DPSU - Full Time - Benefit Snapshot

Transcription

The Williams Family —
Cordell, Dania and newborn Olivia
2016
DPSU - Full Time
O p e n Enrol l ment M a ter ial
2 0 1 6 Summar y of I n su r an ce B en efits
TABLE OF CONTENTS
We l c o m e L e t t e r ( 1 )
O p e n E n r o l l m e n t To - D o ’s ( 2 )
Open Enrollment Deadlines (3)
Open Enrollment Meeting Schedule (4)
Health Insurance (5)
Tu r n i n g 6 5 ? ( 6 )
Overage Dependents (7)
Spousal Rule (7)
HSA Payroll Deduction Form (19)
Creditable Coverage Disclosure (23)
Premium Only Plan (25)
Wa i v e r o f H e a l t h I n s u r a n c e F o r m ( 2 7 )
Dental (29)
Life & Supplemental Life Insurance (30)
L o n g Te r m D i s a b i l i t y ( 3 0 )
We l l n e s s ( 4 2 )
Contacts (53)
2 0 1 6 Op e n Enrollment Ma terial
Welcome to your 2016 City of Dayton Benefits Guide
Dear Fellow Employees,
It is time once again for our annual insurance enrollment. Effective January 1, 2016 there
are changes in the City’s health insurance plan that will affect most City employees. To assist
you and your family in making the best decisions regarding your health insurance and other
insurance benefits, I strongly encourage you to attend one of the many scheduled Open
Enrollment meetings. Representatives from Anthem Insurance, CODE Credit Union, Dayton
Firefighters Credit Union, McGohan Brabender and Human Resources will be there to explain
the changes and to assist you with completing any necessary paperwork.
If you have any questions on any of the information contained in this packet, please come to
an enrollment meeting or contact the Human Resources Department at (937) 333-4051.
Sincerely,
Kenneth R. Couch
Director of Human Resources
1
Enrollment To-Do’s
If you wish to enroll as a new benefit, you must complete a new Anthem Enrollment
form. Dependents that become eligible for coverage during the plan year (e.g., birth,
marriage), must be added to your coverage within 30 days of the date of the event,
otherwise you must wait until open enrollment. For 2016, open enrollment begins
October 13, 2015 and ends October 30, 2015 at 5:00pm. Contact the Human
Resources Department for an appointment to enroll a dependent during the plan year.
Only employees who want to make a change to their HEALTH INSURANCE benefits
need to fill out Anthem enrollment forms. Changes that require a
new form include:
• adding a dependent
• deleting a dependent
• switching from a HSA to HRA. You must stop all payroll deductions
going to your HSA.
• switching from a HRA to HSA. In this situation you must also open
up a HSA bank account with one of the two HSA vendors.
In addition to your health insurance, other considerations that may require
you to submit paperwork include:
• change HSA contributions
• spousal affidavit
• increase Supplemental Life Insurance
• elect or make changes to long term disability coverage
• update Dental dependents
2
2016 OPEN ENROLLMENT
DEADLINE IS 5:00 P.M. OCTOBER 30, 2015
This guide provides benefit highlights. For more detailed information such
as a medical summary plan description or benefit certificates of coverage,
please go to the benefits website at www.daytonbenefits.com.
2016 Open Enrollment Information
Begins: Tuesday, October 13, 2015
Ends:Monday, October 30, 2015
(all changes must be received in Human Resources by 5:00,
we cannot accept forms after this date and time)
The plan selections you make will be in effect from January 1, 2016 through
December 31, 2016.
The City of Dayton will be holding open enrollment meetings that will include a brief
presentation. Representatives from the various carriers will be there to answer your
questions and assist you in completing any necessary paperwork.
All employees are encouraged to attend a benefit meeting.
3
Health Enrollment Meetings
Meeting Start Time Location
Tuesday, October 13, 2015
8:30 am
City Hall — 101 W. Third St
Commission Chambers 2nd Floor
1:30 pm
Water Distribution — 945 Ottawa Street
Assembly Room
Wednesday, October 14, 2015
7:30 am
Waste Water Treatment Plant — 2800 Guthrie Road
Training Room
Thursday, October 15, 2015
7:00 am
Street Maintenance — Ottawa Street Bldg. 4
Assembly Room
2:00 pm
Convention Center — 22 East 5th Street
Room 207
Friday, October 16, 2015
10:00 am
Water Administration Building — 320 W. Monument Ave.
1st FL Conference Room
1:30 pm
Water Supply & Treatment — 3210 Chuck Wagner Lane
Training Room
Monday, October 19, 2015
9:30 am
Aviation — Field Maintenance Building
3848 Wright Drive
9:00 am
Building Services — 371 West Second Street
1st Floor Mediation Center Conference Room
2:00 pm
Sewer Maintenance — 900 Ottawa Street
Assembly Room
Wednesday, October 21, 2015
3:00 pm
Courts — 301 W. Third Street
Courtroom 1B
8:00 am
Safety Building — 335 W. Third Street
War Room
11:00 am
AFSCME Union Hall —15 Gates Street
2:00 pm
City Hall — 101 W. Third St
Commission Chambers 2nd Floor
7:30 am
Water Supply & Treatment — 3210 Chuck Wagner Lane
Training Room
12:00 pm
Waste Collection — 1010 Ottawa Street Bldg. 14
Assembly Room
Monday, October 26, 2015
2:00 pm
Aviation — Main Terminal
5th Floor Conference Room
AVIATION EMPLOYEES ONLY
4
Health Insurance
Employees are eligible for the Anthem Blue Cross and Blue Shield Lumenos High Deductible Health Plan (HDHP).
This HDHP is paired with an HSA or HRA. Effective January 1, 2016, a $200 emergency room co-pay and a
$10 office visit co-pay will apply after the deductible has been met. For all other services the plan will continue
to pay 100% of the medical expenses after the combined medical and pharmacy drug deductible has been
met. The gap between the combined medical and prescription drug deductible and the out-of-pocket maximum
is where the pharmacy co-pays, emergency room co-pays and office room co-pays come into play. Once the
combined $2,100/$4,200 medical and prescription drug deductible has been met, these co-payments will apply
until the out-of-pocket maximum has been met. Once the out-of-pocket maximum has been met there will be
no further out of pocket expenses for the calendar year. HSA or HRA funds can be used to pay for your deductible medical costs. Please refer to medical benefit summary included in this booklet for further details. You may
also review a Summary Plan Description, for more detailed information of covered benefits and exclusions, by
going to the benefits site at www.daytonbenefits.com
Your monthly contributions for medical insurance are as follows:
• Single: $70.00
• Family: $200.00
Your contribution for medical insurance will be deducted from your paycheck on a pre-tax basis starting with the
first paycheck you receive in January 2016.
Health Reimbursement Account (HRA) &
Health Savings Account (HSA)
The City is providing funding for the HRA and HSA accounts in January 2016 in the amounts of:
• Single coverage: $1,500
• Family coverage: $3,000
The choice of HSA vendors are CODE Credit Union and Dayton Firefighters Federal Credit Union.
Representatives will be available at open enrollment meetings. Employees who will complete probation before
1/1/2016 may be eligible to change to the HSA. If you don’t make the change during Open Enrollment you
must wait until Open Enrollment 2017. Please note that per IRS guidelines, you may begin, end or modify
HSA contributions at any time throughout the year on a prospective basis. No action is necessary unless an
employee desires a change.
1. Only employees that need to change their amount, those who terminate their deductions or those
changing their HSA vendor need to complete a new form. All other current deductions will continue.
2. Please call payroll if you have questions about your current deductions at 333-3551.
3. Remember to contact your HSA vendor if you change family status (single or family).
4. Complete 2016 HSA Payroll Deduction Authorization Form. A copy is provided on page 18 of this
booklet or on the benefits website noted above.
5. Target deposit date of HSA funds is January 8, 2016.
5
ELIGIBILITY
Turning 65 in 2016?
Turning 65? Here are some basic
scenarios to help you better
understand your choices:
•
If you are not eligible for Medicare
benefits either on your own or
through a spouse (did not pay into
while working for PERS and spouse
didn’t work outside system), you may
continue participating in the HSA.
•
If you are eligible for Social Security
and decide to receive benefits – you
will automatically be enrolled in Part A
of Medicare and unable to contribute
to an HSA account.
65 and still working?
•
•
•
Y ou should enroll in the HRA plan
instead of the HSA plan - You
can only do this during open
enrollment.
If you enroll in Part A of Medicare
– you will have to discontinue
your HSA contributions – you
must pro-rate the year you enroll
in Part A.
Y ou can only move from the HRA plan
during open enrollment, so
it is good to consider moving into the
HRA plan during open enrollment if
you will take
Medicare Part A next year.
•
Your Prescription Drug Coverage and Medicare
For More Information About Your
Options Under Medicare Prescription
Drug Coverage…
More detailed information about
Medicare plans that offer prescription
drug coverage is in the “Medicare &
You” handbook. You’ll get a copy of the
handbook in the mail every year from
Medicare. You may also be contacted
directly by Medicare drug plans. For
more information about Medicare
prescription drug coverage:
•
Visit www.medicare.gov
•
all your State Health Insurance
C
Assistance Program (see the
inside back cover of your copy
of the “Medicare & You” handbook
for their telephone number) for
personalized help
•
all 1-800-MEDICARE
C
(1-800-633-4227). TTY users
should call 1-877-486-2048.
If you have limited income and
resources, extra help paying for
Medicare prescription drug coverage
is available.
6
For information about this extra help,
visit Social Security on the web at
www.socialsecurity.gov, or call them at
1-800-772-1213
(TTY 1-800-325-0778).
Name of Entity/Sender:
City of Dayton
Contact-Position/Office:
Peggy Thumser,
Human Resources
Address:
101 West Third St, Dayton, Ohio 45401
Phone Number:
937-333-4064
ELIGIBILITY (continued)
Ohio Law Change Regarding Overage Dependents
In accordance with the Patient Protection and Affordability Care Act (PPACA),
adult children that are the natural child,
step child or adopted child of you or
your spouse can be covered to age 26,
regardless of marital status, as long
as they do not have access to other
employer sponsored coverage.
Previously, under the State of Ohio law,
adult children who were the natural
child, step child or adopted child of you
or your spouse, who live in the State
of Ohio and was not eligible for other
employer based coverage or Medicaid/
Medicare, could have been covered
under the City of Dayton plan until age
28. As of January 1, 2016 this is no
longer the case per recent changes
to the State law.
Spousal Rule
As of January 1, 2016 the City of
Dayton will be implementing a new
spousal rule policy. If your spouse
has access to other health insurance
coverage thru their employer, they
are required to elect coverage under
their employer’s plan. They may
also remain covered as a dependent
on your City of Dayton plan thru
Anthem. It is important to note
when coordinating benefit coverage
between the two plans the spouses
employer plan would be considered
primary and the City of Dayton’s
plan would be considered secondary.
Please refer to the FAQ on page 19
for additional details.
7
How do these changes affect your
dependents eligibility?
• If your dependent is 26-28 years old
as of 12/31/15 then coverage will
end 12/31/15
•
If your dependent turns 26 in
2016 they would remain covered
until 12/31/16
DPSU - Full Time
MedicalSummary
Summary of Benefits
Your
of Benefits
Anthem Lumenos High Deductible Health Plan (w/Rx Copay after deductible)
Effective 01/01/2016
Contributions:
City
of Dayton
Lumenos
Health Savings Accounts (w/ Copay after deductible)
Single: $70.00
Effective
1/1/2016
Family: $200.00
Covered Benefits
Deductible
Family coverage requires the family deductible to be met
before coinsurance applies. The single deductible
does not apply to family coverage.
Out-of-Pocket Limit
Physician Home and Office Services (PCP/SCP)
Primary Care Physician(PCP)/Specialty Care Physician (SCP)
Including Office Surgeries and allergy serum:

Allergy injections (PCP and SCP)

Allergy testing

MRAs, MRIs, PETS, C-Scans, Nuclear
Cardiology Imaging Studies, non-maternity
related Ultrasounds and Pharmaceuticals
Preventive Care Services
Services include but are not limited to:
Routine Exams, Mammograms, Pelvic Exams, Pap
testing, PSA tests, Immunizations, Annual diabetic eye
exam, Routine Vision and Hearing exams
Emergency and Urgent Care

Emergency Room Services @ Hospital
(facility/other covered services)
(copayment waived if admitted)

Urgent Care Center Services
Inpatient and Outpatient Professional Services
Include but are not limited to:

Medical Care visits (1 per day), Intensive
Medical Care, Concurrent Care, Consultations,
Surgery and administration of general
anesthesia and Newborn exams
Inpatient Facility Services (Network/Non-Network
combined) Unlimited days except for:

60 days for physical medicine/rehab (limit
includes Day Rehabilitation Therapy Services
on an outpatient basis)

180 days for skilled nursing facility
Outpatient Surgery Hospital/Alternative Care Facility

Surgery and administration of
general anesthesia
Blue 8.0 600 Series
Network
Single: $2,100
Family: $4,200
Non-Network
Single: $2,100
Family: $4,200
Single: $3,000
Family: $6,000
$10
Single: $6,000
Family: $12,000
20%
0%
0%
0%
20%
20%
20%
No cost share
20%
$200
$200
0%
0%
20%
20%
0%
20%
0%
20%
8
Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company. Independent
licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem
Your Summary of Benefits
Medical Summary of Benefits (continued)
Covered Benefits
Other Outpatient Services
including but not limited to:

Non Surgical Outpatient Services
For example: MRIs, C-Scans,
Chemotherapy, Ultrasounds and
other diagnostic outpatient services.

Home Care Services 230 visits (excludes
IV Therapy) (Network/Non-Network combined)

Durable Medical Equipment, Orthotics and
Prosthetics

Physical Medicine Therapy Day
Rehabilitation programs

Hospice Care

Ambulance Services
Accidental Dental Services $3,000 per accident
(Network and Non-network combined)
Outpatient Therapy Services
(Combined Network & Non-Network limits apply)

Physician Home and Office Visits

Other Outpatient Services @
Hospital/Alternative Care Facility
Limits apply to:

Cardiac Rehabilitation 36 visits

Pulmonary Rehabilitation 20 visits

Physical Therapy: 30 visits

Occupational Therapy: 30 visits

Manipulation Therapy: 24 visits

Speech therapy: 20 visits
Behavioral Health Services:
Mental Illness and Substance Abuse 1

Physician Home and Office Visits

Other Outpatient Services @
Hospital/Alternative Care Facility
Human Organ and Tissue Transplants

Acquisition and transplant procedures,
harvest and storage.
Prescription Drugs

Network Retail Pharmacies:
(30-day supply)
Includes diabetic test strip

Home Delivery Service:
(90-day supply)
Includes diabetic test strip
- Specialty medications are limited up to a 30 day supply
regardless of whether they are retail or mail service
- Member may be responsible for additional cost when
not selecting the available generic drug.
Medicare Rx - Wrap
Network
0%
Non-Network
20%
0%
0%
0%
0%
0%
20%
$10
0%
20%
20%
Benefits provided in
accordance with Federal
Mental Health Parity
20%
0%
20%
$10/$20/$30
50% min $75 2
$10/$50/$90
Not covered
9
Your Summary of Benefits
Medical Summary of Benefits (continued)
Notes:

All medical and drug cost shares, deductibles and percentage (%) coinsurance apply toward the out-of-pocket maximum (excluding Non-Network
Human Organ and Tissue Transplant (HOTT) Services).

Deductible(s) apply to covered services listed with a percentage (%) coinsurance, including 0%.

Deductible applies to all prescription drug expenses for Rx plans. Once the deductible is met the appropriate copayment/ coinsurance applies.
Copayments/coinsurance accumulate to the Medical OOP max. Once the Medical OOP max is met, no additional costshare applies.

Network and Non-network Deductible, do accumulate toward each other.

Network and Non-network copayments, coinsurance and out-of-pocket maximums are separate and do not accumulate toward each other.

Dependent Age: to end of the month which the child attains age 26

0% means no coinsurance up to the maximum allowable amount. However, when choosing a Non-network provider, the member is responsible for
any balance due after the plan payment.

Benefit period = calendar year

Behavioral Health Services: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity.

Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits
are covered.

No Cost Share (NCS): No deductible/copayment/coinsurance up to the maximum allowable amount.

Private Duty Nursing – limited to 82 visits/Calendar Year.

Wigs limited to 1 per benefit period

Vision limited services – additional vision services are covered when specifically coded as determination of refraction, routine ophthalmological
examination including refraction for new and established patients, and a visual functional screening for visual acuity. No additional
ophthalmological services are covered as part of the medical coverage.
1 We encourage you to review the Schedule of Benefits for limitations. .
2 Rx non-network diabetic/asthmatic supplies not covered except diabetic test strips.
**4th Tier per script 30 day supply.
Precertification:
Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help the member know if the services are considered not
medically necessary.
Pre-existing Exclusion Period: none
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform
laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor
and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.
This benefit overview is for illustrative purposes and some content may be pending Ohio Department of Insurance approval
Anthem website: http://www.anthem.com/health-insurance/home/overview
Anthem
Customer Service : 1-888-224-4902
This summary of benefits is intended to be a brief outline of coverage. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate and
Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.
Legal Disclaimer: This Summary of Benefits only highlights and summarizes the benefits available through the City of Dayton. This is only a summary and cannot
be relied on to fully determine coverage. You must refer to each Certificate of Coverage for a complete listing of the covered services, limitations, exclusions and a
description of all the terms and conditions of coverage. If the summary listed in this brochure conflicts in any way with the Certificate of Coverage (and, if applicable,
the group policy) issued to the City of Dayton, the Certificate of Coverage (and, if applicable, the group policy) prevails over this summary.
10
Take care of yourself.
Use your preventive
care benefits.
Getting regular checkups and exams can help you stay well and catch problems early. It may even save your life.
Our health plans offer the services listed in this preventive care flier at no cost to you.1 When you get these services from doctors in
your plan’s network, you don’t have to pay anything out of your own pocket. You may have to pay part of the costs if you use a doctor
outside the network.
Preventive versus diagnostic care
What’s the difference? Preventive care helps protect you from getting sick. Diagnostic care is used to find the cause of existing
illnesses. For example, say your doctor suggests you have a colonoscopy because of your age when you have no symptoms. That’s
preventive care. On the other hand, say you have symptoms and your doctor suggests a colonoscopy to see what’s causing them.
That’s diagnostic care.
Child preventive care
Preventive physical exams
Screening tests:











Behavioral counseling to promote a healthy diet
Blood pressure
Cervical dysplasia screening
Cholesterol and lipid level
Depression screening
Development and behavior screening
Type 2 diabetes screening
Hearing screening
Height, weight and body mass index (BMI)
Hemoglobin or hematocrit (blood count)
HPV screening (female)
Immunizations:
 Diphtheria, tetanus and pertussis (whooping cough)
 Haemophilus influenza type b (Hib)
 Hepatitis A and Hepatitis B
 Human papillomavirus (HPV)
 Influenza (flu)
 Measles, mumps and rubella (MMR)













Lead testing
Newborn screening
Screening and counseling for obesity
Counseling for those ages 10–24, with fair skin, about ways to
lower their risk for skin cancer
Oral (dental health) assessment when done as part of a
preventive care visit
Screening and counseling for sexually transmitted infections
Tobacco use: related screening and behavioral counseling
Vision screening2 when done as part of a preventive care visit
Meningococcal (meningitis)
Pneumococcal (pneumonia)
Polio
Rotavirus
Varicella (chickenpox)
Women’s preventive care:






Well-woman visits
Breast cancer, including exam, mammogram, and, including
genetic testing for BRCA 1 and BRCA 2 when certain criteria
are met3
Breast-feeding: primary care intervention to promote
breast-feeding support, supplies and counseling (female)4,5
Contraceptive (birth control) counseling
FDA-approved contraceptive medical services provided by a
doctor, including sterilization
Counseling related to chemoprevention for women with a
high risk of breast cancer





Counseling related to genetic testing for women with a
family history of ovarian or breast cancer
HPV screening5
Screening and counseling for interpersonal and
domestic violence
Pregnancy screenings: includes, but is not limited to,
gestational diabetes, hepatitis, asymptomatic bacteriuria,
Rh incompatibility, syphilis, iron deficiency anemia,
gonorrhea, chlamydia and HIV5
Pelvic exam and Pap test, including screening for
cervical cancer
The preventive care services listed are recommendations as a result of the Affordable Care Act (ACA, or health care reform law). The services listed may not be right
for every person. Ask your doctor what’s right for you, based on your age and health condition(s).
This sheet is not a contract or policy with Anthem Blue Cross and Blue Shield. If there is any difference between this sheet and the group policy, the provisions of
the group policy will govern. Please see your combined Evidence of Coverage and Disclosure Form or Certificate for Exclusions and Limitations.
43199MUMENABS Rev. 12/14
Adult preventive care
Preventive physical exams
Screening tests:










Alcohol misuse: related screening and behavioral counseling
Aortic aneurysm screening (men who have smoked)
Behavioral counseling to promote a healthy diet
Blood pressure
Bone density test to screen for osteoporosis
Cholesterol and lipid (fat) level
Colorectal cancer, including fecal occult blood test, barium
enema, flexible sigmoidoscopy, screening colonoscopy and
related prep kit and CT colonography (as appropriate)
Depression screening
Hepatitis C virus (HCV) for people at high risk for infection and
a one-time screening for adults born between 1945 and 1965
Type 2 diabetes screening










Immunizations:





Diphtheria, tetanus and pertussis (whooping cough)
Hepatitis A and Hepatitis B
HPV
Influenza (flu)
Meningococcal (meningitis)




Eye chart test for vision2
Hearing screening
Height, weight and BMI
HIV screening and counseling
Lung cancer screening for those ages 55-80 who have a
history of smoking 30 packs per year and still smoke, or quit
within the past 15 years6
Obesity: related screening and counseling
Prostate cancer, including digital rectal exam and PSA test
Sexually transmitted infections: related screening
and counseling
Tobacco use: related screening and behavioral counseling
Violence, interpersonal and domestic: related screening
and counseling
Measles, mumps and rubella (MMR)
Pneumococcal (pneumonia)
Varicella (chickenpox)
Zoster (shingles) for those 60 years and older
A word about pharmacy items
For 100% coverage of over-the-counter (OTC) drugs and other pharmacy items listed below, the person receiving the item(s)
must meet the age and other specified criteria. You need to work with your in-network doctor or other health care provider
to get a prescription for the item(s) and take the prescription to an in-network pharmacy. Even if the item(s) do not “need” a
prescription to purchase them, if you want the item(s) covered at 100%, you have to have the prescription.
Child preventive drugs and other pharmacy items — age appropriate:
 Dental fluoride varnish to prevent tooth decay of primary teeth for children from birth to 5 years old
 Fluoride supplements for children from birth through 6 years old
 Iron supplements for children 6-12 months
Adult preventive drugs and other pharmacy items — age appropriate:
 Aspirin use for the prevention of cardiovascular disease including aspirin for men ages 45-79 and
women ages 55-79
 Colonoscopy prep kit (generic or OTC only) when prescribed for preventive colon screening
 Tobacco cessation products including select generic prescription drugs, select brand-name drugs with
no generic alternative, and FDA-approved over-the-counter products, for those 18 and older
Women’s preventive drugs and other pharmacy items — age appropriate:
 Contraceptives including generic prescription drugs, brand-name drugs with no generic alternative, and
over-the-counter items like female condoms or spermicides5,7
 Folic acid for women 55 years old or younger
 Vitamin D for women over 65
 Breast cancer risk-reducing medications following the U.S. Preventive Services Task Force criteria (such as
tamoxifen and raloxifene)6
1 The range of preventive care services covered at no cost share when provided in-network are designed to meet the requirements of federal and state law. The Department of Health and Human Services has defined the preventive services to be covered under federal law with no cost
share as those services described in the U.S. Preventive Services Task Force A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents and
women supported by the Health Resources and Services Administration (HRSA) Guidelines. You may have additional coverage under your insurance policy. To learn more about what your plan covers, see your Certificate of Coverage or call the Customer Service number on your ID card.
2 Some plans cover additional vision services. Please see your contract or Certificate of Coverage for details.
3 Check your medical policy for details.
4 Breast pumps and supplies must be purchased from an in-network medical provider for 100% coverage; we recommend using an in-network durable medical equipment (DME) supplier.
5 This benefit also applies to those younger than 19.
6 You may be required to get prior authorization for these services.
7 A cost share may apply for other prescription contraceptives, based on your drug benefits.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health
Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO
benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten
by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia:
Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which
underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of
the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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31709MUMENABS Rev. 07/14
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As always, you should call 911 with any emergency. Otherwise, you can use
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*As legally permitted in certain states.
LiveHealth Online is the trade name of Health Management Corporation, a separate company providing telehealth services on behalf of Anthem Blue Cross and Blue Shield.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield
of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc.
(RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide
administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of
New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna,
and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or
administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance
Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans
of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by
HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health
Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (“BCBSWi”), which underwrites or administers the
PPO and indemnity policies; Compcare Health Services Insurance Corporation (“Compcare”), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ®
ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
35768ANMENABS Rev. 4/13 F0037390
anthem.com
HSA vs. HRA Comparison
Health Savings Account (HSA)
Health Reimbursement Account (HRA)
1. Account belongs to the employee.
1. Account belongs to the City.
2. Employee keeps account balance when he/she terminates
employment.
2. Employee has access to the account until the HDHP
coverage is terminated.
3. Employee can move the account to a different financial institution.
3. n/a
4. City deposits money in January:
- Single coverage: $1,500
- Family coverage: $3,000
4. City authorizes money in January:
- Single coverage: $1,500;
- Family coverage: $3,000.
5. Employee can contribute additional money on a pre-tax basis
up to the maximum 2016 contribution. The maximum 2016
contributions are: $3,350 for single coverage and $6,750 for
family coverage. The maximum you can contribute after the City
contribution is:
- Single coverage: up to $1,850;
- Family coverage: up to $3,750;
- Age 55 and over: Additional $1,000 (2015 limit).
5. No employee contribution.
6. Employee can earn interest on funds in the account.
6. No interest earnings for the employee.
7. All unused funds can be rolled over from year to year.
There is no limit on the account balance.
7. Unused funds can be rolled over; however, the account balance cannot exceed the amount of the HDHP deductible.
8. Funds can be used for HDHP deductible expenses and other IRS
qualified medical expense such as over-the-counter drugs, dental
expenses, Lasik surgery, and long-term care premiums. Starting
January 1, 2012, over-the-counter drugs and medicines will
need a prescription to qualify for reimbursement.
8. Funds can only be used for HDHP deductible expenses.
9. Before age 65, funds used for non-medical purposes are taxable
and there is a 20% penalty. Employees age 65 and older can use
funds for non-medical purposes. The funds are taxable; however,
there is not a 20% penalty.
9. Funds can only be used for HDHP deductible expenses.
10. Debit cards can be used for all eligible expenses.
10. No debit card
11. Banking fees are paid by the employee from the account.
11. City pays all administration fees for the account.
12. Employee eligibility:
- Must have City HDHP;
- Must enroll at the beginning of the plan year;
- Must have completed initial City probationary period prior to
the beginning of the plan year;
12. Employee eligibility:
Must have city HDHP
- Cannot be claimed as a dependent for tax purposes;
- Cannot be enrolled in Medicare benefits;
- Cannot have other non-HDHP health coverage.
13. Dependent eligibility:
- IRS dependent at time of expenditure.
- Must be a dependent on the City’s HDHP.
13. Dependent eligibility:
Must be a dependent on the city’s HDHP
14. Employee is responsible for compliance with IRS regulations
and must maintain copies of all HSA transactions for IRS audit
purposes
14. No IRS liability
15. Target deposit date of HSA funds is January 8, 2016
15. Available effective January 1, 2016
16
What you should know about
qualified medical expenses for
Health Savings Accounts
If you have a Health Savings Account (HSA) it’s important for you to understand what a qualified medical expense is and
how it relates to your account.
Background:
A Health Savings Account (HSA) is a tax-advantaged savings account combined with a High Deductible Health Plan. You can use
your HSA to help meet your deductible by paying for medical expenses covered by your health plan. Some expenses may not
be covered by your health insurance plan but can still be paid for using your HSA. The IRS considers these“qualified medical
expenses” and are defined in Section 213(d) of the Internal Revenue Code.
What is a qualified medical expense?
£
£
£
£
They’re expenses that include amounts paid for the diagnosis,
treatment or prevention of disease, and for treatments that affect
any part or function of the body.
you established your HSA are not qualified medical expenses. Only expenses
made after you open your HSA are qualified medical and/or dental expenses.
Be sure to keep complete records to show that:
The expenses must be used to prevent or relieve a physical
defect or illness.
£
They’re expenses that would generally qualify for the medical and
dental expenses deduction under tax advantaged accounts.
£
HSA funds spent on non-qualified expense will be considered part
of your taxable income. You will also owe a 20% penalty on that
amount.
£
Whose expenses can be reimbursed?
The money in the HSA can be used to pay for qualified medical and/or dental
expenses spent by the employee, spouse or a dependent for whom an exemption
is claimed under Section 152 of the tax code. Expenses that occurred before
The money in the HSA was used only to pay for or reimburse
qualified medical and/or dental expenses
The qualified medical and/or dental expenses had not been
previously paid for or reimbursed from another source
The medical and/or dental expenses had not been taken as an
itemized deduction in any year
Over-the-Counter (OTC) items impacted by health care law
Effective January 1, 2011 you will no longer be able to use funds from an HSA to
purchase some OTC items that had been covered in the past. Please see the chart
below for more detail.
Eligible over-the-counter items
• Band aids
• Birth control
• Braces and supports
• Contact lens solution and supplies
• Elastic bandages and wraps
• First aid supplies
• Reading glasses
Ineligible over-the-counter medications (unless accompanied by a prescription)
• Acid controllers
• Acne medication
• Allergy and sinus
• Antibiotics
• Anti-itch and insect bite
13503ANMENABS Rev. 10/10 F0084717
• Cough, cold and flu medicine
• Eye drops
• Indigestion
• Laxatives
• Motion sickness
• Nasal sprays
• Ointments and creams
• Pain relief
• Respiratory treatments
• Sleep aids and sedatives
• Stomach remedies
Qualified medical expenses for Health Savings Accounts
Below are two charts that give examples of medical expenses that are eligible (do qualify) and are not eligible (do not qualify)
for reimbursement. Please know that this is only a partial list and is not complete. The list is subject to change based on
regulations, revenue rulings and case law. The list should be used only as a general guideline for covered expenses. All items
on the list may be subject to further restrictions.
Eligible medical expenses
• Abortion
• Acupuncture
• Alcoholism treatment
• Ambulance
• Anesthetist
• Artificial limbs
• Autoette (when used for relief of sickness
or disability)
• Birth control pills (by prescription)
• Blood tests
• Blood transfusions
• Breast Reconstruction Surgery (following a
mastectomy for cancer)
• Cardiographs
• Chiropractor
• Christian Science practitioner
• Contact lenses
• Contraceptive devices (by prescription)
• Crutches
• Dental treatment
• Dental X-rays
• Dentures
• Dermatologist
• Diagnostic fees
• Diagnostic Devices (used in diagnosing and
treating illness and disease)
• Drug addiction therapy
• Drugs (prescription)
• Eyeglasses
• Fees paid to health institute prescribed
by a doctor
• Fertility Enhancement (procedures to overcome
an inability to have children)
• Hearing Aids
• Guide dog
• Gum treatment
• Psychoanalysis
• Psychologist
• Psychotherapy
• Radium therapy
• Registered nurse
• Special school costs for the handicapped
• Spinal fluid test
• Splints
• Sterilization
• Surgeon
• Telephone or TV equipment to assist the
hard-of-hearing
• Therapy equipment
• Transportation expenses
(relative to health care)
• Ultraviolet ray treatment
• Vaccines
• Vasectomy
• Vitamins (if prescribed)
• Wheelchair
• X-rays
Ineligible medical expenses
• Advance payment for services to be
rendered next year
• Athletic club membership
• Automobile insurance premium allocable to
medical coverage
• Boarding school fees
• Bottled water
• Commuting expenses of a disabled person
• Cosmetic surgery and procedures
• Cosmetics, hygiene products and similar
items
• Funeral, cremation or burial expenses
• Health programs offered by resort hotels,
health clubs and gyms
• Illegal operations and treatments
• Illegally procured drugs
• Maternity clothes
• Non-prescription medication
• Over-the-counter drugs
• Premiums for life insurance, income
protection, disability, loss of limbs, sight or
similar benefits
• Scientology counseling
• Social activities
• Special foods and beverages
• Specially designed car for the handicapped
other than an Autoette or special equipment
• Swimming pool
• Travel for general health improvement
• Tuition and travel expenses to send a
problem child to a particular school
• Weight-loss programs
For more detailed information:
£
Please refer to the publication put out by the IRS titled “Medical and Dental Expenses”; number 502, catalog number 15002Q.
£
You can order a copy of the publication by calling 800-TAX-FORM (800-829-3676).
£
Or you can view it online at www.irs.gov/pub/irs-pdf/p502.pdf.
For tax advice, please
contact a tax professional.
This content is provided solely for informational purposes. It is not intended as and does not constitute legal advice. The information contained herein should not be
relied upon or used as a substitute for consultation with legal, accounting, tax and/or other professional advisors.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In
Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and
certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans
of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (serving Virginia excluding the city of Fairfax, the town of Vienna and the area east of State Route 123.): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin (“BCBSWi”)
underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (“Compcare”) underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the
Blue Cross and Blue Shield Association. ® ANTHEM, LUMENOS and 360° Health are registered trademarks of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
2016 HSA Payroll Deduction Authorization Form
This form authorizes the City of Dayton to initiate a payroll deduction and/or adjust entries to your Health Savings Account (HSA)
established with the banks the City of Dayton has contracted with to maintain these accounts.
Deductions for the HSA will be taken each pay on a pre-tax basis. You may revoke your authorization or change your contribution
amount by giving at least ten (10) business days written notice to the Payroll Office. However, you may not change banking institutions
until the next Open Enrollment period. Deductions will also stop once Payroll is notified you are no longer eligible to be in the Health
Savings Account Program.
Note: Each year, the IRS sets a maximum annual contribution amount from all sources (including employee and/or employers) that
may be deposited into your Health Savings Account. Anything contributed over this limit may have tax liability consequences.
The City of Dayton is not responsible for monitoring the contributions to your Health Savings Account or to determine if you are
eligible for a Health Savings Account.
Based on your estimates, enter the amount you want to contribute per paycheck and/or annually to your HSA account in the box below.
Banking institution (circle only one): CODE Credit Union OR Dayton Firefighters Credit Union
Amount to be withheld each pay: $_____________
Total amount per year to be withheld: $_____________
This payroll deduction will automatically renew each year unless you complete a new form.
Employees 55 or older by year’s end are also eligible for an additional $1,000 catch-up contribution.
Maximum contributions for 2016 are $3,350 for employee only and $6,750 for a family.
Do you currently have SINGLE or FAMILY (circle one) Health Insurance Coverage?
Are you eligible for “Catch Up” contributions (age 55 or older)? YES
NO (circle one).
I hereby authorize the pre-tax reduction of my salary, on a per paycheck basis, by the amount designated above.
I understand that any withdrawals/distributions made from my HSA for non-qualified types of expenses will be taxable and may
be subject to additional penalties in accordance with Internal Revenue Service (IRS) regulations. I further understand that it is my
sole responsibility to report any such non-qualifying withdrawals/distributions to the IRS.
_______________________________________________________________________
Print Name
Employee ID # or SS #
_______________________________________________________________________
Department/Division
Phone Number
_______________________________________________________________________
Employee Signature
Date
Send or fax (333-3554) the completed form to the Payroll Office.
19
CITY OF DAYTON, OHIO
CITY HALL  101 WEST THIRD STREET
P.O. BOX 22  DAYTON, OHIO 45401
937 333-4045  FAX 333-4293
www.daytonohio.gov
DEPARTMENT OF HUMAN RESOURCES
RELEASED: Summer 2015
FAQ’s for Insurance benefit changes for all City employees except the IAFF. The City and the IAFF are
currently in negotiations.
Q: What health insurance changes will impact me in 2015?
A: Effective July 01, 2015, the employee cost for family health insurance will increase to $200/month for all
full time employees. Single coverage employee cost will remain at $70.00/month. .
Q: What health insurance eligibility rules will impact me in 2016?
A: Beginning on January 1, 2016, spouses of City employees that are 1) employed and 2) are eligible for health
insurance with their employer will be required to enroll in their employer’s plan.
Q: My spouse is employed; do I have to remove them from my plan?
A: No, absolutely not. Your spouse is allowed to remain on our plan. The new requirement simply states that if
your spouse’s employer offers coverage, your spouse must enroll in their own employer’s plan, and that
insurance will be primary for your spouse. Your spouse may also remain on the City’s plan. The City will then
become secondary coverage for your spouse.
Q: What does secondary coverage mean?
A: That means that all of your spouse’s medical bills should be sent to their own insurance carrier first. The
remaining charges can then be submitted to Anthem under the City’s plan.
Q: My spouse’s employer also has Anthem insurance; does the spousal rule still apply?
A: Yes, even though both employers use the same carrier, the medical expenses will first be charged to the other
employer’s plan and the remaining charges may be submitted to the City’s plan.
Q: Why is the City doing this?
A: These negotiated changes are part of our effort to keep health insurance benefits affordable and still maintain
high quality health coverage. Actuarial predictions indicate that these changes will substantially slow the
increase of insurance costs by adding this requirement.
Q: The coverage at my spouse’s employer is more expensive, does my spouse still have to enroll in their
employer’s plan?
A: Yes, the rule applies regardless of the quality or cost of your spouse’s plan.
Q: Does my spouse have to list our children on my spouse’s plan?
A: No, your eligible children may remain primary on the City’s plan.
Q: How will the City know if my spouse has access to other coverage?
20
CITY OF DAYTON, OHIO
CITY HALL  101 WEST THIRD STREET
P.O. BOX 22  DAYTON, OHIO 45401
937 333-4045  FAX 333-4293
www.daytonohio.gov
DEPARTMENT OF HUMAN RESOURCES
A: All employees with a spouse listed on the City’s health insurance plan will be required to sign an affidavit
verifying if the spouse has access to other coverage through an employer?
Q: What if my spouse becomes employed/unemployed sometime during the year?
A: The City will consider that a qualifying life event and will process changes throughout the year. It is your
responsibility to report the changes to Human Resources. Please remember insurance change forms must be
completed within thirty (30) days of the date of the event.
Q: Are there changes in coverage in 2016?
A: Beginning January 1, 2016 there will be a $200 charge for emergency room visits that occur after your
deductible is met. This fee will be waived if the visit results in a hospital admission.
Also effective January 1, 2016 there will be a $10.00 office visit charge for office visits that occur after you
have met your deductible. Preventive care visits will remain covered at 100%.
Q: My child has a job that offers coverage; do I have to remove them also?
A; Adult children are allowed to remain on the plan regardless of employment status until their 26th birthday.
Currently under Ohio law, qualified children may remain on the plan until age 28. The State of Ohio law was
revised and beginning on January 1, 2016 children over the age of 26 will not be allowed on the plan.
Q: Are there any other future planned health insurance changes?
A: Yes, beginning on January 1, 2017 the office visit co-pay will increase to $20
Q: What should I do if I have further questions?
A: Please attend an Open Enrollment meeting. There will be formal presentations and plenty of time for
personal questions after each presentation. The meetings will be held later this year and the schedule will be
widely publicized. If you have immediate questions call Peggy Thumser in Human Resources at 333-4064.
21
CITY OF DAYTON AFFIDAVIT OF SPOUSAL HEALTH CARE COVERAGE Employee Name (Printed): ___________________________________________ Employee ID: _____________________ Spouse Name (Printed): ____________________________________________________________________ If your spouse is eligible for group health insurance coverage through their employer’s plan he/she must participate in that group coverage in order to qualify for coverage under the City of Dayton plan. In order to enroll your spouse for coverage or maintain your spouse’s coverage you must complete the following: • Is your spouse employed? Yes Yes, City of Dayton Employee No • Is your spouse offered coverage through his/her employer? Yes No N/A 1. Spouse’s Name (first and last): _______________________________________________ 2. Spouse’s Social Security #: _______-‐_____-‐_________ Birth Date: ______/________/_________ 3. Spouse’s Employer Name: _______________________________________________________________ • Is your spouse enrolled or enrolling on his/her employer’s medical plan? Yes, Complete this section No, Skip to Question 4 N/A 1. Spouse’s Medical Insurance Carrier Name and Group #: ________________________________________ 2. Spouse’s Primary Insurance Policy/ID Number (if already enrolled): _______________________________ 3. Coverage Effective Date : ___________________________________________________ The City of Dayton believes that our new eligibility requirement constitutes a “special enrollment” under the rules for employers. As such, your spouse should be eligible to enroll for benefits effective January 1st. If this is not the case, please provide the following Information: 4. Coverage cannot be elected until the next open enrollment period (provide date): ___________________ ! Effective January 1, 2016, if it is determined that your spouse did not elect coverage thru their employer, the City of Dayton plan will pay as secondary regardless of the exclusion of primary coverage. ! Effective January 1, 2016, if it is determined that your spouse is enrolled on both their employer’s plan and the City of Dayton plan, standard coordination of benefit rules will apply. Therefore the City of Dayton plan will pay spousal claims on a secondary basis. Please remember that if you and/or your spouse have a “qualifying event” during the year, you must notify Human Resources within 30 days of the event. This would include, but not limited to, marriage, divorce, and spouse losing/gaining eligibility under their employers plan. As an example, if your spouse is currently not eligible for his/her employer plan and becomes eligible during the year, you must notify Human Resources and your spouse MUST elect their plan as primary. Acknowledgement (By City of Dayton employee) I certify under penalty of perjury, that the foregoing is true and correct. I understand as an employee that falsification of information on this Affidavit will lead to disciplinary action, up to and including termination. Fraud or intentional misrepresentation may result in retroactive termination of my spouse’s medical coverage. __________________________________________________ _________________________________________ Employee Signature Date 22
HRA & HSA Creditable Coverage Disclosure
HRA & HSA Creditable Coverage Disclosure Important Notice from City of Dayton About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with City of Dayton and about your options under Medicare's prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare's prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. City of Dayton has determined that the prescription drug coverage offered by the Anthem's Group Health Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. __________________________________________________________________________ When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current City of Dayton coverage may be affected. If you do decide to join a Medicare drug plan and drop your current City of Dayton coverage, be aware that you and your dependents may be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? 23
HRA & HRA HSA& Creditable
Coverage
Disclosure
(continued)
HSA Creditable Coverage D
isclosure (continued) You should also know that if you drop or lose your current coverage with City of Dayton and don't join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage Contact the person listed below for further information or call City of Dayton at 937-‐333-‐4064. NOTE: You will get this notice each year. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the 'Medicare & You' handbook. You'll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: •Visit www.medicare.gov •Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the 'Medicare & You' handbook for their telephone number) for personalized help •Call 1-‐800-‐MEDICARE (1-‐800-‐633-‐4227). TTY users should call 1-‐877-‐486-‐2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-‐800-‐772-‐1213 (TTY 1-‐800-‐325-‐0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: October 1, 2015 Name of Entity/Sender: City of Dayton Contact-‐-‐Position/Office: Teresa Hanson, Human Resources Address: 101 W. Third Street, Dayton, OH, 45402 Phone Number: 937-‐333-‐4021 24
Important Notice for All Employees Premium Only Plan
CITY OF DAYTON
PREMIUM ONLY PLAN
ENROLLMENT NOTICE
The City of Dayton Premium Only
Plan (the “POP”) is designed to
allow you to pay your portion of the
premiums for the City’s health and/
or dental plans on a pre-tax basis.
This means the amount you pay for
the premiums will not be subject
to federal and state income tax. As
a result, you realize an immediate
tax savings through the POP. If you
waive coverage under the City’s
group health plan you may qualify
for additional cash compensation.
Participation in the health and/or
dental plans as well as the POP is
voluntary. Therefore, you can decline
to participate in the health and
dental plans and the POP. However,
if you elect to participate in the
health and/or dental plans, you will
automatically participate in the POP.
The POP also allows you to waive
coverage under the City’s group
health plan, which may qualify
you for the cash compensation. If
you want to waive coverage under
the City’s group health plan for
additional cash compensation, you
must complete a City of Dayton
Waiver of Health Insurance Form.
You can get the City of Dayton
Waiver of Health Insurance form
at the City of Dayton Human
Resources Department.
According to rules issued by the
IRS, once you begin participating
in the POP you may not drop out
of the POP or vary the amount of
your pre-tax contributions until
the first day of the next plan year.
However, you may drop out of
the POP or vary the amount of
your pre-tax contributions under
the POP at anytime if any of
the following events occur: (i) a
change in your legal marital status
including marriage, death of a
spouse, divorce, legal separation
and annulment; (ii) a change in
the number of your dependents
including the birth, death, adoption
and placement of adoption of
a child; (iii) a change in your
employment status or a change
in your spouse or dependent’s
employment status including the
termination or commencement of
employment, a strike, lockout or
the commencement or termination
of an unpaid leave of absence;
(iv) a change in your or your
spouse’s or dependent child’s
employment status that effects
that individual’s eligibility under a
cafeteria plan (including the POP)
or any benefit plan (including this
25
health plan); (v) your dependent
child or spouse satisfied or ceases
to satisfy the eligibility requirements
because of age, student status
or similar circumstances; (vi) the
commencement or termination of
adoption proceedings; (vii) change in
your or your spouse’s or dependent
child’s residence that impacts their
eligibility under the group health
plan; (viii) a judgment, decree or
court order resulting from a divorce,
legal separation, annulment or
change in legal custody (including
a qualified medical child support
order) that requires coverage under
a group health plan for your child or
foster child; (ix) entitlement or loss
of Medicare or Medicaid by you or
your spouse or dependent child; (x)
the commencement or return from a
period of absence under the Family
and Medical Leave Act; (xi) eligibility
for COBRA coverage (or similar
coverage under state law) offered by
the City; (xii) any change resulting
from a change made under a plan
of your spouse’s, former spouse’s or
dependent child’s employer that is
listed on this form.
Important Notice for All Employees Premium Only Plan
CITY OF DAYTON (continued)
If any of these events, occur it
is imperative that you contact
the Plan Administrator, in
writing, within thirty (30) days.
If you do not contact the Plan
Administrator, in writing, within
thirty (30) days you will not be
able to modify your election
under the POP until the first day
of the next plan year. The Plan
Administrator will provide you with
a Change in Election Form for you
to complete once you notify the
Plan Administrator that one of these
events has occurred.
In addition, if there is an insignificant
change in the amount of premiums
for the group health plan during
the plan year, the amount you are
contributing under the POP will
automatically be adjusted to reflect
the change. On the other hand, if
there is a significant increase in the
cost of the coverage or coverage
under the health plan is significantly
curtailed or ceases during the plan
year, you may revoke your election
under the POP and may make a new
election on a prospective basis under
another group health plan, if any,
that provides similar coverage. Also,
if a new benefit is added during the
plan year, you may elect coverage
under the newly-added option for the
remainder of the plan year.
Finally, you should contact the
Plan Administrator if you have any
questions regarding whether you can
waive coverage under the City group
health plan in exchange for additional
cash compensation and the rules
governing those waivers.
Again, it is important to note that
these rules have been issued by the
IRS and the City must follow the rules.
Otherwise, the POP will become
disqualified.
If you have any questions, please
contact the Plan Administrator
immediately:
Plan Administrator
Teresa Hanson
Human Resources
City of Dayton
101 West Third Street,
Room 330
Dayton, OH 45402
26
2016 DPSU - Full Time
Waiver of Health Insurance Form
In accordance with the terms of the City of Dayton Premium Only Plan, you may waive coverage under the City
of Dayton Group Health Benefit Plan in exchange for additional taxable cash compensation. In order to receive
this cash payment, you cannot be carried as the policyholder or spouse under a City of Dayton plan. The following rules apply for you to waive coverage under the City of Dayton Group Health Benefit Plan in exchange for
additional taxable cash compensation.
1. You must submit this City of Dayton Waiver of Health Insurance Form with proof of other health coverage
during Open Enrollment to receive the full incentive payment. This City of Dayton Waiver of Health Insurance Form must be completed and submitted with proof of other health coverage to the Human Resources
Department on or before October 30, 2015 at 5:00 p.m. You must submit this City of Dayton Waiver of Health
Insurance Form to receive the incentive payment even if you previously waived coverage under the City’s
health plan. A new waiver form and proof of insurance must be submitted each plan year to receive
the incentive, even if you waived coverage in the previous year. If you submit your waiver form after
October 30, 2015, your waiver payment will be prorated based on the remaining portion of the 2016
calendar year.
2. In accordance with the terms of the City of Dayton Premium Only Plan, you may waive coverage under the
City of Dayton Group Health Benefit Plan in exchange for additional taxable cash compensation. In order to
receive cash payment you cannot be carried as the policyholder or spouse under a City of Dayton plan. The
following rules apply for you to waive coverage under the City of Dayton Group Health Benefit Plan in exchange for additional taxable cash compensation.
3. If you (and/or a family member) are not participating in the City of Dayton Group Health Benefit Plan, you
(and/or family member) may only enter the plan during the plan year if you experience a qualifying event.
The qualifying events that will allow you (and your family members) to enroll in the plan mid-year are:
(i) You (or your spouse and/or dependent) had other coverage at the time of the Open Enrollment; and
(ii) The other coverage terminates for certain qualifying reasons. You also may enroll yourself, your spouse,
and any new family member in the plan mid-year if you become married or you acquire a dependent
through birth, adoption or placement for adoption.
Y ou must apply for coverage under the City’s health plan within thirty (30) days of these events. Otherwise,
you must wait until the next Open Enrollment.
4. If you do not participate in the Group Health Benefit Plan as an Employee, or the spouse or dependent of an
Employee, for the entire plan year, you will receive $2,400.06 less all applicable taxes. This amount will be
paid in your bi-weekly pay at the rate of $92.31 for each of 26 paychecks.
27
2016 DPSU - Full Time
Waiver of Health Insurance Form (continued)
I have read and understand the information explaining my rights to participate in the City of Dayton Group
Health Benefit Plan and I have elected to waive coverage under the City of Dayton Group Benefit Health Plan
in exchange for additional taxable cash compensation.
Employee’s Printed Name
Social Security Number
Employee’s Signature
Date
Employee’s Phone Number
I am attaching the following documents to prove that I have other health coverage:
Name of Policy Holder
Policy Holder SS Number
Your Relationship to Policy Holder
Insurance Plan
CHECK ONE OF THE FOLLOWING:
_____ Policyholder has City Coverage
_____ Policyholder does not have City Coverage
28
Dental Insurance
There are no carrier or benefit
changes for 2016 to the dental
insurance provided thru AFSCME
Care.
Any employee who desires a change
in covered dependents needs to
complete a dental enrollment form.
AFSCME Care can be contacted at
1-800-562-1822
Poor oral health can lead
to problems
According to the Academy of General
Dentistry, there is a relationship
between gum (periodontal) disease
and health complications such as a
stroke and heart disease. Research
shows that more than 90% of all
systemic diseases (diseases involving
many organs or the whole body) have
oral manifestations, including swollen
gums, mouth ulcers, dry mouth and
excessive gum problems. Such
diseases include diabetes, leukemia,
oral cancer, pancreatic cancer, heart
disease and kidney disease. It is
important to not overlook taking care
of your teeth and gums as poor oral
hygiene can actually lead to other
health problems, including:
• Oral and facial pain. According to
the Office of the Surgeon General,
this pain may be largely due to
infection of the gums that support
the teeth and can lead to tooth
loss. Gingivitis, an early stage
of gum disease, and advanced
gum disease affect more than 75
percent of the U.S. population.
29
• Problems with the heart and other
major organs. Mouth infections
can affect major organs. For
example, the heart and heart
valves can become inflamed by
bacterial endocarditis, a condition
that affects people with heart
disease or anyone with damaged
heart tissue.
• Digestion problems. Digestion
begins with physical and
chemical processes in the mouth,
and problems here can lead to
intestinal failure, irritable bowel
syndrome and other digestive
disorders.
Life Insurance, Supplemental Life Insurance & Long Term Disability
Life Insurance
Supplemental Life Insurance
Long Term Disability
There are no changes to the basic
life or AD&D coverage provided
thru Hartford. Basic Life and AD&D
insurance is paid for by the City
of Dayton and includes a $25,000
benefit.
Supplemental Life Insurance is
offered thru Hartford. Life insurance
is an important part of your family’s
financial plan and it’s essential to
protect your family’s standard of living
and avoid leaving debt behind. In
addition to the base life policy that the
City of Dayton provides, you have the
opportunity to purchase supplemental
life insurance or increase your
coverage each year. For additional
information, see benefit highlight
sheet and monthly rate table included
in the booklet.
Long Term Disability insurance is
offered thru Standard. Many times
the need for Long Term Disability
insurance is overlooked. Long Term
Disability coverage is insurance on
your income in the event that you
are unable to provide for your family
due to an illness, injury or disability.
Just as you protect your home, car
and family from the unexpected
with the appropriate insurance
plans, long term disability can
protect your financial wellbeing by
replacing lost wages if an illness or
injury prevents you from working.
30
EEBL1_Value|Basic Life and AD&D Insurance
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"Find/Replace" of variable text and the header.
Template: Basic_Life_BHS_NE-FS
Basic Life and AD&D Insurance
Benefit Highlights
City of Dayton
What is basic life and
AD&D insurance?
Your employer provides, at no cost to you, basic life and AD&D insurance in an amount
equal to $25,000. Life insurance pays your beneficiary (please see below) a benefit if you
die while you are covered.
This highlight sheet is an overview of your basic life and AD&D insurance. Once a group
policy is issued to your employer, a certificate of insurance will be available to explain your
coverage in detail.
Am I eligible?
You are eligible if you are active full time, excluding City Managers, Elected Officials,
Fraternal Order of Police and International Association Firefighter employee, who works at
least 40 hours per week on a regularly scheduled basis.
When can I enroll?
As an eligible employee, you are automatically covered by basic life and AD&D insurance;
you do not have to enroll. If you have not already done so, you must designate a
beneficiary as described below.
When is it effective?
Benefit Reductions
What is a beneficiary?
Coverage goes into effect subject to the terms and conditions of the policy. You must be
actively at work with your employer on the day your coverage takes effect.
Does not apply. All coverage cancels at retirement.
Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit
payment if you die while you are covered by the policy. You must select your beneficiary
when you complete your enrollment application; your selection is legally binding.
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford
Life Insurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home
Office is Hartford, CT.
City of Dayton Basic NE-FS Life BHS
00057961
Creation Date: 10/2/2015
Page 1 of 2
Version 11/12
31
57961-0
AD&D Coverage
AD&D provides benefits due to certain injuries or death from an accident. The covered
injuries or death can occur up to 365 days after that accident. The insurance pays
• 100% of the amount of coverage you purchase in the event of accidental loss of life,
two limbs, the sight of both eyes, one limb and the sight of one eye, or speech and
hearing in both ears or quadriplegia.
• 75% for paraplegia or triplegia (paralysis of three limbs).
• One-half (50%) for accidental loss of one limb, sight of one eye, or speech or hearing
in both ears or hemiplegia.
• One-quarter (25%) for accidental loss of thumb and index finger of the same hand or
uniplegia.
Your total benefit for all losses due to the same accident will not be more than 100% of the
amount of coverage you purchase.
Can I keep my
life coverage if I leave
my employer?
What is the Living
Benefits Option?
Yes, subject to the contract, you have the option of:
•
Converting your group life coverage to your own individual policy (policies).
If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible
to receive payment of a portion of your life insurance. The remaining amount of your life
insurance would be paid to your beneficiary when you die.
Important Details
As is standard with most term life insurance, this insurance coverage includes certain limitations and exclusions:
•
the amount of your coverage may be reduced when you reach certain ages.
AD&D insurance does not cover losses caused by or contributed by:
•
sickness; disease; or any treatment for either;
•
•
any infection, except certain ones caused by an
accidental cut or wound;
injury sustained while in the armed forces of any
country or international authority;
•
•
intentionally self-inflicted injury, suicide or suicide
attempt;
taking prescription or illegal drugs unless prescribed
for or administered by a licensed physician;
•
•
war or act of war, whether declared or not;
injury sustained while committing or attempting to
commit a felony;
•
the injured person’s intoxication.
Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of
insurance will be available to explain your coverage in detail.
This benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is
not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder
(your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance
coverage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the
insurance policy apply.
City of Dayton Basic NE-FS Life BHS
00057961
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32
57961-0
SVL1_Value|Supplemental Life Insurance
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"Find/Replace" of variable text and the header.
Template: Life_BHS
Supplemental Life Insurance
Benefit Highlights
City of Dayton
What is supplemental life
insurance?
Supplemental life insurance is coverage that you pay for.
Supplemental life insurance pays your beneficiary (please see below) a benefit if you die
while you are covered.
This highlight sheet is an overview of your supplemental life insurance. Once a group
policy is issued to your employer, a certificate of insurance will be available to explain your
coverage in detail.
Am I eligible?
You are eligible if you are an active full time employee or elected official who works at
least 40 hours per week on a regulary scheduled basis.
When can I enroll?
Enrollment in supplemental life insurance begins 10/13/2015 and ends 10/26/2015. All
Enrollment in supplemental life insurance begins 10/13/2015 and ends 10/26/2015.
elections must be made by 10/30/2015.
When is it effective?
How much supplemental
life insurance can I
purchase?
I already have
supplemental life
insurance coverage; do I
have to do anything?
Am I guaranteed
coverage?
What is a beneficiary?
Coverage goes into effect subject to the terms and conditions of the policy. You must be
actively at work with your employer on the day your coverage takes effect.
You can purchase supplemental life insurance in increments of $10,000.
The maximum amount you can purchase cannot be more than 5 times your annual
earnings or $500,000. Annual earnings are as defined in The Hartford’s contract with your
employer.
If you take no action, your coverage will automatically continue with The Hartford subject
to the terms of the contract.
If you are currently participating in this coverage you may increase your current coverage
by $10,000, not to exceed $200,000, without providing evidence of insurability. If you are
electing coverage for the first time, you may elect coverage in the amount of $10,000.
Additional coverage amounts will require evidence of insurability that is satisfactory to The
Hartford before the excess can become effective.
Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit
payment if you die while you are covered by the policy. You must select your beneficiary
when you complete your enrollment application; your selection is legally binding.
The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford
Life Insurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home
Office is Hartford, CT.
City of Dayton Life BHS
00049665
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33
AMDPHKENFLDIBLAKALGIDNAPEJFLHKDK
AIBJHKMBEOLPPAFKAMBIOEEKHKGJEAMK
ANBIMBNGCLEDLLJKAEKOJHNCNMGEOBLK
AKIAMMCCGGGKMEEKAOMMIAIIOKAMEIKK
APDKCJEKAMEKFPEKAOAJGPCLDLBIHJCK
AHEFMCEFLAGCILFKAAOGCLEDKMICDNMK
AMPGCPBJLBFHHHGKANDGGEFGHEFPHJOK
ACKCEIOIICAGCICKAOAEIIKAMCGGCKGK
49665-0
Are there other limitations
to enrollment?
If you do not enroll within 31 days of your first day of eligibility, you will be considered a
late entrant. Typically, late entrants may need to show evidence of insurability and may be
responsible for the cost of physical exams or other associated costs if they are required.
Does my coverage
reduce as I get older?
Does not apply. All coverage cancels at retirement.
Can I keep my life
coverage if I leave my
employer?
Yes, subject to the contract, you have the option of:
• Converting your group life coverage to your own individual policy (policies).
• If you leave your employer, portability is an option that allows you to continue your life
insurance coverage. To be eligible, you must terminate your employment prior to
Social Security Normal Retirement Age. This option allows you to continue all or a
portion of your life insurance coverage under a separate portability term policy.
Portability is subject to a minimum of $5,000 and a maximum of $250,000 and does
not include coverage for your dependents. To elect portability, you must apply and pay
the premium within 31 days of the termination of your life insurance. Evidence of
insurability will not be required.
What is the living
benefits option?
If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible
to receive payment of a portion of your life insurance. The remaining amount of your life
insurance would be paid to your beneficiary when you die.
Important Details
As is standard with most term life insurance, this insurance coverage includes certain limitations and exclusions:
• the amount of your coverage may be reduced when you reach certain ages.
• death by suicide (two years).
Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of
insurance will be available to explain your coverage in detail.
This benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is
not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder
(your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance
coverage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the
insurance policy apply.
City of Dayton Life BHS
00049665
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Version 11/12
34
AMDPHKENFLDIBLAKALGIDNAPEJFLHKDK
AIBJHKMBEOLPPAFKAMBIOEEKHKGJEAMK
ANBIMBNGCLEDLLJKAEKOJHNCNMGEOBLK
AKIAMMCCGGGKMEEKAOMMIAIIOKAMEIKK
APDKCJEKAMEKFPEKAOAJGPCLDLBIHJCK
AHEFMCEFLAGCILFKAAOGCLEDKMICDNMK
AMPGCPBJLBFHHHGKANDGGEFGHEFPHJOK
ACKCEIOIICAGCICKAOAEIIKAMCGGCKGK
49665-0
35
36
37
38
39
40
Hartford Monthly
Life InsuranceRATES
RatesEFFECTIVE
Effective June
1,1,
2012
HARTFORD
LIFE INSURANCE
June
2012
Under 25
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
Rate
0.077
0.077
0.103
0.116
0.129
0.206
0.347
0.617
0.848
1.632
2.650
2.650
10,000
0.77
0.77
1.03
1.16
1.29
2.06
3.47
6.17
8.48
16.32
26.50
26.50
20,000
1.54
1.54
2.06
2.32
2.58
4.12
6.94
12.34
16.96
32.64
53.00
53.00
30,000
2.31
2.31
3.09
3.48
3.87
6.18
10.41
18.51
25.44
48.96
79.50
79.50
40,000
3.08
3.08
4.12
4.64
5.16
8.24
13.88
24.68
33.92
65.28
106.00
106.00
50,000
3.85
3.85
5.15
5.80
6.45
10.30
17.35
30.85
42.40
81.60
132.50
132.50
60,000
4.62
4.62
6.18
6.96
7.74
12.36
20.82
37.02
50.88
97.92
159.00
159.00
70,000
5.39
5.39
7.21
8.12
9.03
14.42
24.29
43.19
59.36
114.24
185.50
185.50
80,000
6.16
6.16
8.24
9.28
10.32
16.48
27.76
49.36
67.84
130.56
212.00
212.00
90,000
6.93
6.93
9.27
10.44
11.61
18.54
31.23
55.53
76.32
146.88
238.50
238.50
100,000
7.70
7.70
10.30
11.60
12.90
20.60
34.70
61.70
84.80
163.20
265.00
265.00
Under 25
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
Rate
0.077
0.077
0.103
0.116
0.129
0.206
0.347
0.617
0.848
1.632
2.650
2.650
110,000
8.47
8.47
11.33
12.76
14.19
22.66
38.17
67.87
93.28
179.52
291.50
291.50
120,000
9.24
9.24
12.36
13.92
15.48
24.72
41.64
74.04
101.76
195.84
318.00
318.00
130,000
10.01
10.01
13.39
15.08
16.77
26.78
45.11
80.21
110.24
212.16
344.50
344.50
140,000
10.78
10.78
14.42
16.24
18.06
28.84
48.58
86.38
118.72
228.48
371.00
371.00
150,000
11.55
11.55
15.45
17.40
19.35
30.90
52.05
92.55
127.20
244.80
397.50
397.50
160,000
12.32
12.32
16.48
18.56
20.64
32.96
55.52
98.72
135.68
261.12
424.00
424.00
170,000
13.09
13.09
17.51
19.72
21.93
35.02
58.99
104.89
144.16
277.44
450.50
450.50
180,000
13.86
13.86
18.54
20.88
23.22
37.08
62.46
111.06
152.64
293.76
477.00
477.00
190,000
14.63
14.63
19.57
22.04
24.51
39.14
65.93
117.23
161.12
310.08
503.50
503.50
200,000
15.40
15.40
20.60
23.20
25.80
41.20
69.40
123.40
169.60
326.40
530.00
530.00
Under 25
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
Rate
0.077
0.077
0.103
0.116
0.129
0.206
0.347
0.617
0.848
1.632
2.650
2.650
210,000
16.17
16.17
21.63
24.36
27.09
43.26
72.87
129.57
178.08
342.72
556.50
556.50
220,000
16.94
16.94
22.66
25.52
28.38
45.32
76.34
135.74
186.56
359.04
583.00
583.00
230,000
17.71
17.71
23.69
26.68
29.67
47.38
79.81
141.91
195.04
375.36
609.50
609.50
240,000
18.48
18.48
24.72
27.84
30.96
49.44
83.28
148.08
203.52
391.68
636.00
636.00
250,000
19.25
19.25
25.75
29.00
32.25
51.50
86.75
154.25
212.00
408.00
662.50
662.50
260,000
20.02
20.02
26.78
30.16
33.54
53.56
90.22
160.42
220.48
424.32
689.00
689.00
270,000
20.79
20.79
27.81
31.32
34.83
55.62
93.69
166.59
228.96
440.64
715.50
715.50
280,000
21.56
21.56
28.84
32.48
36.12
57.68
97.16
172.76
237.44
456.96
742.00
742.00
290,000
22.33
22.33
29.87
33.64
37.41
59.74
100.63
178.93
245.92
473.28
768.50
768.50
300,000
23.10
23.10
30.90
34.80
38.70
61.80
104.10
185.10
254.40
489.60
795.00
795.00
Under 25
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
Rate
0.077
0.077
0.103
0.116
0.129
0.206
0.347
0.617
0.848
1.632
2.650
2.650
310,000
23.87
23.87
31.93
35.96
39.99
63.86
107.57
191.27
262.88
505.92
821.50
821.50
320,000
24.64
24.64
32.96
37.12
41.28
65.92
111.04
197.44
271.36
522.24
848.00
848.00
330,000
25.41
25.41
33.99
38.28
42.57
67.98
114.51
203.61
279.84
538.56
874.50
874.50
340,000
26.18
26.18
35.02
39.44
43.86
70.04
117.98
209.78
288.32
554.88
901.00
901.00
350,000
26.95
26.95
36.05
40.60
45.15
72.10
121.45
215.95
296.80
571.20
927.50
927.50
360,000
27.72
27.72
37.08
41.76
46.44
74.16
124.92
222.12
305.28
587.52
954.00
954.00
370,000
28.49
28.49
38.11
42.92
47.73
76.22
128.39
228.29
313.76
603.84
980.50
980.50
380,000
29.26
29.26
39.14
44.08
49.02
78.28
131.86
234.46
322.24
620.16
1007.00
1007.00
390,000
30.03
30.03
40.17
45.24
50.31
80.34
135.33
240.63
330.72
636.48
1033.50
1033.50
400,000
30.80
30.80
41.20
46.40
51.60
82.40
138.80
246.80
339.20
652.80
1060.00
1060.00
Under 25
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
Rate
0.077
0.077
0.103
0.116
0.129
0.206
0.347
0.617
0.848
1.632
2.650
2.650
410,000
31.57
31.57
42.23
47.56
52.89
84.46
142.27
252.97
347.68
669.12
1086.50
1086.50
420,000
32.34
32.34
43.26
48.72
54.18
86.52
145.74
259.14
356.16
685.44
1113.00
1113.00
430,000
33.11
33.11
44.29
49.88
55.47
88.58
149.21
265.31
364.64
701.76
1139.50
1139.50
440,000
33.88
33.88
45.32
51.04
56.76
90.64
152.68
271.48
373.12
718.08
1166.00
1166.00
450,000
34.65
34.65
46.35
52.20
58.05
92.70
156.15
277.65
381.60
734.40
1192.50
1192.50
460,000
35.42
35.42
47.38
53.36
59.34
94.76
159.62
283.82
390.08
750.72
1219.00
1219.00
470,000
36.19
36.19
48.41
54.52
60.63
96.82
163.09
289.99
398.56
767.04
1245.50
1245.50
480,000
36.96
36.96
49.44
55.68
61.92
98.88
166.56
296.16
407.04
783.36
1272.00
1272.00
490,000
37.73
37.73
50.47
56.84
63.21
100.94
170.03
302.33
415.52
799.68
1298.50
1298.50
500,000
38.50
38.50
51.50
58.00
64.50
103.00
173.50
308.50
424.00
816.00
1325.00
1325.00
It’s easy to earn
$350!
Log on to:
https://cityofdayton.riteforyouwellness.com
and earn 300 points by June 30, 2016.
You can access the site from anywhere (home, office or mobile device)!
Simply enter the website address on your web browser. This will take you to
your main log in page where you can enter your username and password (if
you have already created an account) or create your profile as a new user.
42
Be Well Dayton Overview
Activities in May and June, 2015 will be accepted
for this program year.
Is there a reward for participating?
Yes. You will earn $100 after you complete both
requirements in Tier 1 on the scorecard (page 4).
You can earn an additional $250 if you complete
activities in Tier 2 that add up to at least 200
additional points. Those who complete Tier 1 and
Tier 2 by June 30, 2016 can earn a reward of up to
$350. If you complete only Tier 1, your payout will
be $100 and if you complete both Tier 1 and 2 you
will receive a total of $350. You cannot receive a
payout for Tier 2 if you do not complete Tier 1.
What is Be Well Dayton?
If you complete Tier 1 by August 31, 2015 you will be
entered into an “Early Bird” drawing and be eligible
to win an extra day off.
Be Well Dayton is a health and wellness program
for eligible City of Dayton employees. The goal of
Be Well Dayton is to help you learn more about
your health and what you can do to be and stay
healthy.
How will I receive my reward?
Participants who meet the requirements for a
reward will receive payment on their regular
paycheck in early August, 2016.
Who is eligible to participate in the Be Well
Dayton wellness program?
If I am a new hire can I still participate in Be
Well Dayton?
City of Dayton full-time and part-time employees
are eligible to participate.
New employees can participate in the program
but you cannot receive the payout until you
successfully complete your probationary period.
Why should I participate in the Be Well
Dayton employee wellness program?
Many times, health risks don’t show any outward
symptoms until the condition has become very
serious and even life threatening. Participating in Be
Well Dayton will allow you to receive a free health
screening (also known as a biometric screening)
so you can know if you have any health risks. Be
Well Dayton also offers you the tools and expert
information on how you can become and stay
healthy at your own pace. There are also a lot of
fun activities and events and it’s FREE! All of your
health results stay private, and by law, remain
confidential from your employer.
Is this program different from last year’s Be
Well Dayton program?
Yes. Based on feedback from employees and
overall wellness needs, the Be Well Dayton program
made some modest changes to simplify the
program and focus on activities that can make the
most impact on health.
This year the program
officially kicks off on
July 1, 2015 and ends
on June 30, 2016.
How do I participate and earn wellness points?
Your Be Well Scorecard (page 4) outlines the
required activities and the points you can earn
for each one listed. Points are only awarded for
activities that occur in this program year. Points
earned in previous years will no longer carry over.
The program year runs July 1, 2015 to June 30, 2016.
2
Important Dates
Date
Event
July 1, 2015
Kick-Off of the 2015-2016 Be Well Dayton Wellness Program
July 23, 2015
City Hall on-site Biometric Screening
July 28, 2015
Aviation On-site Biometric Screening (Aviation Employees Only)
July 30, 2015
Ottawa Yards on-site Biometric Screening: Street Maintenance
August 13, 2015
Ottawa Yards On-site Biometric Screening: Water Distribution
August 31, 2015
Early bird deadline. Complete Tier 1 by August 31 and be
entered into a special prize drawing to win an extra day off.
September 7-18, 2015
Walktober Registration
September 27-October 31, 2015
Walktober
October 9, 2015
Health and Safety Fair
June 30, 2016
End of the 2015-2016 wellness year. All activities must be
completed and forms turned in immediately following.
Early August, 2016
Receive $100 or $350 Be Well reward payout
Wellness Portal
What is the Be Well Dayton wellness portal?
meantime, keep your own records so that you can
put your information into the portal as soon as your
account is live.
The Be Well Dayton wellness portal is the online
feature that offers 24-hour access to a variety of
tools to help you better understand and improve
your health. Once you have registered on the
portal, you can track activities, earn points toward
your reward, watch webinars and access valuable
tools and information related to your health. You
can access the portal site by visiting:
cityofdayton.riteforyouwellness.com.
What do I do if I have forgotten either my
username or password?
n Log in to cityofdayton.riteforyouwellness.com and
click on the Forgot Password link.
n Follow the instructions to recover your username,
password, or both. Use the same email that was
used when you registered on the wellness portal.
n You will receive the recovery e-mail within a few
minutes of the request. Be sure to check your spam
folder.
How do I register to use the wellness
portal?
Log in to cityofdayton.riteforyouwellness.com
Click SIGN-UP TODAY! on the bottom right side of
the page
n Follow the instructions to create a user name and
password
n
What is Rite for You Corporate Wellness?
n
Rite for You Corporate Wellness is an Ohio-based
provider of corporate wellness and population
health management services. They are a team
of compassionate clinicians and business experts
in the field of healthcare and population health
management.
How long after I’m hired does it take to get
access to the wellness portal?
We will make every effort to get your account
active as soon as possible so that you can begin
earning points and tracking your activities. In the
We have a dedicated Program Manager for the
City of Dayton Be Well Program.
3
2015-16 Scorecard
2015-16
Scorecard
Requirements
for TIER 1
July 1, 2015-June 30, 2016
July 1, 2015-June 30, 2016
Requirements
for TIER
1
Both activities must
be completed
to receive credit for the Tier 1 cash payout of $100
Tier
is required
to be eligible
for to
payout
Both1activities
must
completed
receive credit for the Tier 1 cash payout of $100
Tier 1 is required to be eligible for payout
Activity
Point Value
Earning Frequency
Activity
Point Value
Earning Frequency
Personal Health Assessment (PHA)
50
once
50
once
Health Screening (Biometric)
50
once
Health Screening (Biometric)
50
once
Total points required for Tier 1 $100 cash payout
Total points required for Tier 1 $100 cash payout
Options for TIER 2
Options
forTier
TIER
2
Complete
1 AND
Choose
anyTier
combination
of the activities* below to earn a minimum of 200 points:
Complete
1 AND
Choose any combination of the activities* below to earn a minimum of 200 points:
Activity
Point Value
Earning Frequency
Activity
Point Value
Earning Frequency
Annual Primary Care Physician Well Visit
100
once
Annual Primary Care Physician Well Visit
100
once
Blood Pressure: ≤ 140/90 mm Hg
10
once
Blood Pressure: ≤ 140/90 mm Hg
10
once
A1C: ≤ 6.4%
10
once
A1C: ≤ 6.4%
10
once
Total Cholesterol: ≤ 239
10
once
Total Cholesterol: ≤ 239
10
once
Waist Circumference:
10
once
●
Women:
≤ 35
Waist
Circumference:
●Men:
≤ 40≤ 35
10
once
●Women:
Max Points Annually
Max Points Annually
50
50
50
50
100
100
Max Points Annually
Max Points Annually
100
100
10
10
10
10
10
10
10
10
●Men: ≤ 40
Preventative Exams:
●
Dental Cleaning
(up to 2 per year)
Preventative
Exams:
●Prostate
Exam (up to 2 per year)
●
Dental Cleaning
10
10
As directed by
your
medical
As
directed
by
provider
your medical
provider
80
80
25
25
once
once
25
25
5
5
up to 6
up to 6
30
30
10
10
up to 6 separate
educational
topics
up to 6 separate
educational topics
60
60
Tier 2 possible points:
Tier 2 possible points:
Total Tier 2 points required for additional $250 cash payout:
Total Tier 2 points required for additional $250 cash payout:
335
335
200
200
●Colonoscopy
●Prostate Exam
●Flu
Shot
●Colonoscopy
●Vision
Exam
●Flu Shot
●Mammography
●Vision Exam
●Annual
Women's Well Visit
●Mammography
●Annual Women's Well Visit
Walktober
Walktober
Dayton Community Event
Please
refer
to Program Guide**
Dayton
Community
Event for examples of acceptable
community
Please referevents.
to Program Guide** for examples of acceptable
community events.
Structured Educational Programs
Please
refer toEducational
Program Guide**
for a list of available
Structured
Programs
structured
andatheir
Please refereducational
to Programprograms
Guide** for
list ofdetails.
available
structured educational programs and their details.
*In the event that your health screening results differ significantly from recent medical results, an appeal may be submitted with supporting
documentation.
Any
retesting
be at your
expense.
You may also
file recent
an appeal
for conditions
impact
results, such
assupporting
pregnancy. If it is
*In the event that
your
health will
screening
results
differ significantly
from
medical
results, anthat
appeal
mayyour
be submitted
with
.
unreasonably
difficult
for you to
achieve
the standards
due may
to a also
medical
condition,
or ifconditions
it is medically
you to
attempt
to achieve
documentation.
Any retesting
will
be at your
expense. You
file an
appeal for
that inadvisable
impact yourfor
results,
such
as pregnancy.
If the
it is
.
standards
for the
reward,
there
be alternative
ways
to to
qualify
for the
full valueorofifthe
category.
For more
information,
please
refer to
unreasonably
difficult
for you
tomay
achieve
the standards
due
a medical
condition,
it isfailed
medically
inadvisable
for you
to attempt
to achieve
the
https://cityofdayton.riteforyouwellness.com/
or your
Ritetofor
You representative.
standards for the reward, there may be alternative
ways
qualify
for the full value of the failed category. For more information, please refer to
https://cityofdayton.riteforyouwellness.com/ or your Rite for You representative.
**The Program Guide can be located at https://cityofdayton.riteforyouwellness.com/ under the Resources.
**The
Program Guide
canrequired
be located
at https://cityofdayton.riteforyouwellness.com/
under the Resources.
*** Verification
forms
only
for medical related activities.
Tier 1 Activities
What is a PHA?
A PHA is a 15-20 minute confidential questionnaire
that asks about your lifestyle and habits. Your
answers allow the wellness portal to automatically
give you information on potential health risks, how
you can maintain healthy habits, and steps you can
take to improve your health when you are ready.
You will also receive an overall wellness score that
places you in a risk category. Wellness scores are
defined as the following:
Low Risk:
health. Depending on your results, you may be
encouraged to follow up with your doctor.
80 - 100% wellness score
Moderate Risk:
The City will be offering both on-site and offsite biometric screenings that are FREE to all
participants in the Be Well Dayton program. See
the important dates section for a list of the on-site
events (page 2).
High Risk:
What if I can’t attend an on-site biometric
screening?
Contact Human Resources at 333-4045 to obtain
the CompuNet biometric form and schedule
an appointment with your doctor or go to a
participating CompuNet location. Forms must be
postmarked or faxed by June 30, 2016.
How do I take the PHA?
n Click on Take your PHA
n
Why is the Personal Health Assessment
(PHA) and biometric screening required?
Biometric screening
The PHA and biometric screening help you become
aware of potential health risks. The results of the
PHA and biometric screening can also be used
to recommend programs for you. For example, if
your biometric results tell you that you have high
blood pressure, you may wish to seek out programs
that are offered to help you manage your blood
pressure.
What is a biometric screening?
A biometric screening is a short health exam, which
includes drawing blood to test blood glucose levels,
and total cholesterol. In addition the technician
will be taking your blood pressure and measuring
your waist circumference. A biometric screening
shows your potential risk for certain diseases and
medical conditions, and helps you understand
where you should take action to improve your
5
Tier 2 Activities
Annual Primary Care Well Visit & Preventative Exams
Log in to cityofdayton.riteforyouwellness.com.
Download the Preventative Exam Verification Form
found under Resources on the portal or contact
Rite for You at cityofdayton@riteforyouwellness.com
or 1-866-668-RITE to have a paper form mailed
to you. Take the form with you to each doctor
appointment and have the form signed (Your
Anthem Explanation of Benefits (EOB) can be
provided in lieu of physician’s signature). Complete
and submit the form by June 30, 2016. Please only
submit one form that includes all applicable exams.
Refer to Preventative Exams Form for detailed
instructions on how to complete and submit.
Do I need to enter my biometric screening
results into my Personal Health Assessment
(PHA)?
No. Your biometric screening results (whether
completed on-site or through your physician) will
automatically be entered into your PHA. You do
NOT need to enter your biometric screening results.
Dayton Community Event
What is a Dayton Community Event?
The Be Well Dayton wellness program promotes not
only good physical health, but good emotional
health as well. Not all events are fitness and
nutrition driven. Below are examples of activities
which could qualify for points. This list is not
comprehensive, but represents events and activities
commonly available within the community.
Participate in an organized or sanctioned race
such as a 5k, triathlon or marathon
n Participate in a Community Shared Agriculture or
have your own garden plot
n
Volunteer at a non-profit organization
n Go zip lining, horseback riding or canoeing
n Over The Edge Event – rappel down Kettering
Tower for Big Brothers, Big Sisters
n Participate in the Dayton Plane Pull
n Attend COD Annual Health and Safety Fair
n Annual membership to Link Dayton Bike Share
n Take a healthy cooking class
n Join a gym or participate in a class at a
recreation center
n Coach or participate in a community or
recreational team sport
n
If I participated in a Dayton Community
Event not listed, can I still receive credit?
It is difficult to list every possible event. Contact Rite
for You to see if your event qualifies.
How do I receive credit for participating in a
Dayton Community Event?
n Click on your Incentive Plan and then Healthy
Habits
n Submit the name and date of event
n
6
Structured Educational Programs
team or walk as an individual participant. A daily
step goal will be established at the beginning of
the competition. At the end of the competition,
anyone reaching the established goal will be
entered into a prize drawing (date & prizes TBD).
What is a Structured Educational Program?
Participate in a class, workshop, webinar or lunch
and learn (in person or on-line) that is dedicated to
the following topics:
When can I register for Walktober?
Diabetes Prevention
n Stress Management
n Tobacco Cessation
n Financial Wellness
n Stretching and Flexibility
n Proper Emergency Room Use
n Rite for You Portal Workshops
n Digestive Issues
n Weight Loss
n Nutrition
n Exercise
n Future Moms
n Depression
You can register September 7, 2015 through
September 18, 2015. More detailed information
about Walktober will be provided as the event gets
closer.
n
How do I register for Walktober?
Visit cityofdayton.riteforyouwellness.com
Follow registration instructions on the wellness
portal or register using official Walktober registration
forms. You can also Contact Rite for You at
cityofdayton@riteforyouwellness.com or
1-866-668-RITE to obtain additional information and
forms.
n
n
Mobile App
How do I receive credit for participating in a
Structured Educational Program?
Get the Healthy Now mobile app to track
your wellness activities —
n Click on your Incentive Plan and then Healthy
Habits
n Submit the name and date of educational
program
n
Easy access on the go
by downloading the
smartphone
app Healthy Now.
Available for Apple
or Android.
Walktober
What is Walktober?
Walktober is a fun, competitive walking challenge
that occurs every year for the whole month of
October. You can be a part of a five-person
7
City of Dayton Wellness Ambassadors
Any of the COD Wellness Team can help answer questions.
Toni Bankston, Public Affairs
Ruth Bickel, Engineering
Ken Couch, Human Resources
Ryan Demmitt, Waste Collection
Norma Dickens, Law
Shelley Dickstein, City Manager’s Office
Leo Geiger, DPSU
Stewart Halfacre, Public Affairs
Lamonte Hall, Recreation
Monica Jones, City Manager’s Office
Despina Kourt, Water
Gina Mabelitini, City Manager’s Office
Rob Hogeland, Fire
Chris Pawelski, Police
Joey Shope, Purchasing
Sarah Spees, Aviation
Karen Thomas, Water
Peggy Thumser, Human Resources
Norman Vann, Water
Albert “Dutch” Weidenborner, Central Services
Contact Information
Privacy
Below is a list of important contacts
Is my privacy protected?
EMAIL: cityofdayton@riteforyouwellness.com
Rite for You Corporate Wellness complies with
all HIPAA Privacy and Security Standards and
maintains the confidentiality of all information
relating to employees who choose to
participate – which means that individual results
are never released unless the appropriate
written consent is provided by the employee.
A summary of the aggregate results will be
provided to Human Resources to better
understand the impact their efforts are making
on the overall health and well-being of City of
Dayton employees – NO INDIVIDUAL RESULTS
ARE SHARED. To read more about your privacy,
please visit cityofdayton.riteforyouwellness.com.
PHONE: 1-866-668-RITE
FAX: Attn: Data Group 1-844-379-7494
MAIL: Rite for You Corporate Wellness
Attn: Data Group
171 Green Meadows Dr. South
Lewis Center, OH 43035
HUMAN RESOURCES: 333-4045
Please do not email your verification forms. Use the
secure fax line or U.S. mail to submit to Rite for You.
8
Be Well Dayton Preventative Exam(s) Form
SECTION 1: PARTICIPANT INFORMATION (Completed by participant – PLEASE PRINT CLEARLY)
 
__
By signing below, I understand that the purpose of my health screening is to evaluate my health status and any potential health risks. I hereby request and authorize RITE FOR
YOU to transmit health information about me to the health management companies that provide services to my employer so that these companies may help me reduce, manage
and/or control any such risks. I understand that RITE FOR YOU is not responsible for diagnosing, treating, or preventing any medical disease or condition that I currently have
or may have in the future. I also understand that RITE FOR YOU will not give me medical advice and that I must seek such advice from my own physician. I understand that
RITE FOR YOU will not provide my employer any health information that identifies me. I acknowledge and agree that RITE FOR YOU may provide my employer aggregate
statistical health information which includes my health information. I understand that RITE FOR YOU may also use my health information for its own internal business
purposes such as to develop future wellness programs. Finally, I understand that I may faint, bruise, or have other effects as a result of my blood being drawn. I voluntarily
agree and consent to participate in the health screening and accept and assume all risks associated with such participation. I hereby release and forever discharge RITE FOR
YOU, its owners, employees, and agents from any and all claims, demands, actions, and damages, including attorney’s fees and costs, arising out of or in any way related to my
participation in the health screening.
Participant Signature:
Date:
SECTION 2: EXAM SELECTIONS (Completed by provider performing each exam – PLEASE PRINT CLEARLY)
Completion of this section of the form verifies that the individual named above was given a preventative exam. Please select the applicable exam and include the Provider’s details.

_ _/_ _/_ _ _ _
_________________________________________________________________________________________



_ _/_ _/_ _ _ _
_ _/_ _/_ _ _ _
_ _/_ _/_ _ _ _
_________________________________________________________________________________________
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_ _/_ _/_ _ _ _
_________________________________________________________________________________________
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_ _/_ _/_ _ _ _
_________________________________________________________________________________________
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_ _/_ _/_ _ _ _
_________________________________________________________________________________________
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_ _/_ _/_ _ _ _
_________________________________________________________________________________________
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_________________________________________________________________________________________
Rite for You, 171 Green Meadows Drive South, Lewis Center, OH 43035 Call toll free: 1-866-6687
www.riteforyouwellness.com
51
INSTRUCTIONS
IMPORTANT: Please USE ONLY THIS FORM to record each preventative exam for your wellness points for the 2015-16 year. All
sections that apply to you must be completely filled out including signatures to receive your wellness points. This ONE form should
be used to track ALL your preventative exams for this year. Submit this form only after you have received ALL the exams for which
you would like points in the 2015-16 year.
Step 1: Complete participant information section in its entirety.
Step 2: Complete exam selections section by attending your preventative exam appointments and obtaining physician information
and signatures for the exams you select.
Step 3: Fax or mail the completed form:
Rite for You Corporate Wellness
Rite for You Corporate Wellness
OR
ATTN: Data Group
ATTN: Data Group at: 1-844-379-7494
171 Green Meadows Drive South
Lewis Center, OH 43035
PLEASE RETAIN A COPY FOR YOUR RECORDS ALONG WITH THE FAX CONFIRMATION, if applicable. For any questions or concerns,
please contact your Rite for You Account Manager, Melanie Paris, at 614.310.2668, or Melanie@riteforyouwellness.com.
Completed forms must be post mark dated or faxed to Rite for You by June 30, 2016.
INFORMED CONSENT/AUTHORIZATION RELEASE FORM
1.
I agree voluntarily participate in preventative exams of my choosing to earn credit for Be Well Dayton sponsored by the City of
Dayton and Rite for You Corporate Wellness. Preventative exams include:
 Annual wellness exam (physical)
 Dental check-up
 Pelvic exam/pap smear
 Mammogram
 Flexible sigmoidoscopy/colonoscopy
 Vision exam
 Flu vaccine
 Digital rectal exam and PSA
2.
I hereby release Rite for You and/or their agents and staff from any and all liability arising from or in any way connected with my
preventative exams.
3.
I understand it is my responsibility to direct questions regarding testing to those administering the tests and to follow-up with
my physician to discuss the results of these tests, when so advised.
4.
I understand that any information collected as part of this health screening will be treated as confidential. Individual health
information will not be shared with my employer.
5.
I understand that my individual health data will be used by Rite for You to:
 Evaluate the impact of the wellness program.
 Provide my employer aggregate information as part of a group summary report (my individual data will not be
disclosed).
 If an incentive is implemented as part of the Program, I consent to Rite for You Corporate Wellness (RFY) informing my
benefits provider whether or not I qualify for such incentive based on my participation in this screening.
6.
I authorize my physician or lab to perform the above listed tests and release information regarding these tests to Rite for You.
7.
The results and a copy of the release form can be faxed directly to the Data Group at Rite for You at 844-379-7494.
8.
I understand that I am responsible for any potential fees for my physician visit including, but not limited to co-pays, deductibles,
and processing fees to complete necessary paperwork.
Rite for You complies with all HIPAA Privacy and Security Standards, and maintains the confidentiality of all information relating to
employees that choose to participate – which means that individual results are never released unless the appropriate written
consent is provided by the member. A high-level summary of the aggregate results will be provided to the Coordinator(s) to better
understand the impact their efforts are having on the overall health and well-being of the members. This information will assist in
customizing future programs, which will promote the specific health/preventions needs of the members.
By signing the Physician Biometric Screening Forms, I agree to the terms outlines above.
52
Contacts
Human Resources
City of Dayton
Teresa Hanson
937-333-4021
Peggy Thumser
937-333-4064
Medical/Prescription
Drug Plan
Anthem Blue Cross
and Blue Shield
Group # 00171521
1-888-224-4902
6 a.m. – 8 p.m. CT
Dental Plan
AFSCME Care
800-562-1822
8 a.m. – 4:30 p.m. ET
Health Savings
Account
CODE Credit Union
1-937-222-8971
Dayton Location
Monday - Friday / 8:30 a.m. – 5:30 p.m.
www.anthem.com
www.codecu.org
Englewood Location
Monday – Thursday / 9 a.m. – 5 p.m.
Friday 9 a.m. – 6 p.m. /
Saturday 9 a.m. - noon
Mad River Station Location
(across from Dayton Mall)
Monday – Thursday / 9 a.m. – 5 p.m.
Friday 9 a.m. – 6 p.m. /
Saturday 9 a.m. - noon
Health Savings
Account
Dayton Firefighters
Credit Union
1-937-228-1614
Monday - Friday 10 a.m. - 6 p.m.
www.dffcu.org
Wellness
Rite4You
1-800-668-RITE
www.cityofdayton.
riteforyouwellness.com
Deferred Comp
ICMA Deferred Comp
1-800-669-7400
www.icmarc.org
Deferred Comp
Ohio Deferred Comp
1-877-644-6457
www.ohio457.org
Pension
Police & Fire Pension
1-888-864-8363
www.op-f.org
Pension
OPERS
1-800-222-7377
www.opers.org
53

DPSU - Full Time - Benefit Snapshot

Transcription

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