2016 Benefits Summary - Catholic Charities of Buffalo

2016 Benefits Summary
PLAN YEAR
2016
Our employees are our
most valuable asset.
That’s why at Catholic Charities we are committed to a comprehensive employee benefit program
that helps our employees stay healthy, feel secure, and maintain a work/life balance.
Stay Healthy



Medical, Dental, and Vision Care
Flexible Spending Accounts
Health Savings Account
Feeling Secure






Disability Insurance
Life and Accidental Death & Dismemberment
Accident Coverage
Cancer Insurance
Critical Illness
Identity Theft / Legal Advice
Work/Life Balance

Employee Assistance Program
2
Contact Information
Refer to this list when you need to contact one of your benefit vendors. For general information
contact Human Resources.
MEDICAL:
Independent Health
Members Service
Local
1-716-631-8701
Toll-free
1-800-501-3439
www.independenthealth.com
page 5
DENTAL:
ProBenefits Administrators
Dental Claims
1-888-683-3682
www.probenefitsadmin.com
p age 8
VISION:
VSP
Vision Claims
1-800-877-7195
www.vsp.com
p age 11
FLEXIBLE SPENDING ACCOUNTS (FSA):
Pro-Flex Administrators, LLC
Member Service & Claims
1-855-847-9069 or 716-633-2073
www.proflextpa.com
p age 12
HEALTH SAVINGS ACCOUNT (HSA):
Key Bank
Customer Service
1-888-539-2020
www.key.com/HSA
____
p age 14
DISABILITY BENEFITS:
First Niagara Risk Management Inc.
Catholic Charities Human Resources Department
716-218-1400
http://employee.ccwny.org/
p age 16
LIFE & ACCIDENTAL DEATH & DISMEMBERMENT:
The Hartford
Customer Service
1-800-563-1124
www.thehartford.com
p age 17
3
ACCIDENT,CANCER & CRITICAL ILLNESS:
Colonial Voluntary Benefits
1-800-325-4368
www.coloniallife.com
PAGE
18
LEGAL SHIELD & IDENTITY THEFT PROTECTION_______________________________________________PAGE 22
Marty Gilano
1-716-432-8801
Mgilano78@legalshield.com
EMPLOYEE ASSISTANCE PROGRAM (EAP):
Palladian, formerly Prism Health Networks
1-888-276-6632
http://palladianeap.com/
p age 24
4
Medical Insurance
This chart gives a side-by-side look at the amounts you will pay if you are in the Enhanced or
Standard Plan and when you use in-network and out-of-network providers.
** This plan is not available to any staff benefit eligible on or after 1/1/2016
Empower POS
Enhanced
Standard
Office Visits
$25 Copay
$35
Specialist Visits
$40 Copay
$35
Emergency Room Visit (Waived if
Admitted to Hospital)
$150 Copay
20% after deductible
$75 Copay
Urgent Care Center
Outpatient Surgery Facility
$150 Copay
20% after deductible
In-Patient Hospitalization ($0
Copay for Maternity Admissions)
$500 Copay
20% after deductible
Prescription Drug Coverage
$10 / $30 / $100
$200 Aggregate Deductible on 2nd and 3rd tiers
Dependent Coverage
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In-Network:
Deductible
Coinsurance
Out-of-Pocket Maximum
N/A
N/A
$6,350/$12,700
$2,000/$4,000
80%/20%
$6,350/$12,700
Out-of--Network:
Deductible
Coinsurance
Out-of-Pocket Maximum
$1,000/$2,000
70%/30%
$6,350/$12,700
$2,000/$4,000
60%/40%
$6,350/$12,700
5
Medical Insurance
Continued
This chart gives a side-by-side look at the amounts you pay when you use in-network and out-ofnetwork providers.
Empower High Deductible Health Plan
Enhanced
Standard
Office Visits
$10 after deductible
$20 after deductible
Specialist Visits
$20 after deductible
$40 after deductible
Emergency Room Visit
$125 after deductible
$150 after deductible
Outpatient Surgery Facility
$100 after deductible
$150 after deductible
In-Patient Hospitalization (No Coinsurance
for Maternity Admissions)
$300 after deductible
Prescription Drug Coverage
$10 / $30 / $50
after deductible
Dependent Coverage
In-Network:
Deductible
Coinsurance
Out-of-Pocket Maximum
Out-of--Network:
Deductible
Coinsurance
Out-of-Pocket Maximum
$500 after deductible
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$1,500/$3,000 (combined)
N/A
$5,000/$10,000
(combined)
$3,000/$6,000 (combined)
N/A
$5,000/$10,000
(combined)
$1,500/$3,000 (combined)
80% / 20%
$5,000 / $10,000
(combined)
$3,000 / $6,000
70% / 30%
$5,000 / $10,000
(combined)
6
Medical Insurance
Continued
This chart gives a side-by-side look at the amounts you pay when you use in-network and out-ofnetwork providers.
Choice Plus
Network A
Network B
Office Visits
$25 after deductible
40% after deductible
Specialist Visits
Emergency Room Visit
$40 after deductible
40% after deductible
$200 after deductible
Outpatient Surgery Facility
$200 after deductible
In-Patient Hospitalization (No Coinsurance
for Maternity Admissions)
Prescription Drug Coverage
$1,000 after deductible
Out-of--Network:
Deductible
Coinsurance
Out-of-Pocket Maximum
40% after deductible
$10 / $50 / $100
after deductible
Dependent Coverage
In-Network:
Deductible
Coinsurance
Out-of-Pocket Maximum
40% after deductible
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$1,500/$3,000
N/A
$5,000/$10,000
$3,000/$6,000
60% / 40%
$6,350 / $12,700
$3,000 / $6,000
60% / 40%
$10,000 / $20,000
7
Dental Insurance
Core Plan
This chart shows how the plan works and how each type of service is covered.
CORE PLAN
BENEFIT
Plan Summary
Dependents covered to 19, 25 if full-time student
ProBenefits Administrators
In-Network plan utilizes participating
dentists. Out-of-Network allows
freedom of choice.
In-Network
Out-of-Network
Preventative Services:
Oral Exams
X-rays & Diagnostic
Teeth Cleanings (1 every 6 months)
Fluoride Treatment
Topical Sealant
Emergency Treatment
100%
100% of UCR
Minor Restorative Services:
Fillings
Space Maintainers
Oral Surgery
Extractions
Stainless Steel Crowns
Recementation Crowns/Inlays
Occlusion Adjustment
Local Anesthesia
80%
80% of UCR
Major Restorative Services:
Porcelain Crowns
Inlay/Onlay
Endodontics
Root Canals
Periodontic Services
Partial & Full Dentures
Fixed Bridgework
Repair to Dentures/Bridgework
50%
50% of UCR
$50 (3x family)
$50 (3x family)
$750
$750
Deductible (Minor & Major Services)
Annual Maximum per person/per Calendar year
8
Dental Insurance
Enhanced Plan
This chart shows how the plan works and how each type of service is covered.
ENHANCED PLAN
ProBenefits Administrators
In-Network plan utilizes participating dentists. Out-of-Network allows freedom of choice.
Dependents covered to 19, 25 if full-time student
In-Network
Out-of-Network
Preventative Services:
Oral Exams
X-rays & Diagnostic
Teeth Cleanings (1 every 6 months)
Fluoride Treatment
Topical Sealant
Emergency Treatment
100%
100% of UCR
Minor Restorative Services:
Fillings
Space Maintainers
Oral Surgery
Extractions
Stainless Steel Crowns
Endodontics
Root Canals
Periodontic Services
Recementation Crowns/Inlays
Occlusion Adjustment
Local Anesthesia
80%
80% of UCR
Major Restorative Services:
Porcelain Crowns
Inlay/Onlay
Partial & Full Dentures
Fixed Bridgework
Repair to Dentures/Bridgework
50%
50% of UCR
$25 (2x family)
$25 (2x family)
Annual Maximum per person/per Calendar year
$1,500
$1,500
Orthodontia Benefit (dependent children to the
age of 19)
50%
50% of UCR
$1,000
$1,000
Deductible (Minor & Major Services)
Orthodontia Lifetime Maximum
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Dental Insurance
BVS Plan
This chart shows how the plan works and how each type of service is covered.
BVS Dental Clinic Is a General Dentistry Center. Services MUST be provided by BVS Dental Center
to be covered under the plan. Subscriber is responsible for 100% of cost for services rendered
outside the BVS Dental Center. Referrals made by BVS Dental Center to other providers are NOT
covered under the BVS Basic Plan.
Preventative Services:
Oral Exams
X-rays & Diagnostic
Teeth Cleanings (1 every 6 months)
Fluoride Treatment
Topical Sealant
Space Maintainers
Emergency Treatment
100%
Minor Restorative Services:
Fillings
Root Canals (simple)
Periodontic (simple) Scaling & Root
cleaning only
Extractions (simple)
Stainless Steel & Acrylic Crowns
Pin Retention
Repairs to Crowns & Bridgework
Recementation Inlays/Onlay/Crown/Bridge
Repair to Dentures
Occlusion Adjustment
Local Anesthesia
100%
Major Restorative Services:
Porcelain Crowns
Inlay/Onlay
Fixed Bridgework
Partial & Full Dentures
60%
Deductible
Annual Maximum Per Person
Baker Victory Dental Clinic
790 ridge Road
Lackawanna, NY 14218
716.828.9334
$50, 3 per family
Waived for Preventative
$1,000
Hours of Operation:
M-F: 8-6 pm
Sat: 8-12 pm
bvdental@yahoo.com
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Vision Benefits
VSP Signature Plan
Benefit
Frequency
Coverage from a VSP Doctor
Out-Of-Network Reimbursement
Exam
12 months
Covered in full.
Up to $40.00 allowance
$10.00 Copay
Lenses
12 months
$20.00 Copay
Single vision, lined bifocal lenses,
lined trifocal lenses are covered in
full.
Children – Polycarbonate
covered in full
Single vision up to $35.00 allowance
Lined bifocal up to $52.00 allowance
Lined trifocal up to $65.00 allowance
Lenticular up to $80.00 allowance
Frame
24 months
Frame of your choice covered up to
$130.00 Plus, 20% off any out-ofpocket costs.
Up to $52.00 allowance
Contact Lenses in lieu
of glasses
12 months
Covered up to $130.00 allowance
Up to $105.00 allowance
Eye
Examination
VSP offers a thorough eye exam due to the important role that a regularly scheduled eye checkup can play in protecting visual and general wellness. The examination is covered in full, less any
applicable plan copayment.
Materials
Lenses and Frames: The Signature Plan offers a 20 percent discount off the VSP doctor’s usual and
customary fees for complete sets of prescription glasses.
Contact lenses: The Signature Plan offers a 15 percent discount off the VSP doctor’s usual and
customary contact lens professional fees (discount does not apply to materials). Contact lenses
may be chosen instead of glasses.
Cosmetic
Options
Patients may sometimes select lenses or lens characteristics that are not necessary for their visual
welfare, but are desired for cosmetic reasons. Examples are tinted/photochromic lenses,
progressive lenses, or anti-reflective coating(s). These options are also offered at a 20 percent
discount off the VSP doctor’s usual and customary fees for full sets of prescription glasses.
Valuable
Discounts
As an added benefit VSP provides:
 30 percent discount on unlimited additional pairs of prescription and/or non prescription
sunglasses purchased on the same day original services received.
After Initial Date of Service
 20 percent discount on additional complete sets of prescription glasses
 15 percent discount off the VSP doctor’s professional contact lens evaluation and fitting
services (contact lenses not subject to discount)
 averaging 15 percent discount, below usual and customary pricing for laser vision correction
The discounts are available for 12 months through any VSP doctor. Discounts not provided for outof-network services.
Out-of-Network Although more than 93 percent of our patients see VSP doctors, we believe that choice is
essential when it comes to health care. That’s why we provide the following reimbursement
Schedule of
schedule for patients choosing an out-of-network provider.
Allowances
Laser
VSP has contracted with many of the nation’s finest laser surgery facilities and doctors, offering
VisionCareSM
you a discount off PRK and LASIK surgeries, available through contracted laser centers. Visit VSP’s
Web site at www.vsp.com to learn more about this exciting program.
11
Flexible Spending Accounts
(FSA)
FSAs provide you with an important tax advantage that can help you pay health care and dependent
care expenses on a pre-tax basis. By anticipating your family’s health care and dependent care costs
for the next year, you can actually lower your taxable income.
Health Care Reimbursement FSA
This program allows employees pay for certain IRS-approved medical care expenses not covered by
their insurance plan with pre-tax dollars. Some examples include:

Hearing services, including hearing aids and batteries

Vision services, including contact lenses, contact lens solution, eye examinations, and
eyeglasses

Dental services and orthodontia

Chiropractic services

Acupuncture
Dependent Care FSA
The Dependent Care FSA allows employees use pre-tax dollars towards qualified dependent care
such as caring for children under the age 13 or caring for elders. The annual maximum amount you
may contribute to the Dependent Care FSA is $5,000 (or $2,500 if married and filing separately) per
calendar year. Examples include:

The cost of child or adult dependent care

The cost for an individual to provide care either in or out of your house

Nursery schools and preschools (excluding kindergarten)
Adoption Assistance
The Adoption Assistance Option provides reimbursement to you for the reasonable and necessary
expenses that you incur in the process of legally adopting an eligible child, including adoption fees,
court fees, court cost and attorney fees. The maximum amount of reimbursement that you may
receive in connection with the adoption of any one child is $13,170 (this will be adjusted for inflation
each year), based off of your adjusted gross income. This is a total one time amount per child.
Remember: Use it or Lose it Rule (Elect Carefully!)
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Flexible Spending Accounts
(FSA) Continued Catholic Charities
Plan Year
January 1, 2016 – December 31, 2016
Plan Election Maximums
 $2,500 Medical FSA
 $5,000 Dependent Care
 $13,170 Adoption Assistance
Reimbursement Schedule
 Participant medical and dependent care payments issued Daily
 Claims must be received in our office at least three (3) business days prior to disbursement
date
Run Out Period
 90 Days following Year End
Separation/Termination
 60 days (claims must be for services incurred prior to separation date)
For more information, contact Pro-Flex’s Customer Service Department at 716-633-2073 or toll free
at (855) 847-9069
You can also view and manage your account online at
www.proflextpa.com
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Health Savings Account
(HSA)
A Health Savings Account (HSA) is an account that can be funded with your tax-exempt dollars, by
your employer, or both, to help pay for eligible medical expenses not covered by insurance plan,
including deductible, coinsurance and, in some cases, may be used to pay health insurance
premiums.
Who is eligible for an HSA?
Anyone who is:
 Covered by a High Deductible Health Plan (HDHP);

Not covered under another medical health plan that is not a High Deductible Health Plan;

Not entitled to Medicare benefits; and
Not eligible to be claimed on another person’s tax return
What is a High Deductible Health Plan (HDHP)?
A High Deductible Health Plan (HDHP) is a plan with a minimum annual deductible and a maximum
out-of-pocket limit as listed below. These minimums and maximums are determined annually by the
Internal Revenue Service (IRS) and are subject to change.
Type of
Coverage
Minimum Annual
Deductible
Individual
Family
$1,300
$2,600
Maximum
Annual Out of
Pocket
$6,550
$13,100
When do I use my HSA?
After visiting a physician, facility, or pharmacy your medical claim will be submitted to your HDHP for
payment. Your HSA dollars can be used to pay your out-of-pocket expenses (deductibles and
coinsurance) billed by the physician, facility, or pharmacy or you can choose to save your HSA dollars
for a future medical expense.
What is a deductible?
A deductible is a set dollar amount, determined by your plan, that you must pay, out-of-pocket or from
your HSA account, before insurance coverage for medical expenses can begin.
How much can I contribute to an HSA?
As noted by federal law for the 2013 calendar year, the annual contribution limits are equal to:
Type of
Coverage
2016 Contribution
Limit
2016 Catch-Up
Provision
Individual
Family
$3,350
$6,750
Age 55 and older:
Additional $1,000
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Health Savings Account
(HSA)
What is the difference between an HSA and Flexible Savings Account (FSA)?
 An HSA can roll-over unused funds from year to year.

An FSA cannot roll-over unused funds from year to year.

You cannot have an FSA for Medical if you have an HSA.
Why should I elect an HSA?
1. Cost Savings

Tax Benefits
o HSA Contributions are excluded from federal income tax
o Interest earnings are tax-deferred
o Withdrawals for eligible expenses are exempt from federal income tax

Reduction in medical plan contribution

Unused money is held in an interest-bearing savings or investment account
Note: Many states have not passed legislation to provide favorable state tax treatment for HSAs.
Therefore, amounts contributed to HSAs and interest earned on HSA accounts may be included on
the employee’s W-2 for state income tax purposes.
2. Long-Term Financial Benefits

Save for future medical expenses

Funds roll over year to year

This is your account, you take it with you
3. Choice

You control and manage your health care expenses.

You choose when to use your HSA dollars to pay your health care expenses.

You choose when to save your HSA dollars and pay health care expenses out of pocket.
15
Disability Insurance
Catholic Charities provides employees with New York State disability income benefits. In the event
you become disabled from a non work-related injury or sickness, disability income benefits are
provided as a source of income. You are not eligible to receive New York State disability benefits if
you are receiving workers’ compensation benefits.
New York State Disability
Benefits Begin
On the 8th day
Percentage of Income Replaced
50%
Maximum Benefit
$170 per week
Maximum Benefit Period
26 weeks
In addition to the New York State disability income benefits, Catholic Charities provides a salary
continuation program (full or half pay) that you may be eligible for based on your years of service.
You are not eligible to receive our salary continuation program benefits if you are receiving workers’
compensation benefits.
16
Life and AD&D Insurance
Group Term Life and AD&D Insurance
Catholic Charities provides eligible employees with a life and accidental death and dismemberment
(AD&D) insurance policy of $10,000 or greater based on years of service.
Employee Voluntary Term Life and AD&D Insurance
Employees who want to supplement their group life insurance benefits may purchase additional
coverage in increments of $20,000. The maximum amount you can purchase cannot be more than
$500,000. If you elect an amount that exceeds the guaranteed issue amount of $140,000, you will
need to provide evidence of good health that is satisfactory to Guardian before the excess can
become effective.
AGE
Under
25
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Rate
0.05
0.05
0.07
0.10
0.17
0.26
0.40
0.70
1.16
1.85
2.92
5.01
To calculate your Semi-monthly cost, please use the following formula(s):
__________________ Divide by $1,000 = _________X_________ / 2 = $__________________
Life and AD&D Benefit
Rate
My Semi-monthly Cost
Amount
Spouse Voluntary Term Life Insurance
If you purchase Voluntary Life and AD&D Insurance, you can purchase Spouse Voluntary Term Life
Insurance at 50% of employee coverage to a maximum of $250,000. If you elect an amount that
exceeds the guaranteed issue amount of $20,000, your Spouse will need to provide evidence of good
health that is satisfactory to Guardian before the excess can become effective.
AGE
Under
25
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Rate
0.05
0.05
0.07
0.10
0.17
0.26
0.40
0.70
1.16
1.85
2.92
5.01
To calculate your Semi-monthly cost, please use the following formula(s):
_______________ Divide by $1,000 = _________X__________ / 2 = $__________________
Life Benefit Amount
Rate
My Semi-monthly Cost
Child(ren) Voluntary Term Life Insurance
If you purchase Voluntary Life and AD&D Insurance, you can purchase Child(ren) Voluntary Term Life
Insurance for your Dependent Child(ren) between the ages of 14 days and 23 years (25 years if a full
time student), in the amount(s) of 10% of employee coverage to a maximum of $10,000.
To calculate your Semi-monthly cost, please use the following formula(s):
_______________ Divide by $1,000 = ______X_$0.16_X__________ / 2 = $__________________
Life Benefit Amount
Rate
# of Covered
My Semi-monthly Cost
17
Group Critical Illness
Insurance
G
C iti l ll
18
Group Critical Illness
Insurance
We have a wonderful opportunity for you! Catholic Charities and Colonial Voluntary Insurance are
proud to offer you exciting choices in your benefits program.
Catholic Charities Group Critical Illness
 Catholic Charities will provide to the employee only who elects the high
deductible plan or opts out of medical coverage a Critical Illness policy at no
cost.
 Employees who are eligible for the coverage at no cost may purchase coverage
for their spouse or dependents at their own cost.
 Employees that elect medical coverage other than the high deductible are able
to purchase this product for themselves and their spouse or dependents at their
own cost.
 Group specified disease insurance provides the employees with a lump sum
amount, $5,000 for the employee, $2500 for the spouse and $1250 per
dependent in the event of a heart attack, stroke, end stage renal failure, coronary
artery disease. This money goes directly to the employee and can be used to pay
your deductible or applied toward your bills, which ever you decide.
 The Group Critical Illness will be offered on a Guaranteed Issue basis
As a valued employee of Catholic Charities, you are eligible to apply for voluntary insurance.
Participation in these benefits plans is voluntary; however, we feel it is very important for you to
understand the many advantages of the products Catholic Charities and Colonial are making available
to you:




The ability to choose benefits to meet your individual needs.
The convenience of premium payment through payroll deduction
The ability to take most coverage’s with you if you change jobs or retire.
The ability to provide coverage for you and your family, with most products.
Listed below are two additional plans for which you can apply. These benefits are paid directly to
you unless you specify otherwise, and most benefits are paid regardless of other coverage’s you may
have with other insurance companies.
Accident Insurance- helps offset unexpected medical expenses, such as deductibles and copayments that can result from a fracture, dislocation or other covered accidental injury.
Cancer Insurance- helps offset the out-of-pocket medical and nonmedical expenses related to
cancer that most medical plans may not cover. This coverage also provides benefits for specified
cancer-screening tests.
19
Accident Insurance
20
Cancer Insurance
2
The National Cancer
Health, 2008
21
22
23
Employee Assistance
Programs
Who is Eligible and When:
All employees and immediate family members
Benefits You Receive:
The Employee Assistance Program is offered to all employees and immediate family members of
Catholic Charities through Palladian, formerly Prism Health Networks. It is a completely confidential
counseling program that covers issues such as marital and family concerns, depression, substance
abuse, grief and loss, financial entanglements, and other personal stressors.
You can contact Palladian toll free at 888-276-6632, or you can visit their website at
http://palladianeap.com/
The information in this Benefits Summary is presented for illustrative purposes and is based
on information provided by the employer. The text contained in this Summary was taken from
various summary plan descriptions and benefit information. While every effort was taken to
accurately report your benefits, discrepancies, or errors are always possible. In case of
discrepancy between the Benefits Summary and the actual plan documents the actual plan
documents will prevail. All information is confidential, pursuant to the Health Insurance
Portability and Accountability Act of 1996. If you have any questions about this summary,
contact Human Resources.
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