28
EMPLOYEE HEALTH & WELFARE BENEFITS GUIDE 2021
EMPLOYEE
HEALTH amp WELFARE
BENEFITS GUIDE 2021
2 BENEFITS GUIDE | 2021
03 Eligibility
04 Medical
07 Virtual Care
08 Omada
09 POPS
10 Vision
11 Dental
12 Basic Life ADampD LTD
13 Supplmental Life Insurance
14 Whole Life Insurance
15 Critical Illness
16 Accident Insurance
17 Short Term Disability
18 Flexible Spending Account
19 Aviben Mobile amp WEX Card
21 WEX Card FAQ
23 Employee Assistance Program
24 Retirement
25 Enrollment Instructions
WHATrsquoS INSIDE
2 BENEFITS GUIDE | 2020
IMPORTANTCONTACTS
EAPUNUMHealth Advocate800-854-1446wwwunumcomlifebalance
Uer ID and Password lifebalance
VOLUNTARY CRITICAL ILLNESS WHOLE LIFE amp INDIVIDUAL STDUNUM800-635-5597wwwunumcom
TRAVEL ASSISTANCEAssist America800-872-1414medservicesassistamericacom
FLEXIBLE SPENDING ACCOUNT (FSA)Educators Benefit Consultants1-888-507-6053avibencom
MEDICALMedica800-952-3455wwwmedicacom
DENTALDelta Dental800-448-3815wwwdeltadentalmnorg
VISIONAvesis800-828-9341wwwavesiscom
LIFE ACCIDENTAL DEATH AND DISMEMBERMENT (ADampD)UNUMInformation 800-421-0344Claims 800-858-6843wwwunumcom
LONG TERM DISABILITY (LTD)UNUM800-421-0344wwwunumcom
32021 | BENEFITS GUIDE
ELIGIBILITY GUIDELINES
All employees working at least 30 hours per week are eligible for coverage on the first day of the month following the date of hire with continuous full-time employment Eligibility hours vary for certain lines of coverage these are noted in each benefits section If you terminate employment or move to a part-time status your coverage will terminate on the last day of the month the changetermination occurs
Please note It is important that you enroll in a timely manner If you do not enroll within your first 30 days of employment you will not be eligible to enroll without a qualifying life event change until the next open enrollment period
WHOrsquoS ELIGIBLE FOR HEALTH amp WELFARE BENEFITS
3
Grand Forks Public Schools strives to provide a balanced comprehensive benefits program for their employees The Grand Forks Public Schools Employee Benefits program offers you core benefits such as Medical Dental Vision and Life insurance as well as voluntary amp supplemental benefits that help maximize your coverage options
This manual is designed to help you understand the coverage premiums and options for this year This is a reference for you and your family to make informed insurance decisions based on your specific needs
If you have questions please contact your Human Resources Department
Enroll in your benefits at wwwgrandforksbswiftcom
INFORMATION FOR 2021
There will be no rate or plan changes for medical dental and vision plans for this year There are two plans to choose from for health insurance Altru amp You with Medica or Medica Choice Passport Switching from one plan to the other is allowed during open enrollment Premiums depend on which plan you choose
Altru amp You with Medica This is a closed network which means medical services must be used at Altru or one of Altrursquos preferred providers this is a coordinated care model or Accountable Care Organization (ACO)
Medica Choice Passport This is an open network which means medical services can be used outside of the Altru network
Flex enrollment will be included in your benefits enrollment process The medical flex account maximum will remain at $2750
If you have a change in status you must notify Human Resources to complete the necessary change forms within 30 days of the change You may need to present documentation such as a social security card birth certificate marriage certificate death certificate or divorce
ELIGIBLE DEPENDENTS
+ Legal Spouse
+ Children under age 26 for medical dental and vision
+ Children who are disabled live with you and depend on you for support
QUALIFYING LIFE EVENTS
The following events allow you to change your benefits outside the benefit enrollment period (July 29 - August 13 2021)
+ You get married divorced or legally separated
+ You add a dependent child through birth adoption or change in custody
+ Your spouse or a dependent passes away
+ Your dependent loses coverage or gains other coverage
+ Your spouse loses or qualifies for coverage through his or her employer
Not sure if you have a qualifying event Need help changing your elections Please contact Human Resources
4 BENEFITS GUIDE | 2021
MEDICAL PLANSThe Companyrsquos Medical Plans are administered by Medica These plans are designed to help you maintain your health through preventive care services access to an extensive network of providers and affordable prescription medication
FIND A NETWORK DOCTORwwwmedicacom or call
1-800-952-3455
WELCOME TO MEDICA
HTTPGFSCHOOLSSTAGINGWELCOMETOMEDICACOMHOME
TERMS TO KNOW
Co-paymdashA fixed amount paid for receiving a specific healthcare service
DeductiblemdashThe amount you pay for covered services before the Plan will pay
Co-insurancemdashYour share of the cost for covered services calculated as a percentage of the total eligible expenses
Out-of-Pocket (OOP) MaximummdashProtects you from major expenses with a maximum annual limit on the amount you pay for covered services Your OOP max includes your deductible co-insurance and co-payments but not your employee contributions
Once you reach the OOP max the Plan pays 100 of covered services for the remainder of the year
WHAT IS A PPO PLAN
PPO stands for ldquoPreferred Provider Organizationrdquo PPO Plans allow you to visit any in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician
WHAT IS AN ACO PLAN
An Accountable Care Organization ACO is a group of doctors hospitals and other healthcare providers that work together to deliver the most coordinated treatment and care and may prevent you from having costly tests and treatments you may not need
52021 | BENEFITS GUIDE
Medica Choice Passport
Benefits In-Network Out-of-Network
Plan Year Deductible $1000 Single$1500 Single + Child(ren)
$2000 Family
$2000 Single$3000 Single + Child(ren)
$4000 Family
Plan Year Out-of-PocketMaximum
$3000 Single$4500 Single + Child(ren)
$6000 Family
$6000 Single$9000 Single + Child(ren)
$12000 Family
Preventive Care Covered 100 40 AD
Office Visits $25 copay then 20 40 AD
Emergency Room $150 copay
Urgent Care $25 copay then 20
Inpatient Hospital 20 AD 40 AD
Outpatient Hospital 20 AD 40 AD
Chiropractic Visits $25 copay then 20 40 AD 15 visits per year
Mental HealthOutpatientInpatient
$25 copay then 2020 AD
40 AD40 AD
Prescriptions - Retail and Mail Order In-network
GenericPreferred Brand
Non-preferred BrandSpecialty Preferred
Specialty Non-Preferred
$15 copay then 20$20 copay then 20$20 copay then 50$20 copay then 20$20 copay then 50
AD= After Deductible
MEDICA CHOICE PASSPORT PLANEmployees working 30 hours or more per week are eligible
6 BENEFITS GUIDE | 2021
ALTRU amp YOU MEDICAL PLANEmployees working 30 hours or more per week are eligible
Altru amp You
Benefits In-Network Out-of-Network
Plan Year Deductible $1000 Single$1500 Single + Child(ren)
$2000 Family
$2000 Single$3000 Single + Child(ren)
$4000 Family
Plan Year Out-of-PocketMaximum
$3000 Single$4500 Single + Child(ren)
$6000 Family
$6000 Single$9000 Single + Child(ren)
$12000 Family
Preventive Care Covered 100 40 AD
Office Visits $25 copay then 20 40 AD
Emergency Room $150 copay
Urgent Care $25 copay then 20
Inpatient Hospital 20 AD 40 AD
Outpatient Hospital 20 AD 40 AD
Chiropractic Visits $25 copay then 20 40 AD 15 visits per year
Mental HealthOutpatientInpatient
$25 copay then 2020 AD
40 AD40 AD
FIND A NETWORK DOCTOR
To find a network doctor visit wwwmedicacom or call 1-800-952-3455
Prescriptions - Retail and Mail Order In-network
GenericPreferred Brand
Non-preferred BrandSpecialty Preferred
Specialty Non-Preferred
$15 copay then 20$20 copay then 20$20 copay then 50$20 copay then 20$20 copay then 50
AD= After Deductible
72021 | BENEFITS GUIDE
VIRTUAL CARE
SEE A DOCTOR OR THERAPIST1 Launch the online visits app or
website and log in to your account
2 Choose a service medical therapy or psychiatry
3 Pick a doctor or begin a scheduled visit and enter your payment information
4 Meet with a doctor or therapist online
5 Get a prescription if appropriate sent to a local pharmacy
6 Send a visit summary to your primary care doctor or other health care provider at the end of the online visit
247 ACCESS TO CAREVirtual care also known as online care of an e-visit is a convenient way to get care for many
common conditions Connect with a provider from your computer or mobile device to get a
diagnosis treatment plan and prescription (if needed)
With a virtual care visit you
bull Save time ndash avoid a trip to the doctorrsquos office and get care from the comfort of your home
work or wherever you are
bull Initiate the visit at your convenience ndash no appointment needed
bull Get care when you need it ndash visits are often available after clinic hours sometimes even
247
bull May save money ndash a virtual care visit costs Grand Forks Public School plan participants only
$10 copay + 20 which is less than a regular doctor visit
+ Allergies
+ Bladder Infection
+ Bronchitis
+ Cold and Cough
+ Ear Pain
+ Flu
+ High Blood Pressure
+ Migraines
+ Pink Eye
AMWELL (In-Network for Medica and Altru)
Mobile - download the Amwell app
Web - visit Amwellcomcm
Phone - call 1-844-733-3627
You can access virtual care through providers in your planrsquos network Check your virtual care options at MedicacomFindaDoctor Your virtual care options may include
VIRTUWELL (In-Network for Medica)
(Out of Network for Altru Plans)
Web - visit Virtuwellcom
8 BENEFITS GUIDE | 2021
OMADA
JOIN OMADA TO BUILD HEALTHY HABITS THAT LAST
Omada can help you learn how to make smart food choices discover easy ways to boost your activity and overcome challenges preventing you from getting healthier Yoursquoll get support and strategies to motivate you to set and reach your goals
Eat healthier move more discover easy ways to sneak healthy choices into daily life
Develop a personalized plan whether it is meditation or medication zero in on your needs
Track progress seamlessly monitor your activity to discover what is (and is not) working
Break barriers to change gain powerful problem-solving skills to overcome challenges
Feel healthy for life set and reach your evolving goals with strategies and support
YOU WILL GET YOUR OWN
+ An interactive program with an engaging app
+ A wireless smart scale
+ Weekly online lessons
+ A professional health coach
+ A small online group of participants
WHAT IS OMADAAs a Medica member you can help reduce your risk for chronic disease through Omada a digital lifestyle change program Combining the latest technology with ongoing personal support you can make the changes that matter most - whether thatrsquos around eating activity sleep or stress Itrsquos an approach that can help you lose weight and reduce your risks for type 2 diabetes and heart disease
Omada is not available with all Medica health plans To check if you are eligible for this benefit call Medica Customer Service The number is on the back of your ID card
$0 COST TO YOUIf you or your adult dependents are Medica members and are at risk for type 2 diabetes or heart disease Omada is available at no additional cost Watch for more program information from your employer when your Medica health plan starts
GET STARTED WITH OMADA
Visit omadahealthcomgfps
92021 | BENEFITS GUIDE
POPS
POPS DIABETES CAREAs a Medica member you now have the option of participating on the Pops Diabetes Management program This health and wellness benefit is available to employees and their dependents that are covered under the Medica Health Plan and have been diagnosed with diabetes We are partnering with Pops Diabetes Care to offer a simple solution for managing diabetes No need to carry around a separate meter lancets lancet device and test strips Itrsquos all-in-one and at no cost to you
How to Enroll
1 Download the Pops Rebel app from the App Store or Google Play
2 Open the app and select ldquoIrsquom New Hererdquo
3 Enter your personal details including your name address member ID listed on your Medica ID card and Customer Code 52GFS
4 Receive your welcome kit in the mail about seven business days after you enroll Your welcome kit will include your testing equipment and supplies along with instructions
Itrsquos Different Itrsquos Unique You wonrsquot ever be defined by diabetes again - Own Your LIfe
Pops Support Squad1-800-767-7268 | supportsquadpopsdiabetescom | popsdiabetescom
10 BENEFITS GUIDE | 2021
The Company offers a comprehensive Vision Plan provided by Avesis The Vision Plan helps pay the cost of periodic eye examinations and necessary lenses and frames if prescribed The Plan covers services from any licensed provider but benefits are paid at a higher level when you use an in-network provider
In-network co-payments are paid directly to the provider Out-of-network co-payments are deducted from the out-of-network reimbursement
VOLUNTARY VISION PLAN
LOOKING FOR AN IN-NETWORK PROVIDER
For more information about the Vision Plan and to find in-network doctors visit
wwwavesiscom or call 1-800-828-9341
In-Network Out-of-Network
Comprehensive Exam(every 12 months)
$10 copay Up to $35
Standard Plastic Lens
Single $10 copay Up to $25
Bifocal $10 copay Up to $40
Trifocal $10 copay Up to $50
Standard Frames Up to $150 allowance Up to $45
Contacts (in lieu of frames) Up to $130 allowance $110
Medically Necessary Covered in full(Pre-Auth required)
$250
Vision Plan Highlights In-Network
Examinations One every 12 months
Lenses Once every 12 months
Frames Once every 24 months
Coverage Type Employee Cost Per Year
Employee $9216
EE + 1 $16104
Family $23940
LASIK PROVIDER
877-712-2010
Employees working 30 hours or more per week are eligible
112021 | BENEFITS GUIDE
DELTA DENTAL PLANYour dental health is a priority We offer generous coverage through Delta Dental of Minnesota
The Dental Plan encourages preventive treatment and allows you to achieve good oral health while minimizing your out-of-pocket dental expenses
Your out-of-pocket costs will be lower and you may even qualify for in-network discounts How
Check your ID card for your Network Go online to
wwwdeltadentalmnorg or call 800-247-4695
Select the PPO amp Premier Networks
In-Network Out-of-Network
Plan Year Deductible $50 Individual$150 Family
$50 Individual$150 Family
Annual Benefit Maximum $1250 per participant $1250 per participant
Preventive amp Diagnostic(Deductible Does Not Apply)
Covered 100 100 of maximum allowable fee
Basic Services(Fillings Extractions)
20 AD 20 of maximum allowable fee
Major Restorative Services(Crown Root Canal Implants)
50 AD 50 of maximum allowable fee
Orthodontics - Adult Not Covered
Orthodontics - Dependent Child(ren) under age 19
Not Covered
AD=After Deductible
Coverage Type Employee Cost Per Year
Employee $51936
EE + Spouse $117120
Employee + Child(ren) $99912
Family $167136
LOOKING FOR A DENTISTVisit deltadentalmnorg or call 1-800-448-3815
PPO amp Premier Networks
VOLUNTARY DENTAL PLAN
Employees working 30 hours or more per week are eligible
12 BENEFITS GUIDE | 2021
BASIC LIFE ADampD AND LTD BENEFITS
BASIC LIFE AND ADampD
Grand Forks Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Basic Life and ADampD Benefits
Administrator $50000
Certified amp Classified $15000
Accidental Death (ADampD) Mirrors Basic Life
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life expectancy has been reduced to less than
12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at age 68 60 at age 69 and 50 at 70+ years
Monthly Premium 100 Employer Paid
LTD COVERAGE
Grand Forks Public Schools provides LTD coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Long Term Disability
Maximum Benefit 6667 to a defined maximum
Benefit Duration(varies by the age of the employee)
Age at DisabilityLess than age 60Age 60 through age 64Age 65 through age 69Age 70+
Maximum Period of PaymentTo age 65 but not less than 5 years5 yearsTo age 70 but not less than 1 year1 year
Elimination Period After 90 days or end of sick leave (whichever is greater)
Coverage Basis AdministratorsTeachers2 year own occupation
Classified EmployeesAny occupation day one
Emergency Travel Assist(when traveling 100 or more miles or to another country)
Guaranteed hospital admission Emergency medical evacuation Prescription replacement
Monthly Premium 100 Employer Paid
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
2 BENEFITS GUIDE | 2021
03 Eligibility
04 Medical
07 Virtual Care
08 Omada
09 POPS
10 Vision
11 Dental
12 Basic Life ADampD LTD
13 Supplmental Life Insurance
14 Whole Life Insurance
15 Critical Illness
16 Accident Insurance
17 Short Term Disability
18 Flexible Spending Account
19 Aviben Mobile amp WEX Card
21 WEX Card FAQ
23 Employee Assistance Program
24 Retirement
25 Enrollment Instructions
WHATrsquoS INSIDE
2 BENEFITS GUIDE | 2020
IMPORTANTCONTACTS
EAPUNUMHealth Advocate800-854-1446wwwunumcomlifebalance
Uer ID and Password lifebalance
VOLUNTARY CRITICAL ILLNESS WHOLE LIFE amp INDIVIDUAL STDUNUM800-635-5597wwwunumcom
TRAVEL ASSISTANCEAssist America800-872-1414medservicesassistamericacom
FLEXIBLE SPENDING ACCOUNT (FSA)Educators Benefit Consultants1-888-507-6053avibencom
MEDICALMedica800-952-3455wwwmedicacom
DENTALDelta Dental800-448-3815wwwdeltadentalmnorg
VISIONAvesis800-828-9341wwwavesiscom
LIFE ACCIDENTAL DEATH AND DISMEMBERMENT (ADampD)UNUMInformation 800-421-0344Claims 800-858-6843wwwunumcom
LONG TERM DISABILITY (LTD)UNUM800-421-0344wwwunumcom
32021 | BENEFITS GUIDE
ELIGIBILITY GUIDELINES
All employees working at least 30 hours per week are eligible for coverage on the first day of the month following the date of hire with continuous full-time employment Eligibility hours vary for certain lines of coverage these are noted in each benefits section If you terminate employment or move to a part-time status your coverage will terminate on the last day of the month the changetermination occurs
Please note It is important that you enroll in a timely manner If you do not enroll within your first 30 days of employment you will not be eligible to enroll without a qualifying life event change until the next open enrollment period
WHOrsquoS ELIGIBLE FOR HEALTH amp WELFARE BENEFITS
3
Grand Forks Public Schools strives to provide a balanced comprehensive benefits program for their employees The Grand Forks Public Schools Employee Benefits program offers you core benefits such as Medical Dental Vision and Life insurance as well as voluntary amp supplemental benefits that help maximize your coverage options
This manual is designed to help you understand the coverage premiums and options for this year This is a reference for you and your family to make informed insurance decisions based on your specific needs
If you have questions please contact your Human Resources Department
Enroll in your benefits at wwwgrandforksbswiftcom
INFORMATION FOR 2021
There will be no rate or plan changes for medical dental and vision plans for this year There are two plans to choose from for health insurance Altru amp You with Medica or Medica Choice Passport Switching from one plan to the other is allowed during open enrollment Premiums depend on which plan you choose
Altru amp You with Medica This is a closed network which means medical services must be used at Altru or one of Altrursquos preferred providers this is a coordinated care model or Accountable Care Organization (ACO)
Medica Choice Passport This is an open network which means medical services can be used outside of the Altru network
Flex enrollment will be included in your benefits enrollment process The medical flex account maximum will remain at $2750
If you have a change in status you must notify Human Resources to complete the necessary change forms within 30 days of the change You may need to present documentation such as a social security card birth certificate marriage certificate death certificate or divorce
ELIGIBLE DEPENDENTS
+ Legal Spouse
+ Children under age 26 for medical dental and vision
+ Children who are disabled live with you and depend on you for support
QUALIFYING LIFE EVENTS
The following events allow you to change your benefits outside the benefit enrollment period (July 29 - August 13 2021)
+ You get married divorced or legally separated
+ You add a dependent child through birth adoption or change in custody
+ Your spouse or a dependent passes away
+ Your dependent loses coverage or gains other coverage
+ Your spouse loses or qualifies for coverage through his or her employer
Not sure if you have a qualifying event Need help changing your elections Please contact Human Resources
4 BENEFITS GUIDE | 2021
MEDICAL PLANSThe Companyrsquos Medical Plans are administered by Medica These plans are designed to help you maintain your health through preventive care services access to an extensive network of providers and affordable prescription medication
FIND A NETWORK DOCTORwwwmedicacom or call
1-800-952-3455
WELCOME TO MEDICA
HTTPGFSCHOOLSSTAGINGWELCOMETOMEDICACOMHOME
TERMS TO KNOW
Co-paymdashA fixed amount paid for receiving a specific healthcare service
DeductiblemdashThe amount you pay for covered services before the Plan will pay
Co-insurancemdashYour share of the cost for covered services calculated as a percentage of the total eligible expenses
Out-of-Pocket (OOP) MaximummdashProtects you from major expenses with a maximum annual limit on the amount you pay for covered services Your OOP max includes your deductible co-insurance and co-payments but not your employee contributions
Once you reach the OOP max the Plan pays 100 of covered services for the remainder of the year
WHAT IS A PPO PLAN
PPO stands for ldquoPreferred Provider Organizationrdquo PPO Plans allow you to visit any in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician
WHAT IS AN ACO PLAN
An Accountable Care Organization ACO is a group of doctors hospitals and other healthcare providers that work together to deliver the most coordinated treatment and care and may prevent you from having costly tests and treatments you may not need
52021 | BENEFITS GUIDE
Medica Choice Passport
Benefits In-Network Out-of-Network
Plan Year Deductible $1000 Single$1500 Single + Child(ren)
$2000 Family
$2000 Single$3000 Single + Child(ren)
$4000 Family
Plan Year Out-of-PocketMaximum
$3000 Single$4500 Single + Child(ren)
$6000 Family
$6000 Single$9000 Single + Child(ren)
$12000 Family
Preventive Care Covered 100 40 AD
Office Visits $25 copay then 20 40 AD
Emergency Room $150 copay
Urgent Care $25 copay then 20
Inpatient Hospital 20 AD 40 AD
Outpatient Hospital 20 AD 40 AD
Chiropractic Visits $25 copay then 20 40 AD 15 visits per year
Mental HealthOutpatientInpatient
$25 copay then 2020 AD
40 AD40 AD
Prescriptions - Retail and Mail Order In-network
GenericPreferred Brand
Non-preferred BrandSpecialty Preferred
Specialty Non-Preferred
$15 copay then 20$20 copay then 20$20 copay then 50$20 copay then 20$20 copay then 50
AD= After Deductible
MEDICA CHOICE PASSPORT PLANEmployees working 30 hours or more per week are eligible
6 BENEFITS GUIDE | 2021
ALTRU amp YOU MEDICAL PLANEmployees working 30 hours or more per week are eligible
Altru amp You
Benefits In-Network Out-of-Network
Plan Year Deductible $1000 Single$1500 Single + Child(ren)
$2000 Family
$2000 Single$3000 Single + Child(ren)
$4000 Family
Plan Year Out-of-PocketMaximum
$3000 Single$4500 Single + Child(ren)
$6000 Family
$6000 Single$9000 Single + Child(ren)
$12000 Family
Preventive Care Covered 100 40 AD
Office Visits $25 copay then 20 40 AD
Emergency Room $150 copay
Urgent Care $25 copay then 20
Inpatient Hospital 20 AD 40 AD
Outpatient Hospital 20 AD 40 AD
Chiropractic Visits $25 copay then 20 40 AD 15 visits per year
Mental HealthOutpatientInpatient
$25 copay then 2020 AD
40 AD40 AD
FIND A NETWORK DOCTOR
To find a network doctor visit wwwmedicacom or call 1-800-952-3455
Prescriptions - Retail and Mail Order In-network
GenericPreferred Brand
Non-preferred BrandSpecialty Preferred
Specialty Non-Preferred
$15 copay then 20$20 copay then 20$20 copay then 50$20 copay then 20$20 copay then 50
AD= After Deductible
72021 | BENEFITS GUIDE
VIRTUAL CARE
SEE A DOCTOR OR THERAPIST1 Launch the online visits app or
website and log in to your account
2 Choose a service medical therapy or psychiatry
3 Pick a doctor or begin a scheduled visit and enter your payment information
4 Meet with a doctor or therapist online
5 Get a prescription if appropriate sent to a local pharmacy
6 Send a visit summary to your primary care doctor or other health care provider at the end of the online visit
247 ACCESS TO CAREVirtual care also known as online care of an e-visit is a convenient way to get care for many
common conditions Connect with a provider from your computer or mobile device to get a
diagnosis treatment plan and prescription (if needed)
With a virtual care visit you
bull Save time ndash avoid a trip to the doctorrsquos office and get care from the comfort of your home
work or wherever you are
bull Initiate the visit at your convenience ndash no appointment needed
bull Get care when you need it ndash visits are often available after clinic hours sometimes even
247
bull May save money ndash a virtual care visit costs Grand Forks Public School plan participants only
$10 copay + 20 which is less than a regular doctor visit
+ Allergies
+ Bladder Infection
+ Bronchitis
+ Cold and Cough
+ Ear Pain
+ Flu
+ High Blood Pressure
+ Migraines
+ Pink Eye
AMWELL (In-Network for Medica and Altru)
Mobile - download the Amwell app
Web - visit Amwellcomcm
Phone - call 1-844-733-3627
You can access virtual care through providers in your planrsquos network Check your virtual care options at MedicacomFindaDoctor Your virtual care options may include
VIRTUWELL (In-Network for Medica)
(Out of Network for Altru Plans)
Web - visit Virtuwellcom
8 BENEFITS GUIDE | 2021
OMADA
JOIN OMADA TO BUILD HEALTHY HABITS THAT LAST
Omada can help you learn how to make smart food choices discover easy ways to boost your activity and overcome challenges preventing you from getting healthier Yoursquoll get support and strategies to motivate you to set and reach your goals
Eat healthier move more discover easy ways to sneak healthy choices into daily life
Develop a personalized plan whether it is meditation or medication zero in on your needs
Track progress seamlessly monitor your activity to discover what is (and is not) working
Break barriers to change gain powerful problem-solving skills to overcome challenges
Feel healthy for life set and reach your evolving goals with strategies and support
YOU WILL GET YOUR OWN
+ An interactive program with an engaging app
+ A wireless smart scale
+ Weekly online lessons
+ A professional health coach
+ A small online group of participants
WHAT IS OMADAAs a Medica member you can help reduce your risk for chronic disease through Omada a digital lifestyle change program Combining the latest technology with ongoing personal support you can make the changes that matter most - whether thatrsquos around eating activity sleep or stress Itrsquos an approach that can help you lose weight and reduce your risks for type 2 diabetes and heart disease
Omada is not available with all Medica health plans To check if you are eligible for this benefit call Medica Customer Service The number is on the back of your ID card
$0 COST TO YOUIf you or your adult dependents are Medica members and are at risk for type 2 diabetes or heart disease Omada is available at no additional cost Watch for more program information from your employer when your Medica health plan starts
GET STARTED WITH OMADA
Visit omadahealthcomgfps
92021 | BENEFITS GUIDE
POPS
POPS DIABETES CAREAs a Medica member you now have the option of participating on the Pops Diabetes Management program This health and wellness benefit is available to employees and their dependents that are covered under the Medica Health Plan and have been diagnosed with diabetes We are partnering with Pops Diabetes Care to offer a simple solution for managing diabetes No need to carry around a separate meter lancets lancet device and test strips Itrsquos all-in-one and at no cost to you
How to Enroll
1 Download the Pops Rebel app from the App Store or Google Play
2 Open the app and select ldquoIrsquom New Hererdquo
3 Enter your personal details including your name address member ID listed on your Medica ID card and Customer Code 52GFS
4 Receive your welcome kit in the mail about seven business days after you enroll Your welcome kit will include your testing equipment and supplies along with instructions
Itrsquos Different Itrsquos Unique You wonrsquot ever be defined by diabetes again - Own Your LIfe
Pops Support Squad1-800-767-7268 | supportsquadpopsdiabetescom | popsdiabetescom
10 BENEFITS GUIDE | 2021
The Company offers a comprehensive Vision Plan provided by Avesis The Vision Plan helps pay the cost of periodic eye examinations and necessary lenses and frames if prescribed The Plan covers services from any licensed provider but benefits are paid at a higher level when you use an in-network provider
In-network co-payments are paid directly to the provider Out-of-network co-payments are deducted from the out-of-network reimbursement
VOLUNTARY VISION PLAN
LOOKING FOR AN IN-NETWORK PROVIDER
For more information about the Vision Plan and to find in-network doctors visit
wwwavesiscom or call 1-800-828-9341
In-Network Out-of-Network
Comprehensive Exam(every 12 months)
$10 copay Up to $35
Standard Plastic Lens
Single $10 copay Up to $25
Bifocal $10 copay Up to $40
Trifocal $10 copay Up to $50
Standard Frames Up to $150 allowance Up to $45
Contacts (in lieu of frames) Up to $130 allowance $110
Medically Necessary Covered in full(Pre-Auth required)
$250
Vision Plan Highlights In-Network
Examinations One every 12 months
Lenses Once every 12 months
Frames Once every 24 months
Coverage Type Employee Cost Per Year
Employee $9216
EE + 1 $16104
Family $23940
LASIK PROVIDER
877-712-2010
Employees working 30 hours or more per week are eligible
112021 | BENEFITS GUIDE
DELTA DENTAL PLANYour dental health is a priority We offer generous coverage through Delta Dental of Minnesota
The Dental Plan encourages preventive treatment and allows you to achieve good oral health while minimizing your out-of-pocket dental expenses
Your out-of-pocket costs will be lower and you may even qualify for in-network discounts How
Check your ID card for your Network Go online to
wwwdeltadentalmnorg or call 800-247-4695
Select the PPO amp Premier Networks
In-Network Out-of-Network
Plan Year Deductible $50 Individual$150 Family
$50 Individual$150 Family
Annual Benefit Maximum $1250 per participant $1250 per participant
Preventive amp Diagnostic(Deductible Does Not Apply)
Covered 100 100 of maximum allowable fee
Basic Services(Fillings Extractions)
20 AD 20 of maximum allowable fee
Major Restorative Services(Crown Root Canal Implants)
50 AD 50 of maximum allowable fee
Orthodontics - Adult Not Covered
Orthodontics - Dependent Child(ren) under age 19
Not Covered
AD=After Deductible
Coverage Type Employee Cost Per Year
Employee $51936
EE + Spouse $117120
Employee + Child(ren) $99912
Family $167136
LOOKING FOR A DENTISTVisit deltadentalmnorg or call 1-800-448-3815
PPO amp Premier Networks
VOLUNTARY DENTAL PLAN
Employees working 30 hours or more per week are eligible
12 BENEFITS GUIDE | 2021
BASIC LIFE ADampD AND LTD BENEFITS
BASIC LIFE AND ADampD
Grand Forks Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Basic Life and ADampD Benefits
Administrator $50000
Certified amp Classified $15000
Accidental Death (ADampD) Mirrors Basic Life
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life expectancy has been reduced to less than
12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at age 68 60 at age 69 and 50 at 70+ years
Monthly Premium 100 Employer Paid
LTD COVERAGE
Grand Forks Public Schools provides LTD coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Long Term Disability
Maximum Benefit 6667 to a defined maximum
Benefit Duration(varies by the age of the employee)
Age at DisabilityLess than age 60Age 60 through age 64Age 65 through age 69Age 70+
Maximum Period of PaymentTo age 65 but not less than 5 years5 yearsTo age 70 but not less than 1 year1 year
Elimination Period After 90 days or end of sick leave (whichever is greater)
Coverage Basis AdministratorsTeachers2 year own occupation
Classified EmployeesAny occupation day one
Emergency Travel Assist(when traveling 100 or more miles or to another country)
Guaranteed hospital admission Emergency medical evacuation Prescription replacement
Monthly Premium 100 Employer Paid
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
32021 | BENEFITS GUIDE
ELIGIBILITY GUIDELINES
All employees working at least 30 hours per week are eligible for coverage on the first day of the month following the date of hire with continuous full-time employment Eligibility hours vary for certain lines of coverage these are noted in each benefits section If you terminate employment or move to a part-time status your coverage will terminate on the last day of the month the changetermination occurs
Please note It is important that you enroll in a timely manner If you do not enroll within your first 30 days of employment you will not be eligible to enroll without a qualifying life event change until the next open enrollment period
WHOrsquoS ELIGIBLE FOR HEALTH amp WELFARE BENEFITS
3
Grand Forks Public Schools strives to provide a balanced comprehensive benefits program for their employees The Grand Forks Public Schools Employee Benefits program offers you core benefits such as Medical Dental Vision and Life insurance as well as voluntary amp supplemental benefits that help maximize your coverage options
This manual is designed to help you understand the coverage premiums and options for this year This is a reference for you and your family to make informed insurance decisions based on your specific needs
If you have questions please contact your Human Resources Department
Enroll in your benefits at wwwgrandforksbswiftcom
INFORMATION FOR 2021
There will be no rate or plan changes for medical dental and vision plans for this year There are two plans to choose from for health insurance Altru amp You with Medica or Medica Choice Passport Switching from one plan to the other is allowed during open enrollment Premiums depend on which plan you choose
Altru amp You with Medica This is a closed network which means medical services must be used at Altru or one of Altrursquos preferred providers this is a coordinated care model or Accountable Care Organization (ACO)
Medica Choice Passport This is an open network which means medical services can be used outside of the Altru network
Flex enrollment will be included in your benefits enrollment process The medical flex account maximum will remain at $2750
If you have a change in status you must notify Human Resources to complete the necessary change forms within 30 days of the change You may need to present documentation such as a social security card birth certificate marriage certificate death certificate or divorce
ELIGIBLE DEPENDENTS
+ Legal Spouse
+ Children under age 26 for medical dental and vision
+ Children who are disabled live with you and depend on you for support
QUALIFYING LIFE EVENTS
The following events allow you to change your benefits outside the benefit enrollment period (July 29 - August 13 2021)
+ You get married divorced or legally separated
+ You add a dependent child through birth adoption or change in custody
+ Your spouse or a dependent passes away
+ Your dependent loses coverage or gains other coverage
+ Your spouse loses or qualifies for coverage through his or her employer
Not sure if you have a qualifying event Need help changing your elections Please contact Human Resources
4 BENEFITS GUIDE | 2021
MEDICAL PLANSThe Companyrsquos Medical Plans are administered by Medica These plans are designed to help you maintain your health through preventive care services access to an extensive network of providers and affordable prescription medication
FIND A NETWORK DOCTORwwwmedicacom or call
1-800-952-3455
WELCOME TO MEDICA
HTTPGFSCHOOLSSTAGINGWELCOMETOMEDICACOMHOME
TERMS TO KNOW
Co-paymdashA fixed amount paid for receiving a specific healthcare service
DeductiblemdashThe amount you pay for covered services before the Plan will pay
Co-insurancemdashYour share of the cost for covered services calculated as a percentage of the total eligible expenses
Out-of-Pocket (OOP) MaximummdashProtects you from major expenses with a maximum annual limit on the amount you pay for covered services Your OOP max includes your deductible co-insurance and co-payments but not your employee contributions
Once you reach the OOP max the Plan pays 100 of covered services for the remainder of the year
WHAT IS A PPO PLAN
PPO stands for ldquoPreferred Provider Organizationrdquo PPO Plans allow you to visit any in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician
WHAT IS AN ACO PLAN
An Accountable Care Organization ACO is a group of doctors hospitals and other healthcare providers that work together to deliver the most coordinated treatment and care and may prevent you from having costly tests and treatments you may not need
52021 | BENEFITS GUIDE
Medica Choice Passport
Benefits In-Network Out-of-Network
Plan Year Deductible $1000 Single$1500 Single + Child(ren)
$2000 Family
$2000 Single$3000 Single + Child(ren)
$4000 Family
Plan Year Out-of-PocketMaximum
$3000 Single$4500 Single + Child(ren)
$6000 Family
$6000 Single$9000 Single + Child(ren)
$12000 Family
Preventive Care Covered 100 40 AD
Office Visits $25 copay then 20 40 AD
Emergency Room $150 copay
Urgent Care $25 copay then 20
Inpatient Hospital 20 AD 40 AD
Outpatient Hospital 20 AD 40 AD
Chiropractic Visits $25 copay then 20 40 AD 15 visits per year
Mental HealthOutpatientInpatient
$25 copay then 2020 AD
40 AD40 AD
Prescriptions - Retail and Mail Order In-network
GenericPreferred Brand
Non-preferred BrandSpecialty Preferred
Specialty Non-Preferred
$15 copay then 20$20 copay then 20$20 copay then 50$20 copay then 20$20 copay then 50
AD= After Deductible
MEDICA CHOICE PASSPORT PLANEmployees working 30 hours or more per week are eligible
6 BENEFITS GUIDE | 2021
ALTRU amp YOU MEDICAL PLANEmployees working 30 hours or more per week are eligible
Altru amp You
Benefits In-Network Out-of-Network
Plan Year Deductible $1000 Single$1500 Single + Child(ren)
$2000 Family
$2000 Single$3000 Single + Child(ren)
$4000 Family
Plan Year Out-of-PocketMaximum
$3000 Single$4500 Single + Child(ren)
$6000 Family
$6000 Single$9000 Single + Child(ren)
$12000 Family
Preventive Care Covered 100 40 AD
Office Visits $25 copay then 20 40 AD
Emergency Room $150 copay
Urgent Care $25 copay then 20
Inpatient Hospital 20 AD 40 AD
Outpatient Hospital 20 AD 40 AD
Chiropractic Visits $25 copay then 20 40 AD 15 visits per year
Mental HealthOutpatientInpatient
$25 copay then 2020 AD
40 AD40 AD
FIND A NETWORK DOCTOR
To find a network doctor visit wwwmedicacom or call 1-800-952-3455
Prescriptions - Retail and Mail Order In-network
GenericPreferred Brand
Non-preferred BrandSpecialty Preferred
Specialty Non-Preferred
$15 copay then 20$20 copay then 20$20 copay then 50$20 copay then 20$20 copay then 50
AD= After Deductible
72021 | BENEFITS GUIDE
VIRTUAL CARE
SEE A DOCTOR OR THERAPIST1 Launch the online visits app or
website and log in to your account
2 Choose a service medical therapy or psychiatry
3 Pick a doctor or begin a scheduled visit and enter your payment information
4 Meet with a doctor or therapist online
5 Get a prescription if appropriate sent to a local pharmacy
6 Send a visit summary to your primary care doctor or other health care provider at the end of the online visit
247 ACCESS TO CAREVirtual care also known as online care of an e-visit is a convenient way to get care for many
common conditions Connect with a provider from your computer or mobile device to get a
diagnosis treatment plan and prescription (if needed)
With a virtual care visit you
bull Save time ndash avoid a trip to the doctorrsquos office and get care from the comfort of your home
work or wherever you are
bull Initiate the visit at your convenience ndash no appointment needed
bull Get care when you need it ndash visits are often available after clinic hours sometimes even
247
bull May save money ndash a virtual care visit costs Grand Forks Public School plan participants only
$10 copay + 20 which is less than a regular doctor visit
+ Allergies
+ Bladder Infection
+ Bronchitis
+ Cold and Cough
+ Ear Pain
+ Flu
+ High Blood Pressure
+ Migraines
+ Pink Eye
AMWELL (In-Network for Medica and Altru)
Mobile - download the Amwell app
Web - visit Amwellcomcm
Phone - call 1-844-733-3627
You can access virtual care through providers in your planrsquos network Check your virtual care options at MedicacomFindaDoctor Your virtual care options may include
VIRTUWELL (In-Network for Medica)
(Out of Network for Altru Plans)
Web - visit Virtuwellcom
8 BENEFITS GUIDE | 2021
OMADA
JOIN OMADA TO BUILD HEALTHY HABITS THAT LAST
Omada can help you learn how to make smart food choices discover easy ways to boost your activity and overcome challenges preventing you from getting healthier Yoursquoll get support and strategies to motivate you to set and reach your goals
Eat healthier move more discover easy ways to sneak healthy choices into daily life
Develop a personalized plan whether it is meditation or medication zero in on your needs
Track progress seamlessly monitor your activity to discover what is (and is not) working
Break barriers to change gain powerful problem-solving skills to overcome challenges
Feel healthy for life set and reach your evolving goals with strategies and support
YOU WILL GET YOUR OWN
+ An interactive program with an engaging app
+ A wireless smart scale
+ Weekly online lessons
+ A professional health coach
+ A small online group of participants
WHAT IS OMADAAs a Medica member you can help reduce your risk for chronic disease through Omada a digital lifestyle change program Combining the latest technology with ongoing personal support you can make the changes that matter most - whether thatrsquos around eating activity sleep or stress Itrsquos an approach that can help you lose weight and reduce your risks for type 2 diabetes and heart disease
Omada is not available with all Medica health plans To check if you are eligible for this benefit call Medica Customer Service The number is on the back of your ID card
$0 COST TO YOUIf you or your adult dependents are Medica members and are at risk for type 2 diabetes or heart disease Omada is available at no additional cost Watch for more program information from your employer when your Medica health plan starts
GET STARTED WITH OMADA
Visit omadahealthcomgfps
92021 | BENEFITS GUIDE
POPS
POPS DIABETES CAREAs a Medica member you now have the option of participating on the Pops Diabetes Management program This health and wellness benefit is available to employees and their dependents that are covered under the Medica Health Plan and have been diagnosed with diabetes We are partnering with Pops Diabetes Care to offer a simple solution for managing diabetes No need to carry around a separate meter lancets lancet device and test strips Itrsquos all-in-one and at no cost to you
How to Enroll
1 Download the Pops Rebel app from the App Store or Google Play
2 Open the app and select ldquoIrsquom New Hererdquo
3 Enter your personal details including your name address member ID listed on your Medica ID card and Customer Code 52GFS
4 Receive your welcome kit in the mail about seven business days after you enroll Your welcome kit will include your testing equipment and supplies along with instructions
Itrsquos Different Itrsquos Unique You wonrsquot ever be defined by diabetes again - Own Your LIfe
Pops Support Squad1-800-767-7268 | supportsquadpopsdiabetescom | popsdiabetescom
10 BENEFITS GUIDE | 2021
The Company offers a comprehensive Vision Plan provided by Avesis The Vision Plan helps pay the cost of periodic eye examinations and necessary lenses and frames if prescribed The Plan covers services from any licensed provider but benefits are paid at a higher level when you use an in-network provider
In-network co-payments are paid directly to the provider Out-of-network co-payments are deducted from the out-of-network reimbursement
VOLUNTARY VISION PLAN
LOOKING FOR AN IN-NETWORK PROVIDER
For more information about the Vision Plan and to find in-network doctors visit
wwwavesiscom or call 1-800-828-9341
In-Network Out-of-Network
Comprehensive Exam(every 12 months)
$10 copay Up to $35
Standard Plastic Lens
Single $10 copay Up to $25
Bifocal $10 copay Up to $40
Trifocal $10 copay Up to $50
Standard Frames Up to $150 allowance Up to $45
Contacts (in lieu of frames) Up to $130 allowance $110
Medically Necessary Covered in full(Pre-Auth required)
$250
Vision Plan Highlights In-Network
Examinations One every 12 months
Lenses Once every 12 months
Frames Once every 24 months
Coverage Type Employee Cost Per Year
Employee $9216
EE + 1 $16104
Family $23940
LASIK PROVIDER
877-712-2010
Employees working 30 hours or more per week are eligible
112021 | BENEFITS GUIDE
DELTA DENTAL PLANYour dental health is a priority We offer generous coverage through Delta Dental of Minnesota
The Dental Plan encourages preventive treatment and allows you to achieve good oral health while minimizing your out-of-pocket dental expenses
Your out-of-pocket costs will be lower and you may even qualify for in-network discounts How
Check your ID card for your Network Go online to
wwwdeltadentalmnorg or call 800-247-4695
Select the PPO amp Premier Networks
In-Network Out-of-Network
Plan Year Deductible $50 Individual$150 Family
$50 Individual$150 Family
Annual Benefit Maximum $1250 per participant $1250 per participant
Preventive amp Diagnostic(Deductible Does Not Apply)
Covered 100 100 of maximum allowable fee
Basic Services(Fillings Extractions)
20 AD 20 of maximum allowable fee
Major Restorative Services(Crown Root Canal Implants)
50 AD 50 of maximum allowable fee
Orthodontics - Adult Not Covered
Orthodontics - Dependent Child(ren) under age 19
Not Covered
AD=After Deductible
Coverage Type Employee Cost Per Year
Employee $51936
EE + Spouse $117120
Employee + Child(ren) $99912
Family $167136
LOOKING FOR A DENTISTVisit deltadentalmnorg or call 1-800-448-3815
PPO amp Premier Networks
VOLUNTARY DENTAL PLAN
Employees working 30 hours or more per week are eligible
12 BENEFITS GUIDE | 2021
BASIC LIFE ADampD AND LTD BENEFITS
BASIC LIFE AND ADampD
Grand Forks Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Basic Life and ADampD Benefits
Administrator $50000
Certified amp Classified $15000
Accidental Death (ADampD) Mirrors Basic Life
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life expectancy has been reduced to less than
12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at age 68 60 at age 69 and 50 at 70+ years
Monthly Premium 100 Employer Paid
LTD COVERAGE
Grand Forks Public Schools provides LTD coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Long Term Disability
Maximum Benefit 6667 to a defined maximum
Benefit Duration(varies by the age of the employee)
Age at DisabilityLess than age 60Age 60 through age 64Age 65 through age 69Age 70+
Maximum Period of PaymentTo age 65 but not less than 5 years5 yearsTo age 70 but not less than 1 year1 year
Elimination Period After 90 days or end of sick leave (whichever is greater)
Coverage Basis AdministratorsTeachers2 year own occupation
Classified EmployeesAny occupation day one
Emergency Travel Assist(when traveling 100 or more miles or to another country)
Guaranteed hospital admission Emergency medical evacuation Prescription replacement
Monthly Premium 100 Employer Paid
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
4 BENEFITS GUIDE | 2021
MEDICAL PLANSThe Companyrsquos Medical Plans are administered by Medica These plans are designed to help you maintain your health through preventive care services access to an extensive network of providers and affordable prescription medication
FIND A NETWORK DOCTORwwwmedicacom or call
1-800-952-3455
WELCOME TO MEDICA
HTTPGFSCHOOLSSTAGINGWELCOMETOMEDICACOMHOME
TERMS TO KNOW
Co-paymdashA fixed amount paid for receiving a specific healthcare service
DeductiblemdashThe amount you pay for covered services before the Plan will pay
Co-insurancemdashYour share of the cost for covered services calculated as a percentage of the total eligible expenses
Out-of-Pocket (OOP) MaximummdashProtects you from major expenses with a maximum annual limit on the amount you pay for covered services Your OOP max includes your deductible co-insurance and co-payments but not your employee contributions
Once you reach the OOP max the Plan pays 100 of covered services for the remainder of the year
WHAT IS A PPO PLAN
PPO stands for ldquoPreferred Provider Organizationrdquo PPO Plans allow you to visit any in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician
WHAT IS AN ACO PLAN
An Accountable Care Organization ACO is a group of doctors hospitals and other healthcare providers that work together to deliver the most coordinated treatment and care and may prevent you from having costly tests and treatments you may not need
52021 | BENEFITS GUIDE
Medica Choice Passport
Benefits In-Network Out-of-Network
Plan Year Deductible $1000 Single$1500 Single + Child(ren)
$2000 Family
$2000 Single$3000 Single + Child(ren)
$4000 Family
Plan Year Out-of-PocketMaximum
$3000 Single$4500 Single + Child(ren)
$6000 Family
$6000 Single$9000 Single + Child(ren)
$12000 Family
Preventive Care Covered 100 40 AD
Office Visits $25 copay then 20 40 AD
Emergency Room $150 copay
Urgent Care $25 copay then 20
Inpatient Hospital 20 AD 40 AD
Outpatient Hospital 20 AD 40 AD
Chiropractic Visits $25 copay then 20 40 AD 15 visits per year
Mental HealthOutpatientInpatient
$25 copay then 2020 AD
40 AD40 AD
Prescriptions - Retail and Mail Order In-network
GenericPreferred Brand
Non-preferred BrandSpecialty Preferred
Specialty Non-Preferred
$15 copay then 20$20 copay then 20$20 copay then 50$20 copay then 20$20 copay then 50
AD= After Deductible
MEDICA CHOICE PASSPORT PLANEmployees working 30 hours or more per week are eligible
6 BENEFITS GUIDE | 2021
ALTRU amp YOU MEDICAL PLANEmployees working 30 hours or more per week are eligible
Altru amp You
Benefits In-Network Out-of-Network
Plan Year Deductible $1000 Single$1500 Single + Child(ren)
$2000 Family
$2000 Single$3000 Single + Child(ren)
$4000 Family
Plan Year Out-of-PocketMaximum
$3000 Single$4500 Single + Child(ren)
$6000 Family
$6000 Single$9000 Single + Child(ren)
$12000 Family
Preventive Care Covered 100 40 AD
Office Visits $25 copay then 20 40 AD
Emergency Room $150 copay
Urgent Care $25 copay then 20
Inpatient Hospital 20 AD 40 AD
Outpatient Hospital 20 AD 40 AD
Chiropractic Visits $25 copay then 20 40 AD 15 visits per year
Mental HealthOutpatientInpatient
$25 copay then 2020 AD
40 AD40 AD
FIND A NETWORK DOCTOR
To find a network doctor visit wwwmedicacom or call 1-800-952-3455
Prescriptions - Retail and Mail Order In-network
GenericPreferred Brand
Non-preferred BrandSpecialty Preferred
Specialty Non-Preferred
$15 copay then 20$20 copay then 20$20 copay then 50$20 copay then 20$20 copay then 50
AD= After Deductible
72021 | BENEFITS GUIDE
VIRTUAL CARE
SEE A DOCTOR OR THERAPIST1 Launch the online visits app or
website and log in to your account
2 Choose a service medical therapy or psychiatry
3 Pick a doctor or begin a scheduled visit and enter your payment information
4 Meet with a doctor or therapist online
5 Get a prescription if appropriate sent to a local pharmacy
6 Send a visit summary to your primary care doctor or other health care provider at the end of the online visit
247 ACCESS TO CAREVirtual care also known as online care of an e-visit is a convenient way to get care for many
common conditions Connect with a provider from your computer or mobile device to get a
diagnosis treatment plan and prescription (if needed)
With a virtual care visit you
bull Save time ndash avoid a trip to the doctorrsquos office and get care from the comfort of your home
work or wherever you are
bull Initiate the visit at your convenience ndash no appointment needed
bull Get care when you need it ndash visits are often available after clinic hours sometimes even
247
bull May save money ndash a virtual care visit costs Grand Forks Public School plan participants only
$10 copay + 20 which is less than a regular doctor visit
+ Allergies
+ Bladder Infection
+ Bronchitis
+ Cold and Cough
+ Ear Pain
+ Flu
+ High Blood Pressure
+ Migraines
+ Pink Eye
AMWELL (In-Network for Medica and Altru)
Mobile - download the Amwell app
Web - visit Amwellcomcm
Phone - call 1-844-733-3627
You can access virtual care through providers in your planrsquos network Check your virtual care options at MedicacomFindaDoctor Your virtual care options may include
VIRTUWELL (In-Network for Medica)
(Out of Network for Altru Plans)
Web - visit Virtuwellcom
8 BENEFITS GUIDE | 2021
OMADA
JOIN OMADA TO BUILD HEALTHY HABITS THAT LAST
Omada can help you learn how to make smart food choices discover easy ways to boost your activity and overcome challenges preventing you from getting healthier Yoursquoll get support and strategies to motivate you to set and reach your goals
Eat healthier move more discover easy ways to sneak healthy choices into daily life
Develop a personalized plan whether it is meditation or medication zero in on your needs
Track progress seamlessly monitor your activity to discover what is (and is not) working
Break barriers to change gain powerful problem-solving skills to overcome challenges
Feel healthy for life set and reach your evolving goals with strategies and support
YOU WILL GET YOUR OWN
+ An interactive program with an engaging app
+ A wireless smart scale
+ Weekly online lessons
+ A professional health coach
+ A small online group of participants
WHAT IS OMADAAs a Medica member you can help reduce your risk for chronic disease through Omada a digital lifestyle change program Combining the latest technology with ongoing personal support you can make the changes that matter most - whether thatrsquos around eating activity sleep or stress Itrsquos an approach that can help you lose weight and reduce your risks for type 2 diabetes and heart disease
Omada is not available with all Medica health plans To check if you are eligible for this benefit call Medica Customer Service The number is on the back of your ID card
$0 COST TO YOUIf you or your adult dependents are Medica members and are at risk for type 2 diabetes or heart disease Omada is available at no additional cost Watch for more program information from your employer when your Medica health plan starts
GET STARTED WITH OMADA
Visit omadahealthcomgfps
92021 | BENEFITS GUIDE
POPS
POPS DIABETES CAREAs a Medica member you now have the option of participating on the Pops Diabetes Management program This health and wellness benefit is available to employees and their dependents that are covered under the Medica Health Plan and have been diagnosed with diabetes We are partnering with Pops Diabetes Care to offer a simple solution for managing diabetes No need to carry around a separate meter lancets lancet device and test strips Itrsquos all-in-one and at no cost to you
How to Enroll
1 Download the Pops Rebel app from the App Store or Google Play
2 Open the app and select ldquoIrsquom New Hererdquo
3 Enter your personal details including your name address member ID listed on your Medica ID card and Customer Code 52GFS
4 Receive your welcome kit in the mail about seven business days after you enroll Your welcome kit will include your testing equipment and supplies along with instructions
Itrsquos Different Itrsquos Unique You wonrsquot ever be defined by diabetes again - Own Your LIfe
Pops Support Squad1-800-767-7268 | supportsquadpopsdiabetescom | popsdiabetescom
10 BENEFITS GUIDE | 2021
The Company offers a comprehensive Vision Plan provided by Avesis The Vision Plan helps pay the cost of periodic eye examinations and necessary lenses and frames if prescribed The Plan covers services from any licensed provider but benefits are paid at a higher level when you use an in-network provider
In-network co-payments are paid directly to the provider Out-of-network co-payments are deducted from the out-of-network reimbursement
VOLUNTARY VISION PLAN
LOOKING FOR AN IN-NETWORK PROVIDER
For more information about the Vision Plan and to find in-network doctors visit
wwwavesiscom or call 1-800-828-9341
In-Network Out-of-Network
Comprehensive Exam(every 12 months)
$10 copay Up to $35
Standard Plastic Lens
Single $10 copay Up to $25
Bifocal $10 copay Up to $40
Trifocal $10 copay Up to $50
Standard Frames Up to $150 allowance Up to $45
Contacts (in lieu of frames) Up to $130 allowance $110
Medically Necessary Covered in full(Pre-Auth required)
$250
Vision Plan Highlights In-Network
Examinations One every 12 months
Lenses Once every 12 months
Frames Once every 24 months
Coverage Type Employee Cost Per Year
Employee $9216
EE + 1 $16104
Family $23940
LASIK PROVIDER
877-712-2010
Employees working 30 hours or more per week are eligible
112021 | BENEFITS GUIDE
DELTA DENTAL PLANYour dental health is a priority We offer generous coverage through Delta Dental of Minnesota
The Dental Plan encourages preventive treatment and allows you to achieve good oral health while minimizing your out-of-pocket dental expenses
Your out-of-pocket costs will be lower and you may even qualify for in-network discounts How
Check your ID card for your Network Go online to
wwwdeltadentalmnorg or call 800-247-4695
Select the PPO amp Premier Networks
In-Network Out-of-Network
Plan Year Deductible $50 Individual$150 Family
$50 Individual$150 Family
Annual Benefit Maximum $1250 per participant $1250 per participant
Preventive amp Diagnostic(Deductible Does Not Apply)
Covered 100 100 of maximum allowable fee
Basic Services(Fillings Extractions)
20 AD 20 of maximum allowable fee
Major Restorative Services(Crown Root Canal Implants)
50 AD 50 of maximum allowable fee
Orthodontics - Adult Not Covered
Orthodontics - Dependent Child(ren) under age 19
Not Covered
AD=After Deductible
Coverage Type Employee Cost Per Year
Employee $51936
EE + Spouse $117120
Employee + Child(ren) $99912
Family $167136
LOOKING FOR A DENTISTVisit deltadentalmnorg or call 1-800-448-3815
PPO amp Premier Networks
VOLUNTARY DENTAL PLAN
Employees working 30 hours or more per week are eligible
12 BENEFITS GUIDE | 2021
BASIC LIFE ADampD AND LTD BENEFITS
BASIC LIFE AND ADampD
Grand Forks Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Basic Life and ADampD Benefits
Administrator $50000
Certified amp Classified $15000
Accidental Death (ADampD) Mirrors Basic Life
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life expectancy has been reduced to less than
12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at age 68 60 at age 69 and 50 at 70+ years
Monthly Premium 100 Employer Paid
LTD COVERAGE
Grand Forks Public Schools provides LTD coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Long Term Disability
Maximum Benefit 6667 to a defined maximum
Benefit Duration(varies by the age of the employee)
Age at DisabilityLess than age 60Age 60 through age 64Age 65 through age 69Age 70+
Maximum Period of PaymentTo age 65 but not less than 5 years5 yearsTo age 70 but not less than 1 year1 year
Elimination Period After 90 days or end of sick leave (whichever is greater)
Coverage Basis AdministratorsTeachers2 year own occupation
Classified EmployeesAny occupation day one
Emergency Travel Assist(when traveling 100 or more miles or to another country)
Guaranteed hospital admission Emergency medical evacuation Prescription replacement
Monthly Premium 100 Employer Paid
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
52021 | BENEFITS GUIDE
Medica Choice Passport
Benefits In-Network Out-of-Network
Plan Year Deductible $1000 Single$1500 Single + Child(ren)
$2000 Family
$2000 Single$3000 Single + Child(ren)
$4000 Family
Plan Year Out-of-PocketMaximum
$3000 Single$4500 Single + Child(ren)
$6000 Family
$6000 Single$9000 Single + Child(ren)
$12000 Family
Preventive Care Covered 100 40 AD
Office Visits $25 copay then 20 40 AD
Emergency Room $150 copay
Urgent Care $25 copay then 20
Inpatient Hospital 20 AD 40 AD
Outpatient Hospital 20 AD 40 AD
Chiropractic Visits $25 copay then 20 40 AD 15 visits per year
Mental HealthOutpatientInpatient
$25 copay then 2020 AD
40 AD40 AD
Prescriptions - Retail and Mail Order In-network
GenericPreferred Brand
Non-preferred BrandSpecialty Preferred
Specialty Non-Preferred
$15 copay then 20$20 copay then 20$20 copay then 50$20 copay then 20$20 copay then 50
AD= After Deductible
MEDICA CHOICE PASSPORT PLANEmployees working 30 hours or more per week are eligible
6 BENEFITS GUIDE | 2021
ALTRU amp YOU MEDICAL PLANEmployees working 30 hours or more per week are eligible
Altru amp You
Benefits In-Network Out-of-Network
Plan Year Deductible $1000 Single$1500 Single + Child(ren)
$2000 Family
$2000 Single$3000 Single + Child(ren)
$4000 Family
Plan Year Out-of-PocketMaximum
$3000 Single$4500 Single + Child(ren)
$6000 Family
$6000 Single$9000 Single + Child(ren)
$12000 Family
Preventive Care Covered 100 40 AD
Office Visits $25 copay then 20 40 AD
Emergency Room $150 copay
Urgent Care $25 copay then 20
Inpatient Hospital 20 AD 40 AD
Outpatient Hospital 20 AD 40 AD
Chiropractic Visits $25 copay then 20 40 AD 15 visits per year
Mental HealthOutpatientInpatient
$25 copay then 2020 AD
40 AD40 AD
FIND A NETWORK DOCTOR
To find a network doctor visit wwwmedicacom or call 1-800-952-3455
Prescriptions - Retail and Mail Order In-network
GenericPreferred Brand
Non-preferred BrandSpecialty Preferred
Specialty Non-Preferred
$15 copay then 20$20 copay then 20$20 copay then 50$20 copay then 20$20 copay then 50
AD= After Deductible
72021 | BENEFITS GUIDE
VIRTUAL CARE
SEE A DOCTOR OR THERAPIST1 Launch the online visits app or
website and log in to your account
2 Choose a service medical therapy or psychiatry
3 Pick a doctor or begin a scheduled visit and enter your payment information
4 Meet with a doctor or therapist online
5 Get a prescription if appropriate sent to a local pharmacy
6 Send a visit summary to your primary care doctor or other health care provider at the end of the online visit
247 ACCESS TO CAREVirtual care also known as online care of an e-visit is a convenient way to get care for many
common conditions Connect with a provider from your computer or mobile device to get a
diagnosis treatment plan and prescription (if needed)
With a virtual care visit you
bull Save time ndash avoid a trip to the doctorrsquos office and get care from the comfort of your home
work or wherever you are
bull Initiate the visit at your convenience ndash no appointment needed
bull Get care when you need it ndash visits are often available after clinic hours sometimes even
247
bull May save money ndash a virtual care visit costs Grand Forks Public School plan participants only
$10 copay + 20 which is less than a regular doctor visit
+ Allergies
+ Bladder Infection
+ Bronchitis
+ Cold and Cough
+ Ear Pain
+ Flu
+ High Blood Pressure
+ Migraines
+ Pink Eye
AMWELL (In-Network for Medica and Altru)
Mobile - download the Amwell app
Web - visit Amwellcomcm
Phone - call 1-844-733-3627
You can access virtual care through providers in your planrsquos network Check your virtual care options at MedicacomFindaDoctor Your virtual care options may include
VIRTUWELL (In-Network for Medica)
(Out of Network for Altru Plans)
Web - visit Virtuwellcom
8 BENEFITS GUIDE | 2021
OMADA
JOIN OMADA TO BUILD HEALTHY HABITS THAT LAST
Omada can help you learn how to make smart food choices discover easy ways to boost your activity and overcome challenges preventing you from getting healthier Yoursquoll get support and strategies to motivate you to set and reach your goals
Eat healthier move more discover easy ways to sneak healthy choices into daily life
Develop a personalized plan whether it is meditation or medication zero in on your needs
Track progress seamlessly monitor your activity to discover what is (and is not) working
Break barriers to change gain powerful problem-solving skills to overcome challenges
Feel healthy for life set and reach your evolving goals with strategies and support
YOU WILL GET YOUR OWN
+ An interactive program with an engaging app
+ A wireless smart scale
+ Weekly online lessons
+ A professional health coach
+ A small online group of participants
WHAT IS OMADAAs a Medica member you can help reduce your risk for chronic disease through Omada a digital lifestyle change program Combining the latest technology with ongoing personal support you can make the changes that matter most - whether thatrsquos around eating activity sleep or stress Itrsquos an approach that can help you lose weight and reduce your risks for type 2 diabetes and heart disease
Omada is not available with all Medica health plans To check if you are eligible for this benefit call Medica Customer Service The number is on the back of your ID card
$0 COST TO YOUIf you or your adult dependents are Medica members and are at risk for type 2 diabetes or heart disease Omada is available at no additional cost Watch for more program information from your employer when your Medica health plan starts
GET STARTED WITH OMADA
Visit omadahealthcomgfps
92021 | BENEFITS GUIDE
POPS
POPS DIABETES CAREAs a Medica member you now have the option of participating on the Pops Diabetes Management program This health and wellness benefit is available to employees and their dependents that are covered under the Medica Health Plan and have been diagnosed with diabetes We are partnering with Pops Diabetes Care to offer a simple solution for managing diabetes No need to carry around a separate meter lancets lancet device and test strips Itrsquos all-in-one and at no cost to you
How to Enroll
1 Download the Pops Rebel app from the App Store or Google Play
2 Open the app and select ldquoIrsquom New Hererdquo
3 Enter your personal details including your name address member ID listed on your Medica ID card and Customer Code 52GFS
4 Receive your welcome kit in the mail about seven business days after you enroll Your welcome kit will include your testing equipment and supplies along with instructions
Itrsquos Different Itrsquos Unique You wonrsquot ever be defined by diabetes again - Own Your LIfe
Pops Support Squad1-800-767-7268 | supportsquadpopsdiabetescom | popsdiabetescom
10 BENEFITS GUIDE | 2021
The Company offers a comprehensive Vision Plan provided by Avesis The Vision Plan helps pay the cost of periodic eye examinations and necessary lenses and frames if prescribed The Plan covers services from any licensed provider but benefits are paid at a higher level when you use an in-network provider
In-network co-payments are paid directly to the provider Out-of-network co-payments are deducted from the out-of-network reimbursement
VOLUNTARY VISION PLAN
LOOKING FOR AN IN-NETWORK PROVIDER
For more information about the Vision Plan and to find in-network doctors visit
wwwavesiscom or call 1-800-828-9341
In-Network Out-of-Network
Comprehensive Exam(every 12 months)
$10 copay Up to $35
Standard Plastic Lens
Single $10 copay Up to $25
Bifocal $10 copay Up to $40
Trifocal $10 copay Up to $50
Standard Frames Up to $150 allowance Up to $45
Contacts (in lieu of frames) Up to $130 allowance $110
Medically Necessary Covered in full(Pre-Auth required)
$250
Vision Plan Highlights In-Network
Examinations One every 12 months
Lenses Once every 12 months
Frames Once every 24 months
Coverage Type Employee Cost Per Year
Employee $9216
EE + 1 $16104
Family $23940
LASIK PROVIDER
877-712-2010
Employees working 30 hours or more per week are eligible
112021 | BENEFITS GUIDE
DELTA DENTAL PLANYour dental health is a priority We offer generous coverage through Delta Dental of Minnesota
The Dental Plan encourages preventive treatment and allows you to achieve good oral health while minimizing your out-of-pocket dental expenses
Your out-of-pocket costs will be lower and you may even qualify for in-network discounts How
Check your ID card for your Network Go online to
wwwdeltadentalmnorg or call 800-247-4695
Select the PPO amp Premier Networks
In-Network Out-of-Network
Plan Year Deductible $50 Individual$150 Family
$50 Individual$150 Family
Annual Benefit Maximum $1250 per participant $1250 per participant
Preventive amp Diagnostic(Deductible Does Not Apply)
Covered 100 100 of maximum allowable fee
Basic Services(Fillings Extractions)
20 AD 20 of maximum allowable fee
Major Restorative Services(Crown Root Canal Implants)
50 AD 50 of maximum allowable fee
Orthodontics - Adult Not Covered
Orthodontics - Dependent Child(ren) under age 19
Not Covered
AD=After Deductible
Coverage Type Employee Cost Per Year
Employee $51936
EE + Spouse $117120
Employee + Child(ren) $99912
Family $167136
LOOKING FOR A DENTISTVisit deltadentalmnorg or call 1-800-448-3815
PPO amp Premier Networks
VOLUNTARY DENTAL PLAN
Employees working 30 hours or more per week are eligible
12 BENEFITS GUIDE | 2021
BASIC LIFE ADampD AND LTD BENEFITS
BASIC LIFE AND ADampD
Grand Forks Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Basic Life and ADampD Benefits
Administrator $50000
Certified amp Classified $15000
Accidental Death (ADampD) Mirrors Basic Life
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life expectancy has been reduced to less than
12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at age 68 60 at age 69 and 50 at 70+ years
Monthly Premium 100 Employer Paid
LTD COVERAGE
Grand Forks Public Schools provides LTD coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Long Term Disability
Maximum Benefit 6667 to a defined maximum
Benefit Duration(varies by the age of the employee)
Age at DisabilityLess than age 60Age 60 through age 64Age 65 through age 69Age 70+
Maximum Period of PaymentTo age 65 but not less than 5 years5 yearsTo age 70 but not less than 1 year1 year
Elimination Period After 90 days or end of sick leave (whichever is greater)
Coverage Basis AdministratorsTeachers2 year own occupation
Classified EmployeesAny occupation day one
Emergency Travel Assist(when traveling 100 or more miles or to another country)
Guaranteed hospital admission Emergency medical evacuation Prescription replacement
Monthly Premium 100 Employer Paid
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
6 BENEFITS GUIDE | 2021
ALTRU amp YOU MEDICAL PLANEmployees working 30 hours or more per week are eligible
Altru amp You
Benefits In-Network Out-of-Network
Plan Year Deductible $1000 Single$1500 Single + Child(ren)
$2000 Family
$2000 Single$3000 Single + Child(ren)
$4000 Family
Plan Year Out-of-PocketMaximum
$3000 Single$4500 Single + Child(ren)
$6000 Family
$6000 Single$9000 Single + Child(ren)
$12000 Family
Preventive Care Covered 100 40 AD
Office Visits $25 copay then 20 40 AD
Emergency Room $150 copay
Urgent Care $25 copay then 20
Inpatient Hospital 20 AD 40 AD
Outpatient Hospital 20 AD 40 AD
Chiropractic Visits $25 copay then 20 40 AD 15 visits per year
Mental HealthOutpatientInpatient
$25 copay then 2020 AD
40 AD40 AD
FIND A NETWORK DOCTOR
To find a network doctor visit wwwmedicacom or call 1-800-952-3455
Prescriptions - Retail and Mail Order In-network
GenericPreferred Brand
Non-preferred BrandSpecialty Preferred
Specialty Non-Preferred
$15 copay then 20$20 copay then 20$20 copay then 50$20 copay then 20$20 copay then 50
AD= After Deductible
72021 | BENEFITS GUIDE
VIRTUAL CARE
SEE A DOCTOR OR THERAPIST1 Launch the online visits app or
website and log in to your account
2 Choose a service medical therapy or psychiatry
3 Pick a doctor or begin a scheduled visit and enter your payment information
4 Meet with a doctor or therapist online
5 Get a prescription if appropriate sent to a local pharmacy
6 Send a visit summary to your primary care doctor or other health care provider at the end of the online visit
247 ACCESS TO CAREVirtual care also known as online care of an e-visit is a convenient way to get care for many
common conditions Connect with a provider from your computer or mobile device to get a
diagnosis treatment plan and prescription (if needed)
With a virtual care visit you
bull Save time ndash avoid a trip to the doctorrsquos office and get care from the comfort of your home
work or wherever you are
bull Initiate the visit at your convenience ndash no appointment needed
bull Get care when you need it ndash visits are often available after clinic hours sometimes even
247
bull May save money ndash a virtual care visit costs Grand Forks Public School plan participants only
$10 copay + 20 which is less than a regular doctor visit
+ Allergies
+ Bladder Infection
+ Bronchitis
+ Cold and Cough
+ Ear Pain
+ Flu
+ High Blood Pressure
+ Migraines
+ Pink Eye
AMWELL (In-Network for Medica and Altru)
Mobile - download the Amwell app
Web - visit Amwellcomcm
Phone - call 1-844-733-3627
You can access virtual care through providers in your planrsquos network Check your virtual care options at MedicacomFindaDoctor Your virtual care options may include
VIRTUWELL (In-Network for Medica)
(Out of Network for Altru Plans)
Web - visit Virtuwellcom
8 BENEFITS GUIDE | 2021
OMADA
JOIN OMADA TO BUILD HEALTHY HABITS THAT LAST
Omada can help you learn how to make smart food choices discover easy ways to boost your activity and overcome challenges preventing you from getting healthier Yoursquoll get support and strategies to motivate you to set and reach your goals
Eat healthier move more discover easy ways to sneak healthy choices into daily life
Develop a personalized plan whether it is meditation or medication zero in on your needs
Track progress seamlessly monitor your activity to discover what is (and is not) working
Break barriers to change gain powerful problem-solving skills to overcome challenges
Feel healthy for life set and reach your evolving goals with strategies and support
YOU WILL GET YOUR OWN
+ An interactive program with an engaging app
+ A wireless smart scale
+ Weekly online lessons
+ A professional health coach
+ A small online group of participants
WHAT IS OMADAAs a Medica member you can help reduce your risk for chronic disease through Omada a digital lifestyle change program Combining the latest technology with ongoing personal support you can make the changes that matter most - whether thatrsquos around eating activity sleep or stress Itrsquos an approach that can help you lose weight and reduce your risks for type 2 diabetes and heart disease
Omada is not available with all Medica health plans To check if you are eligible for this benefit call Medica Customer Service The number is on the back of your ID card
$0 COST TO YOUIf you or your adult dependents are Medica members and are at risk for type 2 diabetes or heart disease Omada is available at no additional cost Watch for more program information from your employer when your Medica health plan starts
GET STARTED WITH OMADA
Visit omadahealthcomgfps
92021 | BENEFITS GUIDE
POPS
POPS DIABETES CAREAs a Medica member you now have the option of participating on the Pops Diabetes Management program This health and wellness benefit is available to employees and their dependents that are covered under the Medica Health Plan and have been diagnosed with diabetes We are partnering with Pops Diabetes Care to offer a simple solution for managing diabetes No need to carry around a separate meter lancets lancet device and test strips Itrsquos all-in-one and at no cost to you
How to Enroll
1 Download the Pops Rebel app from the App Store or Google Play
2 Open the app and select ldquoIrsquom New Hererdquo
3 Enter your personal details including your name address member ID listed on your Medica ID card and Customer Code 52GFS
4 Receive your welcome kit in the mail about seven business days after you enroll Your welcome kit will include your testing equipment and supplies along with instructions
Itrsquos Different Itrsquos Unique You wonrsquot ever be defined by diabetes again - Own Your LIfe
Pops Support Squad1-800-767-7268 | supportsquadpopsdiabetescom | popsdiabetescom
10 BENEFITS GUIDE | 2021
The Company offers a comprehensive Vision Plan provided by Avesis The Vision Plan helps pay the cost of periodic eye examinations and necessary lenses and frames if prescribed The Plan covers services from any licensed provider but benefits are paid at a higher level when you use an in-network provider
In-network co-payments are paid directly to the provider Out-of-network co-payments are deducted from the out-of-network reimbursement
VOLUNTARY VISION PLAN
LOOKING FOR AN IN-NETWORK PROVIDER
For more information about the Vision Plan and to find in-network doctors visit
wwwavesiscom or call 1-800-828-9341
In-Network Out-of-Network
Comprehensive Exam(every 12 months)
$10 copay Up to $35
Standard Plastic Lens
Single $10 copay Up to $25
Bifocal $10 copay Up to $40
Trifocal $10 copay Up to $50
Standard Frames Up to $150 allowance Up to $45
Contacts (in lieu of frames) Up to $130 allowance $110
Medically Necessary Covered in full(Pre-Auth required)
$250
Vision Plan Highlights In-Network
Examinations One every 12 months
Lenses Once every 12 months
Frames Once every 24 months
Coverage Type Employee Cost Per Year
Employee $9216
EE + 1 $16104
Family $23940
LASIK PROVIDER
877-712-2010
Employees working 30 hours or more per week are eligible
112021 | BENEFITS GUIDE
DELTA DENTAL PLANYour dental health is a priority We offer generous coverage through Delta Dental of Minnesota
The Dental Plan encourages preventive treatment and allows you to achieve good oral health while minimizing your out-of-pocket dental expenses
Your out-of-pocket costs will be lower and you may even qualify for in-network discounts How
Check your ID card for your Network Go online to
wwwdeltadentalmnorg or call 800-247-4695
Select the PPO amp Premier Networks
In-Network Out-of-Network
Plan Year Deductible $50 Individual$150 Family
$50 Individual$150 Family
Annual Benefit Maximum $1250 per participant $1250 per participant
Preventive amp Diagnostic(Deductible Does Not Apply)
Covered 100 100 of maximum allowable fee
Basic Services(Fillings Extractions)
20 AD 20 of maximum allowable fee
Major Restorative Services(Crown Root Canal Implants)
50 AD 50 of maximum allowable fee
Orthodontics - Adult Not Covered
Orthodontics - Dependent Child(ren) under age 19
Not Covered
AD=After Deductible
Coverage Type Employee Cost Per Year
Employee $51936
EE + Spouse $117120
Employee + Child(ren) $99912
Family $167136
LOOKING FOR A DENTISTVisit deltadentalmnorg or call 1-800-448-3815
PPO amp Premier Networks
VOLUNTARY DENTAL PLAN
Employees working 30 hours or more per week are eligible
12 BENEFITS GUIDE | 2021
BASIC LIFE ADampD AND LTD BENEFITS
BASIC LIFE AND ADampD
Grand Forks Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Basic Life and ADampD Benefits
Administrator $50000
Certified amp Classified $15000
Accidental Death (ADampD) Mirrors Basic Life
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life expectancy has been reduced to less than
12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at age 68 60 at age 69 and 50 at 70+ years
Monthly Premium 100 Employer Paid
LTD COVERAGE
Grand Forks Public Schools provides LTD coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Long Term Disability
Maximum Benefit 6667 to a defined maximum
Benefit Duration(varies by the age of the employee)
Age at DisabilityLess than age 60Age 60 through age 64Age 65 through age 69Age 70+
Maximum Period of PaymentTo age 65 but not less than 5 years5 yearsTo age 70 but not less than 1 year1 year
Elimination Period After 90 days or end of sick leave (whichever is greater)
Coverage Basis AdministratorsTeachers2 year own occupation
Classified EmployeesAny occupation day one
Emergency Travel Assist(when traveling 100 or more miles or to another country)
Guaranteed hospital admission Emergency medical evacuation Prescription replacement
Monthly Premium 100 Employer Paid
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
72021 | BENEFITS GUIDE
VIRTUAL CARE
SEE A DOCTOR OR THERAPIST1 Launch the online visits app or
website and log in to your account
2 Choose a service medical therapy or psychiatry
3 Pick a doctor or begin a scheduled visit and enter your payment information
4 Meet with a doctor or therapist online
5 Get a prescription if appropriate sent to a local pharmacy
6 Send a visit summary to your primary care doctor or other health care provider at the end of the online visit
247 ACCESS TO CAREVirtual care also known as online care of an e-visit is a convenient way to get care for many
common conditions Connect with a provider from your computer or mobile device to get a
diagnosis treatment plan and prescription (if needed)
With a virtual care visit you
bull Save time ndash avoid a trip to the doctorrsquos office and get care from the comfort of your home
work or wherever you are
bull Initiate the visit at your convenience ndash no appointment needed
bull Get care when you need it ndash visits are often available after clinic hours sometimes even
247
bull May save money ndash a virtual care visit costs Grand Forks Public School plan participants only
$10 copay + 20 which is less than a regular doctor visit
+ Allergies
+ Bladder Infection
+ Bronchitis
+ Cold and Cough
+ Ear Pain
+ Flu
+ High Blood Pressure
+ Migraines
+ Pink Eye
AMWELL (In-Network for Medica and Altru)
Mobile - download the Amwell app
Web - visit Amwellcomcm
Phone - call 1-844-733-3627
You can access virtual care through providers in your planrsquos network Check your virtual care options at MedicacomFindaDoctor Your virtual care options may include
VIRTUWELL (In-Network for Medica)
(Out of Network for Altru Plans)
Web - visit Virtuwellcom
8 BENEFITS GUIDE | 2021
OMADA
JOIN OMADA TO BUILD HEALTHY HABITS THAT LAST
Omada can help you learn how to make smart food choices discover easy ways to boost your activity and overcome challenges preventing you from getting healthier Yoursquoll get support and strategies to motivate you to set and reach your goals
Eat healthier move more discover easy ways to sneak healthy choices into daily life
Develop a personalized plan whether it is meditation or medication zero in on your needs
Track progress seamlessly monitor your activity to discover what is (and is not) working
Break barriers to change gain powerful problem-solving skills to overcome challenges
Feel healthy for life set and reach your evolving goals with strategies and support
YOU WILL GET YOUR OWN
+ An interactive program with an engaging app
+ A wireless smart scale
+ Weekly online lessons
+ A professional health coach
+ A small online group of participants
WHAT IS OMADAAs a Medica member you can help reduce your risk for chronic disease through Omada a digital lifestyle change program Combining the latest technology with ongoing personal support you can make the changes that matter most - whether thatrsquos around eating activity sleep or stress Itrsquos an approach that can help you lose weight and reduce your risks for type 2 diabetes and heart disease
Omada is not available with all Medica health plans To check if you are eligible for this benefit call Medica Customer Service The number is on the back of your ID card
$0 COST TO YOUIf you or your adult dependents are Medica members and are at risk for type 2 diabetes or heart disease Omada is available at no additional cost Watch for more program information from your employer when your Medica health plan starts
GET STARTED WITH OMADA
Visit omadahealthcomgfps
92021 | BENEFITS GUIDE
POPS
POPS DIABETES CAREAs a Medica member you now have the option of participating on the Pops Diabetes Management program This health and wellness benefit is available to employees and their dependents that are covered under the Medica Health Plan and have been diagnosed with diabetes We are partnering with Pops Diabetes Care to offer a simple solution for managing diabetes No need to carry around a separate meter lancets lancet device and test strips Itrsquos all-in-one and at no cost to you
How to Enroll
1 Download the Pops Rebel app from the App Store or Google Play
2 Open the app and select ldquoIrsquom New Hererdquo
3 Enter your personal details including your name address member ID listed on your Medica ID card and Customer Code 52GFS
4 Receive your welcome kit in the mail about seven business days after you enroll Your welcome kit will include your testing equipment and supplies along with instructions
Itrsquos Different Itrsquos Unique You wonrsquot ever be defined by diabetes again - Own Your LIfe
Pops Support Squad1-800-767-7268 | supportsquadpopsdiabetescom | popsdiabetescom
10 BENEFITS GUIDE | 2021
The Company offers a comprehensive Vision Plan provided by Avesis The Vision Plan helps pay the cost of periodic eye examinations and necessary lenses and frames if prescribed The Plan covers services from any licensed provider but benefits are paid at a higher level when you use an in-network provider
In-network co-payments are paid directly to the provider Out-of-network co-payments are deducted from the out-of-network reimbursement
VOLUNTARY VISION PLAN
LOOKING FOR AN IN-NETWORK PROVIDER
For more information about the Vision Plan and to find in-network doctors visit
wwwavesiscom or call 1-800-828-9341
In-Network Out-of-Network
Comprehensive Exam(every 12 months)
$10 copay Up to $35
Standard Plastic Lens
Single $10 copay Up to $25
Bifocal $10 copay Up to $40
Trifocal $10 copay Up to $50
Standard Frames Up to $150 allowance Up to $45
Contacts (in lieu of frames) Up to $130 allowance $110
Medically Necessary Covered in full(Pre-Auth required)
$250
Vision Plan Highlights In-Network
Examinations One every 12 months
Lenses Once every 12 months
Frames Once every 24 months
Coverage Type Employee Cost Per Year
Employee $9216
EE + 1 $16104
Family $23940
LASIK PROVIDER
877-712-2010
Employees working 30 hours or more per week are eligible
112021 | BENEFITS GUIDE
DELTA DENTAL PLANYour dental health is a priority We offer generous coverage through Delta Dental of Minnesota
The Dental Plan encourages preventive treatment and allows you to achieve good oral health while minimizing your out-of-pocket dental expenses
Your out-of-pocket costs will be lower and you may even qualify for in-network discounts How
Check your ID card for your Network Go online to
wwwdeltadentalmnorg or call 800-247-4695
Select the PPO amp Premier Networks
In-Network Out-of-Network
Plan Year Deductible $50 Individual$150 Family
$50 Individual$150 Family
Annual Benefit Maximum $1250 per participant $1250 per participant
Preventive amp Diagnostic(Deductible Does Not Apply)
Covered 100 100 of maximum allowable fee
Basic Services(Fillings Extractions)
20 AD 20 of maximum allowable fee
Major Restorative Services(Crown Root Canal Implants)
50 AD 50 of maximum allowable fee
Orthodontics - Adult Not Covered
Orthodontics - Dependent Child(ren) under age 19
Not Covered
AD=After Deductible
Coverage Type Employee Cost Per Year
Employee $51936
EE + Spouse $117120
Employee + Child(ren) $99912
Family $167136
LOOKING FOR A DENTISTVisit deltadentalmnorg or call 1-800-448-3815
PPO amp Premier Networks
VOLUNTARY DENTAL PLAN
Employees working 30 hours or more per week are eligible
12 BENEFITS GUIDE | 2021
BASIC LIFE ADampD AND LTD BENEFITS
BASIC LIFE AND ADampD
Grand Forks Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Basic Life and ADampD Benefits
Administrator $50000
Certified amp Classified $15000
Accidental Death (ADampD) Mirrors Basic Life
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life expectancy has been reduced to less than
12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at age 68 60 at age 69 and 50 at 70+ years
Monthly Premium 100 Employer Paid
LTD COVERAGE
Grand Forks Public Schools provides LTD coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Long Term Disability
Maximum Benefit 6667 to a defined maximum
Benefit Duration(varies by the age of the employee)
Age at DisabilityLess than age 60Age 60 through age 64Age 65 through age 69Age 70+
Maximum Period of PaymentTo age 65 but not less than 5 years5 yearsTo age 70 but not less than 1 year1 year
Elimination Period After 90 days or end of sick leave (whichever is greater)
Coverage Basis AdministratorsTeachers2 year own occupation
Classified EmployeesAny occupation day one
Emergency Travel Assist(when traveling 100 or more miles or to another country)
Guaranteed hospital admission Emergency medical evacuation Prescription replacement
Monthly Premium 100 Employer Paid
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
8 BENEFITS GUIDE | 2021
OMADA
JOIN OMADA TO BUILD HEALTHY HABITS THAT LAST
Omada can help you learn how to make smart food choices discover easy ways to boost your activity and overcome challenges preventing you from getting healthier Yoursquoll get support and strategies to motivate you to set and reach your goals
Eat healthier move more discover easy ways to sneak healthy choices into daily life
Develop a personalized plan whether it is meditation or medication zero in on your needs
Track progress seamlessly monitor your activity to discover what is (and is not) working
Break barriers to change gain powerful problem-solving skills to overcome challenges
Feel healthy for life set and reach your evolving goals with strategies and support
YOU WILL GET YOUR OWN
+ An interactive program with an engaging app
+ A wireless smart scale
+ Weekly online lessons
+ A professional health coach
+ A small online group of participants
WHAT IS OMADAAs a Medica member you can help reduce your risk for chronic disease through Omada a digital lifestyle change program Combining the latest technology with ongoing personal support you can make the changes that matter most - whether thatrsquos around eating activity sleep or stress Itrsquos an approach that can help you lose weight and reduce your risks for type 2 diabetes and heart disease
Omada is not available with all Medica health plans To check if you are eligible for this benefit call Medica Customer Service The number is on the back of your ID card
$0 COST TO YOUIf you or your adult dependents are Medica members and are at risk for type 2 diabetes or heart disease Omada is available at no additional cost Watch for more program information from your employer when your Medica health plan starts
GET STARTED WITH OMADA
Visit omadahealthcomgfps
92021 | BENEFITS GUIDE
POPS
POPS DIABETES CAREAs a Medica member you now have the option of participating on the Pops Diabetes Management program This health and wellness benefit is available to employees and their dependents that are covered under the Medica Health Plan and have been diagnosed with diabetes We are partnering with Pops Diabetes Care to offer a simple solution for managing diabetes No need to carry around a separate meter lancets lancet device and test strips Itrsquos all-in-one and at no cost to you
How to Enroll
1 Download the Pops Rebel app from the App Store or Google Play
2 Open the app and select ldquoIrsquom New Hererdquo
3 Enter your personal details including your name address member ID listed on your Medica ID card and Customer Code 52GFS
4 Receive your welcome kit in the mail about seven business days after you enroll Your welcome kit will include your testing equipment and supplies along with instructions
Itrsquos Different Itrsquos Unique You wonrsquot ever be defined by diabetes again - Own Your LIfe
Pops Support Squad1-800-767-7268 | supportsquadpopsdiabetescom | popsdiabetescom
10 BENEFITS GUIDE | 2021
The Company offers a comprehensive Vision Plan provided by Avesis The Vision Plan helps pay the cost of periodic eye examinations and necessary lenses and frames if prescribed The Plan covers services from any licensed provider but benefits are paid at a higher level when you use an in-network provider
In-network co-payments are paid directly to the provider Out-of-network co-payments are deducted from the out-of-network reimbursement
VOLUNTARY VISION PLAN
LOOKING FOR AN IN-NETWORK PROVIDER
For more information about the Vision Plan and to find in-network doctors visit
wwwavesiscom or call 1-800-828-9341
In-Network Out-of-Network
Comprehensive Exam(every 12 months)
$10 copay Up to $35
Standard Plastic Lens
Single $10 copay Up to $25
Bifocal $10 copay Up to $40
Trifocal $10 copay Up to $50
Standard Frames Up to $150 allowance Up to $45
Contacts (in lieu of frames) Up to $130 allowance $110
Medically Necessary Covered in full(Pre-Auth required)
$250
Vision Plan Highlights In-Network
Examinations One every 12 months
Lenses Once every 12 months
Frames Once every 24 months
Coverage Type Employee Cost Per Year
Employee $9216
EE + 1 $16104
Family $23940
LASIK PROVIDER
877-712-2010
Employees working 30 hours or more per week are eligible
112021 | BENEFITS GUIDE
DELTA DENTAL PLANYour dental health is a priority We offer generous coverage through Delta Dental of Minnesota
The Dental Plan encourages preventive treatment and allows you to achieve good oral health while minimizing your out-of-pocket dental expenses
Your out-of-pocket costs will be lower and you may even qualify for in-network discounts How
Check your ID card for your Network Go online to
wwwdeltadentalmnorg or call 800-247-4695
Select the PPO amp Premier Networks
In-Network Out-of-Network
Plan Year Deductible $50 Individual$150 Family
$50 Individual$150 Family
Annual Benefit Maximum $1250 per participant $1250 per participant
Preventive amp Diagnostic(Deductible Does Not Apply)
Covered 100 100 of maximum allowable fee
Basic Services(Fillings Extractions)
20 AD 20 of maximum allowable fee
Major Restorative Services(Crown Root Canal Implants)
50 AD 50 of maximum allowable fee
Orthodontics - Adult Not Covered
Orthodontics - Dependent Child(ren) under age 19
Not Covered
AD=After Deductible
Coverage Type Employee Cost Per Year
Employee $51936
EE + Spouse $117120
Employee + Child(ren) $99912
Family $167136
LOOKING FOR A DENTISTVisit deltadentalmnorg or call 1-800-448-3815
PPO amp Premier Networks
VOLUNTARY DENTAL PLAN
Employees working 30 hours or more per week are eligible
12 BENEFITS GUIDE | 2021
BASIC LIFE ADampD AND LTD BENEFITS
BASIC LIFE AND ADampD
Grand Forks Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Basic Life and ADampD Benefits
Administrator $50000
Certified amp Classified $15000
Accidental Death (ADampD) Mirrors Basic Life
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life expectancy has been reduced to less than
12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at age 68 60 at age 69 and 50 at 70+ years
Monthly Premium 100 Employer Paid
LTD COVERAGE
Grand Forks Public Schools provides LTD coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Long Term Disability
Maximum Benefit 6667 to a defined maximum
Benefit Duration(varies by the age of the employee)
Age at DisabilityLess than age 60Age 60 through age 64Age 65 through age 69Age 70+
Maximum Period of PaymentTo age 65 but not less than 5 years5 yearsTo age 70 but not less than 1 year1 year
Elimination Period After 90 days or end of sick leave (whichever is greater)
Coverage Basis AdministratorsTeachers2 year own occupation
Classified EmployeesAny occupation day one
Emergency Travel Assist(when traveling 100 or more miles or to another country)
Guaranteed hospital admission Emergency medical evacuation Prescription replacement
Monthly Premium 100 Employer Paid
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
92021 | BENEFITS GUIDE
POPS
POPS DIABETES CAREAs a Medica member you now have the option of participating on the Pops Diabetes Management program This health and wellness benefit is available to employees and their dependents that are covered under the Medica Health Plan and have been diagnosed with diabetes We are partnering with Pops Diabetes Care to offer a simple solution for managing diabetes No need to carry around a separate meter lancets lancet device and test strips Itrsquos all-in-one and at no cost to you
How to Enroll
1 Download the Pops Rebel app from the App Store or Google Play
2 Open the app and select ldquoIrsquom New Hererdquo
3 Enter your personal details including your name address member ID listed on your Medica ID card and Customer Code 52GFS
4 Receive your welcome kit in the mail about seven business days after you enroll Your welcome kit will include your testing equipment and supplies along with instructions
Itrsquos Different Itrsquos Unique You wonrsquot ever be defined by diabetes again - Own Your LIfe
Pops Support Squad1-800-767-7268 | supportsquadpopsdiabetescom | popsdiabetescom
10 BENEFITS GUIDE | 2021
The Company offers a comprehensive Vision Plan provided by Avesis The Vision Plan helps pay the cost of periodic eye examinations and necessary lenses and frames if prescribed The Plan covers services from any licensed provider but benefits are paid at a higher level when you use an in-network provider
In-network co-payments are paid directly to the provider Out-of-network co-payments are deducted from the out-of-network reimbursement
VOLUNTARY VISION PLAN
LOOKING FOR AN IN-NETWORK PROVIDER
For more information about the Vision Plan and to find in-network doctors visit
wwwavesiscom or call 1-800-828-9341
In-Network Out-of-Network
Comprehensive Exam(every 12 months)
$10 copay Up to $35
Standard Plastic Lens
Single $10 copay Up to $25
Bifocal $10 copay Up to $40
Trifocal $10 copay Up to $50
Standard Frames Up to $150 allowance Up to $45
Contacts (in lieu of frames) Up to $130 allowance $110
Medically Necessary Covered in full(Pre-Auth required)
$250
Vision Plan Highlights In-Network
Examinations One every 12 months
Lenses Once every 12 months
Frames Once every 24 months
Coverage Type Employee Cost Per Year
Employee $9216
EE + 1 $16104
Family $23940
LASIK PROVIDER
877-712-2010
Employees working 30 hours or more per week are eligible
112021 | BENEFITS GUIDE
DELTA DENTAL PLANYour dental health is a priority We offer generous coverage through Delta Dental of Minnesota
The Dental Plan encourages preventive treatment and allows you to achieve good oral health while minimizing your out-of-pocket dental expenses
Your out-of-pocket costs will be lower and you may even qualify for in-network discounts How
Check your ID card for your Network Go online to
wwwdeltadentalmnorg or call 800-247-4695
Select the PPO amp Premier Networks
In-Network Out-of-Network
Plan Year Deductible $50 Individual$150 Family
$50 Individual$150 Family
Annual Benefit Maximum $1250 per participant $1250 per participant
Preventive amp Diagnostic(Deductible Does Not Apply)
Covered 100 100 of maximum allowable fee
Basic Services(Fillings Extractions)
20 AD 20 of maximum allowable fee
Major Restorative Services(Crown Root Canal Implants)
50 AD 50 of maximum allowable fee
Orthodontics - Adult Not Covered
Orthodontics - Dependent Child(ren) under age 19
Not Covered
AD=After Deductible
Coverage Type Employee Cost Per Year
Employee $51936
EE + Spouse $117120
Employee + Child(ren) $99912
Family $167136
LOOKING FOR A DENTISTVisit deltadentalmnorg or call 1-800-448-3815
PPO amp Premier Networks
VOLUNTARY DENTAL PLAN
Employees working 30 hours or more per week are eligible
12 BENEFITS GUIDE | 2021
BASIC LIFE ADampD AND LTD BENEFITS
BASIC LIFE AND ADampD
Grand Forks Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Basic Life and ADampD Benefits
Administrator $50000
Certified amp Classified $15000
Accidental Death (ADampD) Mirrors Basic Life
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life expectancy has been reduced to less than
12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at age 68 60 at age 69 and 50 at 70+ years
Monthly Premium 100 Employer Paid
LTD COVERAGE
Grand Forks Public Schools provides LTD coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Long Term Disability
Maximum Benefit 6667 to a defined maximum
Benefit Duration(varies by the age of the employee)
Age at DisabilityLess than age 60Age 60 through age 64Age 65 through age 69Age 70+
Maximum Period of PaymentTo age 65 but not less than 5 years5 yearsTo age 70 but not less than 1 year1 year
Elimination Period After 90 days or end of sick leave (whichever is greater)
Coverage Basis AdministratorsTeachers2 year own occupation
Classified EmployeesAny occupation day one
Emergency Travel Assist(when traveling 100 or more miles or to another country)
Guaranteed hospital admission Emergency medical evacuation Prescription replacement
Monthly Premium 100 Employer Paid
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
10 BENEFITS GUIDE | 2021
The Company offers a comprehensive Vision Plan provided by Avesis The Vision Plan helps pay the cost of periodic eye examinations and necessary lenses and frames if prescribed The Plan covers services from any licensed provider but benefits are paid at a higher level when you use an in-network provider
In-network co-payments are paid directly to the provider Out-of-network co-payments are deducted from the out-of-network reimbursement
VOLUNTARY VISION PLAN
LOOKING FOR AN IN-NETWORK PROVIDER
For more information about the Vision Plan and to find in-network doctors visit
wwwavesiscom or call 1-800-828-9341
In-Network Out-of-Network
Comprehensive Exam(every 12 months)
$10 copay Up to $35
Standard Plastic Lens
Single $10 copay Up to $25
Bifocal $10 copay Up to $40
Trifocal $10 copay Up to $50
Standard Frames Up to $150 allowance Up to $45
Contacts (in lieu of frames) Up to $130 allowance $110
Medically Necessary Covered in full(Pre-Auth required)
$250
Vision Plan Highlights In-Network
Examinations One every 12 months
Lenses Once every 12 months
Frames Once every 24 months
Coverage Type Employee Cost Per Year
Employee $9216
EE + 1 $16104
Family $23940
LASIK PROVIDER
877-712-2010
Employees working 30 hours or more per week are eligible
112021 | BENEFITS GUIDE
DELTA DENTAL PLANYour dental health is a priority We offer generous coverage through Delta Dental of Minnesota
The Dental Plan encourages preventive treatment and allows you to achieve good oral health while minimizing your out-of-pocket dental expenses
Your out-of-pocket costs will be lower and you may even qualify for in-network discounts How
Check your ID card for your Network Go online to
wwwdeltadentalmnorg or call 800-247-4695
Select the PPO amp Premier Networks
In-Network Out-of-Network
Plan Year Deductible $50 Individual$150 Family
$50 Individual$150 Family
Annual Benefit Maximum $1250 per participant $1250 per participant
Preventive amp Diagnostic(Deductible Does Not Apply)
Covered 100 100 of maximum allowable fee
Basic Services(Fillings Extractions)
20 AD 20 of maximum allowable fee
Major Restorative Services(Crown Root Canal Implants)
50 AD 50 of maximum allowable fee
Orthodontics - Adult Not Covered
Orthodontics - Dependent Child(ren) under age 19
Not Covered
AD=After Deductible
Coverage Type Employee Cost Per Year
Employee $51936
EE + Spouse $117120
Employee + Child(ren) $99912
Family $167136
LOOKING FOR A DENTISTVisit deltadentalmnorg or call 1-800-448-3815
PPO amp Premier Networks
VOLUNTARY DENTAL PLAN
Employees working 30 hours or more per week are eligible
12 BENEFITS GUIDE | 2021
BASIC LIFE ADampD AND LTD BENEFITS
BASIC LIFE AND ADampD
Grand Forks Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Basic Life and ADampD Benefits
Administrator $50000
Certified amp Classified $15000
Accidental Death (ADampD) Mirrors Basic Life
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life expectancy has been reduced to less than
12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at age 68 60 at age 69 and 50 at 70+ years
Monthly Premium 100 Employer Paid
LTD COVERAGE
Grand Forks Public Schools provides LTD coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Long Term Disability
Maximum Benefit 6667 to a defined maximum
Benefit Duration(varies by the age of the employee)
Age at DisabilityLess than age 60Age 60 through age 64Age 65 through age 69Age 70+
Maximum Period of PaymentTo age 65 but not less than 5 years5 yearsTo age 70 but not less than 1 year1 year
Elimination Period After 90 days or end of sick leave (whichever is greater)
Coverage Basis AdministratorsTeachers2 year own occupation
Classified EmployeesAny occupation day one
Emergency Travel Assist(when traveling 100 or more miles or to another country)
Guaranteed hospital admission Emergency medical evacuation Prescription replacement
Monthly Premium 100 Employer Paid
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
112021 | BENEFITS GUIDE
DELTA DENTAL PLANYour dental health is a priority We offer generous coverage through Delta Dental of Minnesota
The Dental Plan encourages preventive treatment and allows you to achieve good oral health while minimizing your out-of-pocket dental expenses
Your out-of-pocket costs will be lower and you may even qualify for in-network discounts How
Check your ID card for your Network Go online to
wwwdeltadentalmnorg or call 800-247-4695
Select the PPO amp Premier Networks
In-Network Out-of-Network
Plan Year Deductible $50 Individual$150 Family
$50 Individual$150 Family
Annual Benefit Maximum $1250 per participant $1250 per participant
Preventive amp Diagnostic(Deductible Does Not Apply)
Covered 100 100 of maximum allowable fee
Basic Services(Fillings Extractions)
20 AD 20 of maximum allowable fee
Major Restorative Services(Crown Root Canal Implants)
50 AD 50 of maximum allowable fee
Orthodontics - Adult Not Covered
Orthodontics - Dependent Child(ren) under age 19
Not Covered
AD=After Deductible
Coverage Type Employee Cost Per Year
Employee $51936
EE + Spouse $117120
Employee + Child(ren) $99912
Family $167136
LOOKING FOR A DENTISTVisit deltadentalmnorg or call 1-800-448-3815
PPO amp Premier Networks
VOLUNTARY DENTAL PLAN
Employees working 30 hours or more per week are eligible
12 BENEFITS GUIDE | 2021
BASIC LIFE ADampD AND LTD BENEFITS
BASIC LIFE AND ADampD
Grand Forks Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Basic Life and ADampD Benefits
Administrator $50000
Certified amp Classified $15000
Accidental Death (ADampD) Mirrors Basic Life
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life expectancy has been reduced to less than
12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at age 68 60 at age 69 and 50 at 70+ years
Monthly Premium 100 Employer Paid
LTD COVERAGE
Grand Forks Public Schools provides LTD coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Long Term Disability
Maximum Benefit 6667 to a defined maximum
Benefit Duration(varies by the age of the employee)
Age at DisabilityLess than age 60Age 60 through age 64Age 65 through age 69Age 70+
Maximum Period of PaymentTo age 65 but not less than 5 years5 yearsTo age 70 but not less than 1 year1 year
Elimination Period After 90 days or end of sick leave (whichever is greater)
Coverage Basis AdministratorsTeachers2 year own occupation
Classified EmployeesAny occupation day one
Emergency Travel Assist(when traveling 100 or more miles or to another country)
Guaranteed hospital admission Emergency medical evacuation Prescription replacement
Monthly Premium 100 Employer Paid
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
12 BENEFITS GUIDE | 2021
BASIC LIFE ADampD AND LTD BENEFITS
BASIC LIFE AND ADampD
Grand Forks Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Basic Life and ADampD Benefits
Administrator $50000
Certified amp Classified $15000
Accidental Death (ADampD) Mirrors Basic Life
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life expectancy has been reduced to less than
12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at age 68 60 at age 69 and 50 at 70+ years
Monthly Premium 100 Employer Paid
LTD COVERAGE
Grand Forks Public Schools provides LTD coverage for all active employees working as follows
Certified 15 hours or more per week Classified 30 hours or more per week
Long Term Disability
Maximum Benefit 6667 to a defined maximum
Benefit Duration(varies by the age of the employee)
Age at DisabilityLess than age 60Age 60 through age 64Age 65 through age 69Age 70+
Maximum Period of PaymentTo age 65 but not less than 5 years5 yearsTo age 70 but not less than 1 year1 year
Elimination Period After 90 days or end of sick leave (whichever is greater)
Coverage Basis AdministratorsTeachers2 year own occupation
Classified EmployeesAny occupation day one
Emergency Travel Assist(when traveling 100 or more miles or to another country)
Guaranteed hospital admission Emergency medical evacuation Prescription replacement
Monthly Premium 100 Employer Paid
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
132021 | BENEFITS GUIDE
VOLUNTARY - SUPPLEMENTAL LIFE INSURANCE
SUPPLEMENTAL LIFE INSURANCE
Supplemental Life Insurance is in addition to the basic life insurance Supplemental Group Life Insurance provides term life insurance at low rates Current coverage includes financial protection in the event you your spouse andor one of your dependents die while covered under this benefit
Employees working as follows are eligible
Certified 15 hours or more per week Classified 30 hours or more per week
Voluntary Life Benefits
Certified amp Classified Option of $20000 or $40000
Administrator $50000
Dependent - Spouse andor Children $5000 per dependent
Accelerated Death Benefit Pays a portion of the insured employeersquos life benefit in the event the insured employee becomes terminally ill and the employees life
expectancy has been reduced to less than 12 months
Age Reduction Reduces to 92 of the original amount at age 65 reduces to 84 at age 66 76 at age 67 68 at ae 68 60 at age 69 and 50
at 70+ years
Guaranteed Issue If you enroll within 31 days of becoming eligible then you qualify for the Guaranteed Issue amounts listed without having to prove good
health
Late Enrollment If you do not enroll in the first 31 days of employment and want to add the coverage at a later date you will need to wait until the next benefit enrollment period At that time you will have to provide proof
of good health This may include a physical examination
Coverage Amounts Annual Rates
$20000 $6000
$40000 $12000
$50000 $15000
Dependent $2376
Delayed Effective Date Employee Insurance coverage will be delayed if you are not in active employment because of an injury sickness temporary layoff or leave of absence on the date that insurance would otherwise become effective Regularly scheduled vacation time is considered active employment
Dependent Insurance coverage will be delayed if the dependent is totally disabled on the date that insurance would otherwise be effective Exception infants are insured from live birth ldquoTotally Disabledrdquo means that as a result of an injury a sickness or a disorder your dependent is confined in a hospital or similar institution confined at home under the care of a physician for a sickness or injury
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
14 BENEFITS GUIDE | 2021
VOLUNTARY - WHOLE LIFE INSURANCEWHOLE LIFE INSURANCE
Grand Fork Public Schools offers voluntary Whole Life Insurance Through UNUM eligible employees can purchase permanent whole life insurance for themselves spouse and dependents
EMPLOYEE Guaranteed issue for newly eligible in amounts up to $70000 in $10000 increments
SPOUSE Guaranteed issue for newly eligible in amounts up to $30000 in $10000 increments
CHILD(REN) Guaranteed issue for amounts up to $3 a week
Child Term Rider available in the amount of $10000
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
+ Individual Policies are owned by you completely portable if you change jobs or retire
+ Rates and amount of coverage will NOT CHANGE as you age
+ Policy earns cash value at a guaranteed interest rate
Who can have it Whatrsquos the benefit amount How long can they keep it
Individual employee coverage
Ages 15-80
You can choose to purchase $10000 $20000 $30000 $40000 $50000 $60000 or $70000 of coverage for yourself
You can keep it as long as you want If you leave your employer you would be billed directly at home
Individual spouse coverage
Ages 17-64
You can choose to purchase $10000 $20000 or $30000 of coverage for your spouse
If you leave your employer you can keep your spousersquos policy and be billed directly at home
Individual child coverage
No employee or spouse purchase needed Available to eligible children stepchildren legally adopted children or grandchildren (14 days until their 26th birthday) of the primary insured adult
You can purchase coverage for as low as $1 a week Benefit amounts are based on the childrsquos issue age and premium selected
Your children can keep it even if you leave your employer You would be billed directly at home
Child Term Life Benefit
With pruchase of employee or spouse policy
available to eligible children legally adopted
children and stepchildren (14 days until their 25th
birthday of the primary insured adult
$1000 to $10000 - one rider covers all children Coverage ends when your policy ends or when the
children turn 25 At that time children are guaranteed
the right to buy an individual Whole Life Policy at 5
times the amount of their rider
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
152021 | BENEFITS GUIDE
VOLUNTARY - CRITICAL ILLNESS
Grand Fork Public Schools offers voluntary Critical Illness Insurance Critical Illness Insurance is designed to protect your income and personal assets when your out-of-pocket expenses increase as a result of an illness Health insurance is not always enough to cover all of the unforeseen expenses associated with a serious medical condition like a heart attack or cancer
CRITICAL ILLNESS INSURANCE
This pays a lump sum benefit that can be used any way you choose and benefits are paid in addition to any other insurance coverage you may have
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouse must be between the ages of 17and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
COVERED ILLNESSES amp PAYMENT PERCENTAGES (NOT ALL INCLUSIVE)
+ Heart Attack 100
+ Stroke 100
+ Major Organ Failure 100
+ End Stage Renal (Kidney) Failure 100
+ Cancer - Malignant Tumors 100
+ Coronary Artery Bypass Surgery 25
+ Carcinoma in Situ 25
PLAN FEATURES
+ Coverage is Guaranteed Issue for amounts up to $30000 for employee $15000 for the spouse and 50 of the employee coverage amount for dependent children which means you will not be asked medical questions
+ A health Screening Benefit Rider is included
+ Coverage is portable - you can take your policy with you if you change jobs or retire
+ Rates based on age and tobacco use
+ 30 day benefit waiting period
+ 1212 pre-existing condition limitation This means UNUM will not pay benefits for a claim that is caused by contributed to or occurs as a result of a pre-exisiting condition or any medical or surgical treatment for that condition for which the date of diagnosis occurred during the previous 12 months until yoursquove been covered for 12 months
+ For 2 or more covered illnesses there needs to be a separation period of 90 days and canrsquot be medically related
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
16 BENEFITS GUIDE | 2021
VOLUNTARY - ACCIDENT INSURANCE
ACCIDENT INSURANCE
Grand Fork Public Schools offers voluntary Accident Insurance UNUMrsquos Accident Insurance pays benefits based on the injury you receive and the treatment you need including emergency-room care and related surgery The benefit can help offset the out-of-pocket expenses that medical insurance does not pay including deductibles and co-pays Benefits are paid for accidents that occur off-the-job You can also elect to cover your dependents
EXAMPLES OF COVERED INJURIES AND ACCIDENT RELATED EXPENSES INCLUDE
+ Hospitalization
+ Emergency room treatment
+ Fractures and dislocations
+ Physical Therapy
+ Doctorrsquos visits
ELIGIBILITY
Employees working 30 hours or more per week are eligible Spouses must be between the ages of 17 and 64 This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
ADDITIONAL FEATURES
Your coverage is portable which means you can take your policy with you if you leave the company
Policy pays the benefit directly to you not the doctor or hospital
Wellness Benefit pays you $50year for having a qualified screening exam
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
172021 | BENEFITS GUIDE
SHORT TERM DISABILITY
A disabling injury or illness that keeps you out of work could have a devastating impact on your income jeopardizing your ability to cover normal household expenses With the right disability insurance your income is protected relieving you of the anxiety of depleting your savings to pay your bills
ELIGIBILITY
Employees working 30 hours or more per week are eligible This benefit can be added during initial eligibility period for new hires or during the district benefit enrollment period
Short Term Disability Insurance replaces a portion of your income if an injury or illness forces you out of work for an extended period of time
VOLUNTARY - INDIVIDUAL SHORT TERM DISABILITY
COVERAGE IS FOR EMPLOYEE ONLY
(rates are based on salary and coverage elected)
+ Benefit Percentage Options of 40 50 or 60 of base earnings
+ Maximum Benefit Amount $3000
+ Elimination Period Accident 14 Days
+ Elimination Period Sickness 14 Days
+ Benefit Period 12 weeks
+ Eligibility 30 or more hours week
+ Age Issuance 17 to 69 years old
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
18 BENEFITS GUIDE | 2021
VOLUNTARY FLEXIBLE SPENDING ACCOUNTSWHAT IS A FLEXIBLE SPENDING ACCOUNT
The flexible spending account (FSA) is an optional account where you can set aside money for health care expenses andor Dependent Care on a pre-tax basis In order to participate in the Medical FSA you must be eligible to participate in your employer sponsored group health plan or another family memberrsquos group health plan
HEALTHCARE FSA
The Medical FSA allows you to set aside pre-tax money to pay for a variety of qualified medical dental vision and pharmacy expenses Some examples of eligible health care expense are
+ Deductibles
+ Copays and coinsurance
+ Non-cosmetic procedures not covered by your medical or dental plan
+ Contact lenses and glasses
+ Hearing aids and eye surgery
2021 annual maximum contribution for your Medical FSA is $2750
A complete list of qualified expenses can also be found in IRS Publication 502 - Medical and Dental Expenses
Participants have a 212 month grace period after the plan year ends to incur eligible expenses Participants have six months after this grace period to submit the expenses that were incurred
DEPENDENT CARE FSA
The Dependent Care FSA can be used to pay for day care expenses for eligible dependents under age 13 as well as adults who are physically or mentally incapable of caring for themselves
2021 annual maximum contribution for Dependent Care is $5000 if you file your taxes as married filing jointly or $2500 per year if filing separately
OUTSIDE HEALTH FSA
Outside Health FSA is for certain limited policy insurance premiums individually purchased such as cancer policy premiums (as long as there is no return of premium feature in the plan) hospitalization insurance premiums specific illness policy premiums and accidental death and dismemberment policy
No individually-purchased overall health or exchange purchase health policy premiums are allowed in this category
GROUP-TERM LIFE INSURANCE FSA
Group-term life insurance FSA is for certain life insurance premiums for employer sponsored plans where coverage is for the employee only
Note Current participants must enroll each year to continue participating Enrollment does NOT carry forward year to year
PLAN CAREFULLY bull Annual contribution amounts you
elect must be set during enrollment
and can not be changed except for
changes in family status
bull Expenses must be incurred within the
plan year and the 212 month grace
period - This benefit is a ldquouse it or
lose itrdquo
bull IRS governed save receipts
HOW TO FILE A FLEX CLAIMGo to gfschoolsorgbenefits to
find ldquoHow to File a Flex Claimrdquo
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
192021 | BENEFITS GUIDE
AVIBEN MOBILE BENEFITS amp WEX CARD
Introducing a different way to manage your healthcare financesWith Aviben Mobile Benefits and the whole new WEX Health Payment card managing your FSA account is easier than itrsquos ever been
Make payments with easeAll it takes is a swipe of your benefits debit card to pay for a healthcare expense Payments are automatically withdrawn from your reimbursement account so there are no out-of-pocket costs And because the majority of your purchases are verified (or substantiated) at the point of purchase you will need to submit fewer receipts manually You can also have reimbursements direct deposited to the account of your choice select to pay the provider directly and schedule recurring payments such as monthly prescriptions
Receipts may be required upon request in accordance to plan rules
Access your accounts anytime anywhereWith Aviben Mobile Benefits you can get to the healthcare account information you needmdashfast Wondering whether you have enough money to pay a bill or make a purchase puts the answers at your fingertips
bull Quickly check available balances and account details for medical and dependent care FSA HSA HRA VEBA 501(C)(9) and premium reimbursement plans
bull View charts summarizing account information
bull Set account alerts and get notifications via text message
bull View claims requiring receipts
bull Link to an external web page to obtain helpful information such as a list of eligible expenses
bull Retrieve a lost username or password
bull Use your device of choice ndash including iPhonereg iPadreg iPod touchreg and Androidtrade smartphones and tablet devices
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
20 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQAVIBEN MOBILE BENEFITS amp WEX CARD CONTINUED
Get up and going quicklyEven if this is the first time using benefits software yoursquoll find the experience is intuitive and easy-to-use most importantly yoursquoll have 247 access to your benefit accounts When you log in to your portal you can
bull See your balances in real- time
bull File claims
bull Upload receipts
bull Visualize spending with charts and graphs
Yoursquoll find everything you need to manage your healthcare finances simply
See it plan for it manage itPlanning and budgeting for healthcare expenses is an important part of managing your finances The consumer portal provides the information you need to stay on top of your familyrsquos healthcare expenses Use the dashboard to dynamically interact with expenses and claims Graphic displays provide you with numbers that help you
bull Analyze out-of-pocket expenses
bull Identify the providers who yoursquore spending the most money with
bull Manage your HSA investments like your 401K
bull Compare expenditures year-to-year
Save timeAll the reasons mentioned so far will help save you time but there are many more ways to streamline your healthcare management You can
bull Set up text alerts to be notified automatically when a contribution posts a deduction goes through or your account reaches a pre-set balance that you determine
bull Quickly locate forms you need for processing
Managing your healthcare and taking control of your decisions has never been more convenient and fast so you can spend more time doing the things you love without the hassle or worry If you have any questions please contact HR
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
212021 | BENEFITS GUIDE
WEX HEALTH PAYMENT CARD FAQ
1 What is the WEX Health Payment card The all new WEX Health Payment card is a special-purpose Visareg card that gives participants an easy automatic way to pay for eligible health carebenefit expenses The Card lets participants electronically access the pre-tax amounts set aside in their respective employee FSA benefits accounts
2 How does the WEX Health Payment card work The value of the participantrsquos account(s) contribution is stored on the benefits debit card When participants have eligible expenses at a business that accepts benefit debit cards they simply use their Card The amount of the eligible purchases will be deducted ndash automatically ndash from their account and the pre-tax dollars will be electronically transferred to the providermerchant for immediate payment
3 Is the WEX Health Payment card just like other Visareg Card No The WEX Health Payment card is a special-purpose Visa Card that can be used only for eligible health carebenefits expenses It cannot be used for instance at gas stations or restaurants There are no monthly bills and no interest
4 How many WEX Health Payment cards will the participant receive The participant will receive two Cards If participants would like additional Cards for other family members they should contact their Plan Administrator at the telephone number or website address printed on the back of the Card
5 Will participants receive a new WEX Health Payment card each year No Although you must re-enroll each year to use the card participants will not receive a new Card each year If the participant will again have a benefit associated with the Card for the following plan year ndash and heshe used the Card in the current benefit year ndash the participant will simply keep using the same Card the following year The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period based on the type of account(s) the participant has
6 What if the WEX Health Payment card is lost or stolen Participants should call their Plan Administrator at the telephone number or website address printed on the back of the Card Report a Card lost or stolen as soon as they realize it is missing so the Administrator can turn off their current Card(s) and issue replacement Card(s) There may be a fee for replacement cards
7 What dollar amount is on the WEX Health Payment card when it is activated The dollar value on the Card will be the annual amount that participants elected to contribute to their respective employee benefit account(s) during their annual benefits enrollment Itrsquos from that total dollar amount that eligible expenses will be deducted as participants use their Cards or submit manual claims
8 Where may participants use the WEX Health Payment card IRS regulations allow participants to use their WEX Health Payment cards in participating pharmacies mail-order pharmacies discount stores department stores and supermarkets that can identify FSA-eligible items at checkout and accept benefit prepaid cards Eligible expenses are deducted from the account balance at the point of sale Transactions are fully substantiated and in most cases no paper follow-up is needed Participants can find out which merchants are participating by visiting the web site on the back of the Card or consulting with Aviben
Participants may also use the Card to pay a hospital doctor dentist or vision provider that accepts prepaid benefit cards In this case auto-substantiation technology is used to electronically verify the transactionrsquos eligibility according to IRS rules If the transaction cannot be auto substantiated paper follow-up will be required
9 Are there places the WEX Health Payment card wonrsquot be accepted Yes The Card will not be accepted at locations that do not offer the eligible goods and services such as hardware stores restaurants bookstores
gas stations and home improvement stores
Cards will not be accepted at pharmacies mail-order pharmacies discount stores department stores and supermarkets that cannot identify HSA
FSA-eligible items at checkout The Card transaction may be declined Participants can find out which merchants are participating by visiting the web
site on the back of the Card
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
22 BENEFITS GUIDE | 2021
WEX HEALTH PAYMENT CARD FAQ CONTINUED
10 If asked should participants select ldquoDebitrdquo or ldquoCreditrdquo
If the participant has elected to use a PIN (Personal Identification Number) with their WEX Health Payment card they should select ldquoDebitrdquo and enter
the PIN when prompted If the participant is not using a PIN with their WEX Health Payment card they should select ldquoCreditrdquo and will be asked to
sign for the benefit card purchase Participants cannot get cash with the WEX Health Payment card
11 Why do participants need to save all of their itemized receipts
Participants and their other eligible users should always save itemized receipts for FSA purchases made with the WEX Health Payment card They
may be asked to submit receipts to verify that their expenses comply with IRS guidelines Each receipt must show the merchant or provider name the
service received or the item purchased the date and the amount of the purchase The IRS requires that every card transaction must be substantiated
This can occur through automated processing as outlined by the IRS (eg copay matching etc) If the automated processing is unable to substantiate
a transaction the IRS requires that itemized receipts must be submitted in order to validate expense eligibility
12 How will a participant know to submit receipts to verify a charge
The participant will receive a letter or notification from their administrator if there is a need to submit a receipt All receipts should be saved per the IRS
regulations
13 What if a participant fails to submit receipts to verify a charge
If receipts are not submitted as requested to verify a charge made with WEX Health Payment card then the Card may be suspended until receipts
are received The participant may be required to repay the amount charged
14 May participants use the WEX Health Payment card for prescriptions ordered prior to activating the Card
No The Card must be activated prior to the order andor purchase date of prescriptions In some cases participants need to wait 1 business day
after activating the Card to purchase prescriptions at their pharmacy For example if the Card is activated on Tuesday a prescription can be ordered
and picked up on Wednesday
15 May participants use the WEX Health Payment card if they receive a statement with a Patient Due Balance for a
medical service
Yes As long as they have money in their account for the balance due the services were incurred during the current plan year and the provider
accepts prepaid benefit debit cards participants can simply write the Card number on their statement and send it back to the provider
16 What if participants have an expense that is more than the amount left in their account
When incurring an expense that is greater than the amount remaining in their account participants may be able to split the cost at the register (Check
with the merchant) For example participants may tell the clerk to use the WEX Health Payment card for the exact amount left in the account and then
pay the remaining balance separately Alternatively participants may pay by another means and submit the eligible transaction manually via a claim
form with the appropriate documentation
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
232021 | BENEFITS GUIDE
EMPLOYEE ASSISTANCE PROGRAM (EAP)
An Employee Assistance Program (EAP) offers short-term counseling on all aspects of life Grand Forks Public Schools provides this program at no additional cost to you Employees and household members can confidentially address and resolve personal and work related challenges including
EVERY DAY CHALLENGES
+ Childcare andor eldercare referrals
+ Personal relationship information
+ Health information and online tools
+ Legal consultations with licensed attorneys
+ Financial Planning Assistance
+ Career Development
PROTECT YOURSELF FROM FINANCIAL FRAUD
+ Online research and information on ID theft and financial fraud
+ Toll-free telephone access to masterrsquos level work-life balance consultants
+ Referrals to a local counselor
WILL PREPARATION
+ Estate Planning
+ Advance directive or living will
+ Power of Attorney
+ Final arrangements memorandum
HELP IS EASY TO ACCESS
+ Telephone Consultations Speak confidentially with a masterrsquos level consultant to clarify your need evaluate options and create an action plan
+ Face-to-Face meeting Meet with a local consultant up to 3 times per issue for short-term problem resolution
+ Educational materials Receive information through our online library of downloadable materials and interactive tools
WHO IS COVERED
Unumrsquos EAP services are available to all eligible employees their spouses or domestic partners dependent children and parents-in-law
ALWAYS BY YOUR SIDE
+ Expert support 247
+ Convenient website
+ Short-term help
+ Referrals for additional care
+ Monthly webinars
+ Medical Bill Saver
- helps you save on medical bills
Confidential assistance is available 24 hours a day 7 days a week1-800-854-1446 | wwwunumcomlifebalance
Username and Password lifebalance
WEX HEALTH PAYMENT CARD FAQ CONTINUED
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
24 BENEFITS GUIDE | 2021
RETIREMENT INFORMATION
TEACHERS amp ADMINISTRATORS
Certified teachers and administrators participate in the North Dakota Teacherrsquos Fund For Retirement (TFFR) program TFFR was established under North Dakota Century Code to provide retirement income to public educators It is a qualified defined benefit public pension plan covered under Section 401(a) of the Internal Revenue Code In 2015-2016 ND state law requires that 1175 of your salary is deducted from payroll for this program The school District contributes an additional 1275 on your behalf
Social Workers Occupational Therapists and Physical Therapists covered under the teacher negotiated agreement but not eligible to participate in the TFFR program and non-certified administrators will authorize an 1175 payroll deduction to a Tax Sheltered Annuity (TSA403b) and receive a 1275 employer contribution to this account The employee must open an account with a Vendor from the approved vendor list
In addition TFFR covered teachers and administrators have the opportunity to authorize a payroll deduction to a Tax Sheltered Annuity (TSA403b) There are no employer contribution in this circumstance
CLASSIFIED EMPLOYEES
For Classified Employees working 30 hours or more per week the School District matches the employeersquos contribution to a Tax Sheltered Annuity (TSA403b) dollar for dollar up to 50 of the employeersquos earnings This contribution must be made through payroll deduction TSA403b deductions are FICA taxable only Employees working less than 30 hours per week may contribute to a TSA403b through payroll deduction without an employer match To participate an employee must have an account established with a Vendor from the approved list (contact Human Resources) Employees can start suspend or change the contribution amount at anytime
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
252021 | BENEFITS GUIDE
ENROLLMENT INSTRUCTIONS
LOG IN
URL wwwgrandforksbswiftcom
Username Your username is your Employee ID located on your badge
Password Your birth date (MMDDYYYY) You will be prompted to change your password when you log in
ENROLLMENT THREE STEPSPlease note you must complete all steps of your enrollment in order for your elections to be saved
Click the Start Your Enrollment button to get started You may access your confirmation statement and other important documents from this page at any time
If you need more help or information on this process please reach out to your Human Resources Department
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
26 BENEFITS GUIDE | 2021
STEP 1 VERIFY YOUR PERSONAL AND FAMILY INFORMATION
Personal Information
+ Verify your personal information for accuracy and fill in any required fields If you need to make changes to any non-editable fields please contact HR
+ Verify that all information is accurate
+ Check the checkbox next to ldquoI agreerdquo
+ Click the Continue button
Family Information
+ Please be sure to add all dependents to the Family Information section before proceeding to the next section (enrollment) To do so click on the + Add Dependents link To edit an existing dependent click on Edit gt under his or her name
+ Once you have finished entering a dependent you may either Save amp Add Another or Save amp Continue
+ After confirming all your family information is accurate check the box next to ldquoI agreerdquo
+ Click the Continue button to proceed with your enrollment
STEP 2 SELECT YOUR BENEFITS
After completing your personal and family information you will be taken to Your Benefits page During this portion of the enrollment you will be able to view and edit you and your dependentsrsquo benefit elections You must make an election whether enrolling or waiving in each box with the Selection Required warning before you may continue to the next step As you make your elections your total cost per pay period will accumulate on the right side of the screen
+ Under each plan type you may keep your prior selection waive or View Plan Options to see what choices are available to you
+ If you click View Plan Options you will be asked to choose any dependents you intend to cover on this plan You will also be able to make changes on the next step
+ Click Continue
+ As you add and remove dependents the costs and tiers next to each plan will change Click the blue arrow next to the cost to view the company contribution
+ To view all plan details next to each other click the View All Plans Side-by-Side button or for just one plan click View plan details underneath the plan name
+ When you have decided on a plan click the Select button to the right of the plan name
BENEFICIARIES
+ You may add beneficiaries that are not your dependents (parents siblings etc) by clicking + Add New Beneficiary Enter all required information and then click Save or Save amp Add Another
+ You may split the amount amongst your beneficiaries but both primary and secondary percentages must total 100
+ When you are finished with beneficiaries questions andor other coverages click the Continue button to proceed to the final step of enrollment
STEP 3 LAST STEP - CONFIRM AND SAVE YOUR ELECTIONS
+ Please review your selections
If needed you may still edit your elections by clicking Edit Selection on the bottom of any plan type
+ Please read over any agreement text at the bottom of the page
+ Check the ldquoI agree and Irsquom finished with my enrollmentrdquo checkbox and click the Complete Enrollment button
CONFIRMATION STATEMENTS
When you reach the Confirmation Statement (pictured below) you have completed your enrollment
+ You may access a copy of your confirmation statement at any time by clicking My Benefits in the upper right-hand corner of your homepage
+ You may edit your enrollment until the end of your enrollment window by clicking the Change My Elections button on your homepage
+ If you would like to waive coverage scroll to the bottom of the benefit planrsquos page and select the ldquoWaive Medicalrdquo plan
+ When you have finished making all of your benefit elections (the boxes will have a green checkmark and be marked radic Completed) click the Continue button on the right hand side of the screen If you would like to edit any of your selections click on the planrsquos View Plan Options button Note you will not be able to complete your enrollment until each benefit has been completed
+ If applicable you will be taken to Beneficiary Designation Questions or Other Coverages pages
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
272021 | BENEFITS GUIDE
IMPORTANT NOTICESHIPAA PRIVACY NOTICE
A portion of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information It applies to all health benefit plans In short the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential This individually identifiable health information is known as ldquoprotected health informationrdquo (PHI) and it will not be used or disclosed without your written authorization except as described in the Planrsquos HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws A copy of the Planrsquos Notice of Privacy Practices that describes the Planrsquos policies practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider For more information regarding this Notice please contact
Human Resources
WOMENrsquoS HEALTH AND CANCER RIGHTS ACT
Your medical plan as required by the Womenrsquos Health and Cancer Rights Act of 1998 provides benefits for mastectomy-related services These services include
+ All stages of reconstruction of the breast on which the mastectomy was performed
+ Surgery and reconstruction of the other breast to produce symmetrical appearance
+ Prostheses and treatment of physical complications resulting from mastectomy (including lymphedema)
COBRA RIGHTS
Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) Federal law makes it possible for certain employees and their eligible dependents to continue participation in health care plans if the coverage would have otherwise been terminated
Visit healthcaregov for information on health plans available through the Healthcare Marketplace in your area
INDIVIDUAL COVERAGE MANDATE
Federal law requires that you have health care coverage or you may be subject to an income tax penalty You can enroll in this health plan or you may want to consider visiting wwwhealthcaregov for information on health plans available through the Healthcare Marketplace in your area
NEWBORNrsquoS AND MOTHERrsquoS HEALTH PROTECTION ACTThe Newbornrsquos and Motherrsquos Heath Protection Act of 1996 (NMHPA) affects the amount of time you and your newborn child are covered for a hospital stay following childbirth In general health insurers and HMOs may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section If you deliver in the hospital the 48 hour (or 96 hour) period starts at the time of delivery If you deliver somewhere other than the hospital and you are later admitted to the hospital in connection with the childbirth the period begins at the time of admission Also a health insurer or HMO cannot require you or your attending provider to obtain prior authorization for your delivery or show that the 48 hour (or 96 hour) stay is medically necessary However a health insurer or HMO may require you to get prior authorization for any portion of a stay after the 48 hours (or 96 hours)
MEDICAID AND THE CHILDRENrsquoS HEALTH INSURANCE PROGRAM (CHIP) OFFER FREE OR LOW-COST HEALTH COVERAGE TO CHILDREN AND
FAMILIES
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 office to find out if premium assistance is available
If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or wwwinsurekidsnowgov to find 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 60 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)
MINNESOTA ndash MEDICAID
Website httpwwwdhsstatemnus
Phone 1-800-657-3629
NORTH DAKOTA ndash MEDICAID
Website httpwwwndgovdhsservicesmedicalservmedicaid
Phone 1-800-755-2604
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either
US DEPARTMENT OF LABOR
Employee Benefits Security Administration
wwwdolgovagenciesebsa
1-866-444-EBSA (3272)
US DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare amp Medicaid Services
wwwcmshhsgov
1-877-267-2323 Menu Option 4 Ext 61565
This is not an all inclusive list of states Please contact Human Resources for detailed information on these federal laws and a full
copy of the notice
