscom employee-benefts-risk-management

Retirement Plans Virginia Retirement System (VRS) 1-888-827-3847 wwwvaretireorg

Long Term Care (LTC) Genworth 1-866-859-6060 wwwvaretireorgmembersbenefts

long-term-care voluntary-long-term-careindexasp

ChesapeakePUBLIC SCHOOLS

INSPIRE ENGAGE EMPOWER

Welcome Chesapeake Public Schools (CPS) is excited to offer you and your family comprehensive benefts options designed to help you grow personally fnancially and professionally

This benefts guide contains an overview of the benefts package available to you through CPS You will fnd helpful information herein to assist you in understanding all benefts offered Please read your materials carefully to choose the options that best meet the needs of you and your family

As you prepare to enroll for benefts or make changes to your coverage consider the needs of you and your family throughout the entire year Keep this guide as reference to use throughout the year If you have any questions contact Employee Benefts and Risk Management or carrier directly

Availability of Summary Health Plan Information As an employee the health benefts available to you represent a signifcant component of your compensation package They also provide important protection for you and your family in the case of illness or injury

Your plan offers a series of health coverage options Choosing a health coverage option is an important decision To help you make an informed choice your plan makes available a Summary of Benefts and Coverage (SBC) which summarizes important information about any health coverage option in a standard format to help you compare across options

Disclaimer This document is an outline of the coverage proposed by the carrier(s) based on information provided by your company It does not include all of the terms coverage exclusions limitations and conditions of the actual contract language

The intent of this document is to provide you with general information regarding the status of andor potential concerns related to your current employee benefts environment It does not necessarily fully address all of your specifc issues It should not be construed as nor is it intended to provide legal advice

Medicare Part D mdash Prescription Drug Information If you are covered by Medicare or will become eligible for Medicare in the next 12 months a Federal law gives you more choices about your prescription drug coverage Please see page 23 for more details

2


Eligibility 5

Enrollment 6


Medical 9-11

Telehealth 12



Dental Plan 15

Long Term Care 16



Whole Life 18


Critical Illness 19

Accident 20


Legal Plan 22


Legal Notices 24-26

Resources 27

3

Benefts Glossary
















4

Eligibility
















5

Enrollment











6

Health and Wellness










7











8

9


















Coverage







their services




specialist














admission




















Employee Only $2900 $11200 $2100


Employee + Spouse $14300 $24900 $7100

Employee + Family $20300 $31900 $12900




10 10


Delivery Pharmacy

CPS Wellness Center


$20 copay $40 copay

$2 copay $4 copay



$20 copay


$40 copay



$80 copay


Specialty Drugs










11

Telehealth











12




Taxab1e Income





$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59
















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources




















Eligibility 5

Enrollment 6


Medical 9-11

Telehealth 12



Dental Plan 15

Long Term Care 16



Whole Life 18


Critical Illness 19

Accident 20


Legal Plan 22


Legal Notices 24-26

Resources 27

3

Benefts Glossary
















4

Eligibility
















5

Enrollment











6

Health and Wellness










7











8

9


















Coverage







their services




specialist














admission




















Employee Only $2900 $11200 $2100


Employee + Spouse $14300 $24900 $7100

Employee + Family $20300 $31900 $12900




10 10


Delivery Pharmacy

CPS Wellness Center


$20 copay $40 copay

$2 copay $4 copay



$20 copay


$40 copay



$80 copay


Specialty Drugs










11

Telehealth











12




Taxab1e Income





$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59
















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources



















Benefts Glossary
















4

Eligibility
















5

Enrollment











6

Health and Wellness










7











8

9


















Coverage







their services




specialist














admission




















Employee Only $2900 $11200 $2100


Employee + Spouse $14300 $24900 $7100

Employee + Family $20300 $31900 $12900




10 10


Delivery Pharmacy

CPS Wellness Center


$20 copay $40 copay

$2 copay $4 copay



$20 copay


$40 copay



$80 copay


Specialty Drugs










11

Telehealth











12




Taxab1e Income





$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59
















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources



















Eligibility
















5

Enrollment











6

Health and Wellness










7











8

9


















Coverage







their services




specialist














admission




















Employee Only $2900 $11200 $2100


Employee + Spouse $14300 $24900 $7100

Employee + Family $20300 $31900 $12900




10 10


Delivery Pharmacy

CPS Wellness Center


$20 copay $40 copay

$2 copay $4 copay



$20 copay


$40 copay



$80 copay


Specialty Drugs










11

Telehealth











12




Taxab1e Income





$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59
















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources



















Enrollment











6

Health and Wellness










7











8

9


















Coverage







their services




specialist














admission




















Employee Only $2900 $11200 $2100


Employee + Spouse $14300 $24900 $7100

Employee + Family $20300 $31900 $12900




10 10


Delivery Pharmacy

CPS Wellness Center


$20 copay $40 copay

$2 copay $4 copay



$20 copay


$40 copay



$80 copay


Specialty Drugs










11

Telehealth











12




Taxab1e Income





$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59
















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources



















Health and Wellness










7











8

9


















Coverage







their services




specialist














admission




















Employee Only $2900 $11200 $2100


Employee + Spouse $14300 $24900 $7100

Employee + Family $20300 $31900 $12900




10 10


Delivery Pharmacy

CPS Wellness Center


$20 copay $40 copay

$2 copay $4 copay



$20 copay


$40 copay



$80 copay


Specialty Drugs










11

Telehealth











12




Taxab1e Income





$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59
















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources





























8

9


















Coverage







their services




specialist














admission




















Employee Only $2900 $11200 $2100


Employee + Spouse $14300 $24900 $7100

Employee + Family $20300 $31900 $12900




10 10


Delivery Pharmacy

CPS Wellness Center


$20 copay $40 copay

$2 copay $4 copay



$20 copay


$40 copay



$80 copay


Specialty Drugs










11

Telehealth











12




Taxab1e Income





$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59
















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources



















9


















Coverage







their services




specialist














admission




















Employee Only $2900 $11200 $2100


Employee + Spouse $14300 $24900 $7100

Employee + Family $20300 $31900 $12900




10 10


Delivery Pharmacy

CPS Wellness Center


$20 copay $40 copay

$2 copay $4 copay



$20 copay


$40 copay



$80 copay


Specialty Drugs










11

Telehealth











12




Taxab1e Income





$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59
















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources




























Coverage







their services




specialist














admission




















Employee Only $2900 $11200 $2100


Employee + Spouse $14300 $24900 $7100

Employee + Family $20300 $31900 $12900




10 10


Delivery Pharmacy

CPS Wellness Center


$20 copay $40 copay

$2 copay $4 copay



$20 copay


$40 copay



$80 copay


Specialty Drugs










11

Telehealth











12




Taxab1e Income





$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59
















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources




















Delivery Pharmacy

CPS Wellness Center


$20 copay $40 copay

$2 copay $4 copay



$20 copay


$40 copay



$80 copay


Specialty Drugs










11

Telehealth











12




Taxab1e Income





$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59
















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources



















Telehealth











12




Taxab1e Income





$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59
















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources






















Taxab1e Income





$ 000 $ 000 $ 000

$2 50000

$ 37500 $ 12500 $ 19125

$ 20000 $ 6000 $ 30000

$124875

With Flex Benefits

$ 2500 00

$ 000 s 6000 $ 300 DO

$1 940 00

s 29100 $ 97 00 $ 14841

s 000 $ 0 00 $ 0 00

S 1403 59
















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources



















HSA




















14




$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources






















$50 $100

$50 $100



deductible


deductible










Employee Only $000



15






16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources
























16







17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources

























17











18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources





























18













19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources































19









20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources



























20












21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources






























21














22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources
































22




Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources






















Tier 1 $20 $2









plan



23



lymphedemas








24










25





26

Resources





















lymphedemas








24










25





26

Resources




























25





26

Resources























26

Resources



















Resources





















Date post:	04-Aug-2020
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