FULL-TIME FACULTY & STAFF AND PART-TIME STAFF HOURS

(1)



You must use myBenefits, the online

enrollment application, to enroll in your

benefit plans. Instructions are included

with this benefit packet.



FULL-TIME FACULTY & STAFF

AND PART-TIME STAFF 30-39 HOURS

2015–2016

EMPLOYEE BENEFITS

We’re glad you’re here

As part of your total compensation, Cleveland State University (CSU) offers a competitive and comprehensive benefit package that includes medical, dental, vision, life and long-term disability insurance, flexible spending accounts, mandatory and voluntary retirement plans, voluntary insurance offerings, and a health and well-being program, VikeHealth. Most benefits are available for enrollment on your first full day of employment. Once you have selected coverage and the election is processed with the insurance provider, medical, dental and vision coverage is effective retroactive to your benefits eligible hire date. Descriptions of your benefits are contained in this booklet and are available on the Human Resources web page at http://mycsu.csuohio.edu/offices/hrd/benefits.html.

Enrolling in your benefits is made easy through the myBenefits online enrollment

application. Human Resources will authorize your access to myBenefits and notify you by email when it is available for you to indicate your selections. The email includes a notice of the “open date”— the first date the application is available to make your benefit selection and the “close date”— the last date the application will be available. Access instructions for myBenefits are enclosed in your benefits packet. Proof of dependent eligibility is required (refer to pages 2-3 of this booklet). Selections must be submitted online within 31 days of your hire date (or effective date of a qualified change of status). When enrolling a dependent for coverage, the appropriate documentation to prove eligibility must be submitted to Human Resources in order to process your enrollment.

Don’t miss your enrollment deadline! NOTE: If you do not make your online enrollment elections by the close date, health benefits will be waived and enrollment in voluntary Insurance plans in the future will require evidence of insurability. Your next opportunity to elect or change health coverage will be during the annual open enrollment period unless you have a qualified change in status (refer to page 3 of this booklet for a description).

Contact a member of the Human Resources Benefits staff for assistance at (216) 687-3636.

Welcome to

Cleveland State University!

Eligibility Guidelines ...2-3

Qualified Change In Status ...3

Helpful Definitions ...4

Federal & State Health Care Reform ...5

CSU Medical Plan Choices ...6-7 CSU Health & Wellness Services ...7

Medical & Prescription Drug Plan Comparison Charts ...8-10 Dental Plan ...11

Vision Plans ...12

Flexible Spending Account Plan ... 13

VikeHealth & Well-Being Program ...14

Tobacco Free Campus ...14

Life Insurance Benefits ...15

Family and Medical Leave ...16

Sick Leave Benefits ...16

Vacation Leave Benefits ...17

Paid Holiday Benefits ...17

UNUM Voluntary Benefits ...18

Long Term Disability Coverage ...18

Employee Assistance Programs ...19

Business Travel Accident Insurance ...19

Travel Assistance Programs ...20

Workers Compensation ...20

Retirement Plans ...21

Tuition Benefits ...22

Employee Discount Programs ...22

Huntington Bank Program ...23

Notifications ...23

CSU Benefits Directory ...24

http://mycsu.csuohio.edu/offices/hrd

Information contained in this booklet is in summary form. Certain benefits, limitations or exceptions may not be described in detail. If there are any discrepancies between the information presented and the actual plan documents, the plan documents will govern.

(2)

2 FACULTY/STAFF BENEFITS ELIGIBILITY

The following classifications of employees are eligible to participate in the University’s employee benefit plans and programs: • Full-time faculty and staff with an appointment of six months or longer, and

• Part-time staff with an appointment of six months or longer who are scheduled to work 30 - 39 hours per week.

The following are eligibility rules, guidelines and documentation requirements for enrollment of qualifying dependents in Cleveland State University’s group benefit plans, including provisions of Federal and State legislation for Adult Children. Information in this chart is in summary form. Refer to the University’s Eligibility Rules Chart for details on the Human Resources Benefits web page under the “Frequently Requested Enrollment Information” Dependent Eligibility section. Adult children can be covered under the Plan until they attain age 26, regardless of their student or marital status and regardless whether they live at home or whether you support them.

DEPENDENT BENEFITS ELIGIBILITY

Dependent Type Eligibility Requirement Plan Coverage Documentation Requirement

Spouse Husband or wife of a covered employee • Medical • Dental • Vision

• Supplemental Life Insurance

• State issued marriage certificate

• Federal tax return issued within last 2 years

Same-Sex Spouse Same gender husband or wife of a covered employee • Medical • Dental • Vision

• State issued marriage certificate from a jurisdiction that permits such marriages

• Federal tax return issued for most recent tax year

Same-Sex Domestic

Partner A person of same gender who meets the following criteria:_{• Shares a residence with an eligible employee for at}

least 6 months • At least 18 years of age

• Is not related to the employee by blood to a degree of closeness that would prohibit legal marriage • Listed as Domestic Partner on the most recent

notarized CSU Affidavit of Domestic Partnership • Is not in relationship solely for the purpose of obtaining

benefit coverage

• Is not married or separated from any other person

• Medical • Dental • Vision

• Notarized Affidavit of Domestic Partnership • Two proofs of joint ownership

or joint residency issued within last 6 months

(3)

3 Experience a Qualified Change in Status? Contact Human Resources

When a life-changing event occurs, you can make a mid-year benefit enrollment change to your current coverage without waiting for the annual open enrollment period. CSU permits a change in your benefit enrollment when you experience a qualified change in status event. You must notify Human Resources within 31 days of the event to make a change to your coverage. For more information, see Frequently Requested Enrollment Information on the Human Resources website of myCSU. Generally, the following change in status events qualify to make a mid-year enrollment change:

marriage or divorce • birth or adoption of a child • death of a dependent • change in spouse’s employment status resulting in loss of coverage or

acquiring new coverage • loss of dependent child’s eligibility for coverage • change in circumstance for Adult Dependent Child for HB1 coverage

Effective July 1, 2015: Obtaining coverage through the ACA Health Insurance Marketplace qualifies as a mid-year change in status permitting you to make a change to your CSU medical coverage outside of CSU’s annual open enrollment time period.

Dependent Type Eligibility Requirement Plan Coverage Documentation Requirement Dependent Child _{Child related to a covered employee up to age 26}

including:

• Biological child • Adopted child • Step child • Legal ward

• Child of which employee or spouse of employee is legal guardian

• Child(ren) may be married, do not have

to reside with parents, or be financially dependent upon them, and may be eligible to enroll in their employers plan.

• Medical • Dental • Vision • Supplemental

Life Insurance (to age 26)

• State issued birth certificate • Adoption certificate • Court ordered document of

legal custody

Adult Dependent Child (Coverage beyond age limit of Federal Health Reform Coverage)

State of Ohio House Bill 1 (HB1) Legislation (age 26 to 28):

• Biological, adopted or step child; and • Unmarried; and

• Resident of the State of Ohio or full-time student outside State of Ohio at an accredited public or private institution of higher education; and

• Not eligible for health care coverage under his/her employer’s health benefit plans; and • Not eligible for coverage under Medicare

or Medicaid

• Medical coverage only

The following forms (based on parent’s enrollment) must be submitted to Human Resources before enrollment is processed:

• HealthSpan HMO (formerly

Kaiser) 1_{HB1 Attestation Form}

• Medical Mutual of Ohio

Traditional Plan, Value Plan or MetroHealth Select Plan

1_{Adult Dependent Child HB1}

Certification Form

1_{Forms are located at http://mycsu.csuohio.edu/} offices/hrd/benefits.html

Dependent Child and Adult Dependent Child (Same-Sex Domestic Partner)

Domestic Partner Child to age 26 with relationship to a covered employee: • The child of the employee’s covered

Same-Sex Domestic Partner: – Biological, adopted or legal ward

• Medical • Dental • Vision • Supplemental

Life Insurance (to age 26)

• Required documentation for Same-Sex Domestic Partnership

(4)

4 HELPFUL DEFINITIONS

The following are a few definitions which may be helpful when making your health plan choice. More definitions are located in the health plan provider’s certificate of coverage.

Co-Insurance – The percentage of a health care provider’s fee that is paid after the annual calendar-year deductible is taken. For example, the MMO Value Plan pays 80% of an in-network covered expense after the calendar-year deductible is met. You pay 20%.

Co-Payment – The fixed dollar amount you pay each time you receive specific services, supplies or prescriptions. For example, the MMO Traditional Plan requires $20 co-payment each time you have an office visit with an in-network health care provider. The co-payment is not applied to the deductible.

Deductible – The specified amount of covered medical expenses you pay for yourself and/or covered dependents each calendar year before any additional covered medical expenses are paid by the Plan. (For example, the MMO Traditional Plan expenses for covered outpatient surgical procedures are covered in full at 90% after you pay the $250 annual deductible).

Maximum Annual Co-Insurance Limit – The maximum amount you pay in co-insurance for covered expenses in a calendar year before the Plan pays 100% (this excludes amounts that are paid towards co-payments and deductibles).

Maximum Out-of-Pocket Limit (MOOP) – The most you pay during a calendar year before your health plan starts to pay 100% for covered essential health benefits. This new limit is a result of the Affordable Care Act and includes deductibles, co-insurance, co-payments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. For calendar year 2015, the maximum pocket cost limit for a health plan can be no more than $6,600 for an individual plan and $13,200 for a family plan. Also for 2015, the maximum out-of-pocket expense for prescription drug benefit will be accounted for within these limits.

Allowable Charges (for MMO administered plans) – Changes allowed by a health plan for physicians and other professional services limited to the lesser amount of billed charges or the traditional amount. For non-contracting providers, the maximum amount determined as payable and allowed by a health plan for a covered service. Non-contracting providers may bill participants the difference between the allowed charges by a health plan and their billed charges (balance billing).

Covered Services – A medically necessary service or supply for which the benefit plan will reimburse expenses according to the plan’s limits.

Formulary Brand Name Prescription Drug – A listing of preferred prescription drugs provided by a medical plan that provides a discounted cost to participants. The tiered formulary provides financial incentives for participants to select lower-cost drugs.

Brand Name Prescription Drug – A prescription drug that has been patented with the brand name and is produced by the original manufacturer under that brand name.

Generic Prescription Drug – A prescription drug that is produced by more than one manufacturer. It is chemically the same as, and usually costs less than, the brand name prescription drug for which it is being substituted and will produce comparable effective clinical results.

Exclusive Provider Organization (EPO) – A type of managed health care organization in which no coverage is typically provided for services received outside the EPO’s network.

Preferred Provider Organization (PPO) – A type of health plan that provides participants with reduced costs when utilizing services within a network of health providers. This plan also provides covered services outside a network but may result in more out-of-pocket costs to participants. Medical Mutual Traditional and Value Plans are PPO Point of Service plans.

Point of Service (POS) – A feature within a health plan that permits participants to choose an in-network physician for specialty services without a referral from a primary care physician. (MMO PPO plans are POS plans).

Tier – Terminology used by Medical Mutual to identify the provider network used by a participant.

(5)

5 FEDERAL HEALTH CARE REFORM

Federal Health Care Reform —

Also Known as The Affordable Care Act (ACA) of 2010

How is Health Care Reform affecting CSU’s employee health benefits?

As you may know, CSU has implemented many of the provisions of the Affordable Care Act of 2010 as these changes were scheduled to be made. Some significant changes to date include: increasing the age for covered dependents under medical to age 26; covering eligible preventive care at 100% with no cost sharing; eliminating plan lifetime maximums.

Changes for July 1, 2015

• CSU medical plans must accumulate the amounts you pay out-of-pocket for deductible, flat-dollar co-payments, and co-insurance (% of charges) and apply that total to the maximum out-of-pocket (MOOP) limit. Once you reach the MOOP limit, the plan will pay at 100% for covered services for the remainder of the calendar year. This new limit is somewhat different than the existing “Maximum Annual Co-insurance Limit” which included co-insurance amounts paid, but not deductible or flat-dollar co-payments. The MOOP accumulator will now include prescription drug expenses for the 2015-2016 plan year.

• CSU will be providing a Summary of Benefits and Coverage (SBC) for each of the CSU medical plans. These SBCs are intended to aid in plan comparison. • The Individual Coverage Mandate went into effect on January 1, 2014. This rule requires many people to enroll in health coverage or pay a penalty for not having coverage. If you do not have health insurance, this may be the time for you to consider enrolling in coverage. CSU’s Open Enrollment period is your once-a-year chance to enroll in CSU medical benefits unless you have a qualified status change.

• You can generally buy insurance from the Health Insurance Marketplace only during its annual open enrollment period. The next open enrollment period for the Marketplace begins on November 1, 2015 and ends on January 31, 2016. To buy Marketplace insurance outside of open enrollment, you must qualify for a special enrollment period due to a qualifying event such as marriage, divorce, birth or adoption of a child, or loss of a job. If you work over 30 hours per week and are eligible for CSU benefits, you will not be eligible for a federal subsidy to offset the cost, since CSU’s offered coverage is both affordable and provides coverage of sufficient value.

State of Ohio House Bill 1 (HB1) Legislation

The State of Ohio enacted House Bill 1 allows employees the opportunity to purchase health care coverage for unmarried children ages 26 to 28. Employees are permitted to enroll adult dependent children under their family health coverage. However, employees are required to pay a family premium plus an additional premium cost for the adult child’s coverage. Below are coverage provisions of HB1 legislation and guidelines for an adult dependent child who is no longer eligible for coverage under Federal Health Reform legislation.

1. Health care coverage is contingent upon the adult dependent child meeting the following criteria: • Has not reached the age of 28 (i.e. 28th birthday); and

• Is the employee’s biological child, step child or adopted child; and • Is not married; and

• Is a resident of the State of Ohio or a full-time student at an accredited public or private institution of higher education outside the State of Ohio; and • Is not employed by an employer that offers any health benefit plan under which the child is eligible for coverage; and

• Is not eligible for coverage under Medicaid or Medicare.

2. If an adult dependent child meets the HB1 coverage criteria, the employee must enroll the dependent under his/her coverage and submit required documentation before the enrollment is processed. Refer to Dependent Eligibility Guidelines section of this booklet.

3. Eligibility for HB1 adult dependent coverage does not require: • the child live with a parent;

• be financially dependent upon the parent; or • be a student

4. A premium is paid for adult dependent children in addition to the parent’s family premium and is withheld through payroll deduction. The HB1 coverage premium is deducted on an after-tax basis. Monthly HB1 health plan premiums:

Medical Mutual Traditional: $243.36/month Medical Mutual Value: $206.86/month MetroHealth Select: $190.58/month

HealthSpan (formerly Kaiser): $188.98/month

(6)

6 CSU MEDICAL PLAN CHOICES

CSU’s plan year for enrollment in all medical plan choices (Medical, Dental, Vision, Flexible Spending Accounts Plan) is July 1 – June 30. For the purposes of out-of pocket limitations and benefits provided, the benefit year is a calendar year (January 1 – December 31).

You have five medical plan choices for the July 1, 2015 – June 30, 2016 plan year: 1. HealthSpan (formerly Kaiser Permanente) Health Maintenance Organization (HMO) 2. Medical Mutual (MMO) Traditional Preferred Provider Organization (PPO)

3. Medical Mutual (MMO) Value Preferred Provider Organization (PPO) 4. MetroHealth Select Exclusive Provider Organization (EPO) 5. Taxable Cash

The option which is best for you depends on your family circumstances, your choice of providers, premiums and the expenses you may need to assume if you or a family member needs medical care. Refer to the Medical Plan Comparison Chart on page 8 for a summary of the CSU medical plan options. Enrollment in any of the options requires the submission of your enrollment through the myBenefits online enrollment application within 31 days of your hire date or a qualifying change in status. After your enrollment is processed, the effective date of coverage will be your hire date.

HealthSpan HMO

HealthSpan is a Health Maintenance Organization (HMO). An HMO only pays for benefits when members use HMO network doctors and hospitals. You must select a primary care physician; otherwise a physician will be selected for you and your family. If participants receive care outside of the network, the HMO pays no benefits, except in a medical emergency and within plan limits.

The HealthSpan HMO plan covers a wide range of comprehensive medical benefits and services at 90%, including urgent care, after a $35 co-payment. Emergency room services require a $100 co-payment per visit, which is waived upon hospital admission. A summary of the plan is provided on the chart on pages 8-9 of this booklet.

HealthSpan HMO Prescription Drug Coverage

Generic and brand name prescription drugs are available from HealthSpan pharmacies after a co-payment is paid, $10 Generic/$25 Brand. A 62-day supply of prescription medication is available from HealthSpan’s mail order pharmacy for the same co-payments. Beginning January 2015, HealthSpan will offer access to 65,000 pharmacies nationwide in addition to HealthSpan’s local pharmacies. Contact HealthSpan for listing of national network pharmacies.

Medical Mutual of Ohio—SuperMed Plus PPO Plans

The University offers two Medical Mutual of Ohio (MMO) SuperMed Plus plans — Traditional or Value. Both plans are Preferred Provider Organizations (PPOs), and cover a wide range of inpatient and outpatient services, including wellness care. The MMO plans give you the option of seeking care within the Medical Mutual Network of physicians and facilities or using non-network providers. When you use network providers, benefits are paid at a higher coverage level. Both plans require co-payments for office visits. Certain services are subject to an annual deductible. Preventive care services are not subject to an annual deductible.

The major differences between the Traditional and Value plans are the contributions, co-payments, deductibles and co-insurance. For example: if you select the Value Plan, you pay lower contributions. However, your annual deductible, your share of the cost for medical services and prescriptions under the Value Plan are higher than if you were enrolled in the Traditional Plan. A comparison of the plans is located on the chart on pages 8-9. All services under both plans are subject to medical necessity.

MMO Prescription Drug Coverage

Both the Traditional and Value plans include a three-tier retail and mail order prescription drug plan, a formulary (preferred drug list), and a mail order incentive for maintenance medications, through Express Scripts. A maintenance medication is a prescription drug that you take regularly to manage a chronic health condition (e.g., high blood pressure or diabetes).

(7)

7

Co-payments for each of the Medical Mutual plans are summarized in the chart on page 8 of this booklet. Note that co-payments for maintenance medications dispensed at a retail pharmacy are the same as non-maintenance medications the first time dispensed up to three refills. After the third fill of a maintenance medication at a retail pharmacy, the co-payment will increase to the mail order copayment amount. By using mail order for maintenance medications, you will save money.

MetroHealth Select

MetroHealth Select EPO (Exclusive Provider Organization) is CSU’s new low cost health care plan administered by Medical Mutual of Ohio (MMO). Enrollment in this plan requires ALL health care services to be rendered within the MetroHealth Network. The plan offers 17 convenient health centers throughout Cuyahoga County. In addition, it provides access to an independent multi-specialty practice with locations across the county. You can only use physicians and facilities outside the MetroHealth network (including outside the state of Ohio) in the case of an emergency. Certain covered services that are not available from MetroHealth network physicians and facilities may be available through MMO’s Preferred Provider Organization (PPO) Network.

To schedule an appointment or locate physicians/network facilities, call MetroHealth concierge service at (216) 778-8818. Questions related to MetroHealth Select plan coverage, pre-authorization of services within Medical Mutual PPO network, or to obtain an ID card(s), call Customer Service at Medical Mutual

Taxable Cash Medical Coverage Waiver

The taxable cash option provides you with the ability to waive medical coverage and receive an annual taxable cash payment. To receive taxable cash you must enroll in the Taxable Cash Plan in the myBenefits online application and provide proof of other medical coverage in order to be eligible for a payment at the end of the plan year. Generally, the payment is made the first paycheck in June. If you are currently enrolled in the taxable cash option, you do not need to re-enroll in the Taxable Cash Option or re-submit proof of coverage. In the event of a status change outside of the open enrollment period, taxable cash payments are prorated.

Annual Taxable Cash Payments

Full-time Faculty and Staff Up to $1,200

Part-time Staff 30-39 Hours Up to $900

Free On-Campus Health Care

Got a sore throat or think you have the flu?

Need a blood draw, some lab work, a flu shot or other vaccination?

Need an antibiotic prescription or a prescription for an over-the-counter allergy medication so you can be reimbursed by your Flex Spending Account?

The convenience of FREE on-campus health care for Faculty and Staff is now available at CSU Health & Wellness Services. CSU has made arrangements with Medical Mutual so that Faculty and Staff enrolled in the MMO Traditional, Value and the MetroHealth Select plans can receive routine office visit care at no out-of-pocket cost from the CSU Health & Wellness Services medical staff. The medical staff is included in the MMO and MetroHealth networks as a Tier 1 provider.

• No deductible or co-payment is required for care or services received from CSU Health & Wellness Services clinical staff. • Many generic prescription medications are available for a $5 co-pay.

• You will be referred to another Medical Mutual or MetroHealth provider for treatment or care that cannot be provided by CSU Health & Wellness Services. • Dependents of Faculty and Staff are NOT eligible for care from CSU Health & Wellness Services.

• Visits by appointment only - same day appointments are available.

The on-campus clinic is located in the Union Building (UN), Room 264. Call (216) 687.3649.

CSU Health & Wellness Services is nationally accredited by AAAHC (Accreditation Association for Ambulatory Health Care).

CSU HEALTH AND WELLNESS SERVICES

(AN ON-CAMPUS CLINIC)

Get Well. Stay Well. Live Well.

Vike

Health

Well-Being

&

Limited screenings & immunizations available

CSU MEDICAL PLAN CHOICES

(8)

MEDICAL PLAN COMPARISON CHART JULY 1, 2015 - JUNE 30, 2016

(The comparison chart has been updated throughout to reflect

YOUR

cost share for covered services)

MEDICAL PLAN COMPARISON CHART July 1, 2015 -‐ June 30, 2016

The comparison chart has been updated to reflect your cost share for covered services

Plan Name MMO4_Traditional _MMO4_Traditional _MMO4_Value _MMO4_Value _{CSU Health & Wellness} _{MetroHealth Select} _HealthSpan

PPO In-‐Network Out-‐of-‐Network PPO In-‐Network Out-‐of-‐Network Services (Faculty & Staff only) EPO In-‐Network HMO In-‐Network MMO Tier Tier 2 Tier 3 Tier 2 Tier 3 Tier 1 (formerly Kaiser) Monthly Employee Pre-‐Tax

Payroll Contributions1

Full-‐time Faculty/Staff Single $120.54 Single $76.84 n/a Single $23.60 Single $70.20

Family $314.34 Family $200.54 n/a Family $61.70 Family $187.68

Part-‐time Staff Single $150.68 Single $128.08 Single $118.00 Single $117.00

(30-‐39 hours) Family $392.94 Family $334.24 Family $308.50 Family $312.78

1_{Note: IRS rules require that the value of any benefits provided to a same-‐sex domestic partner is taxable to the employee.}

Benefit Period

(A) Annual Deductible (Calendar Year) $250 / Single $750 / Single $750/ Single $1,500/Single No Deductible No Deductible No Deductible

$500 / Family $1,500 / Family $1,500/Family $3,000/Family

(Covered preventive care services are NOT subject to deductible)

(B)

Co-‐Insurance Maximum

(excludes co-‐payments and deductible except for

HealthSpan) $750 / Single $2,250 / Single $2,250 / Single $4,500 / Single Not Applicable Not Applicable $1,000 / Single

$1,500 / Family $4,500 / Family $4,500 / Family $9,000 / Family $2,000 / Family

(D)

Maximum Out-‐of-‐Pocket

(includes in-‐network co-‐ payments, co-‐insurance and deductible except for HealthSpan)

(C) Physician Office Visit $20 co-‐payment 30%2 after deductible $30 co-‐payment 40%2 after deductible No Cost $10 co-‐payment $25 co-‐payment

(C) Routine, Preventive & Wellness Services No Cost3 _30%2 _{No Cost}3 _40%2 _{Limited services at no cost} _{No Cost}3 _{No Cost}

(B) Laboratory & Diagnostic Services 10% after deductible 30%2 after deductible 20% after deductible 40%2 after deductible Limited services at no cost No Cost 10%

(C) Convenience Care Clinic $20 co-‐payment 30%2 after deductible $30 co-‐payment 40%2 after deductible Services Not Available Services Not Available Services Not Available

(C) Urgent Care Office Visit $35 co-‐payment 30%2 after deductible $50 co-‐payment 40%2 after deductible Limited services at no cost $10 co-‐payment in-‐network only $35 co-‐payment

(B) Inpatient Medical & Surgical Hospital Services 10% after deductible 30%2 after deductible 20% after deductible 40%2 after deductible Services Not Available No Cost 10%

(B)

Outpatient Medical, Surgical &

Hospital Services 10% after deductible 30%2 after deductible 20% after deductible 40%2 after deductible Limited services at no cost No Cost 10%

(B)(C) Institutional Charge for use ofEmergency Room:

Emergency payment (co-‐payment 10% after $100 co-‐ waived if admitted)

10%2_{after $100 co-‐} payment (co-‐ payment waived if

admitted)

20% after $150 co-‐ payment (co-‐payment

waived if admitted)

20%2_{after $150 co-‐payment} (co-‐payment waived if

admitted)

Services Not Available

No Cost after $75 co-‐ payment including out-‐ of-‐network (co-‐payment

waived if admitted)

No Cost after $100 co-‐ payment (co-‐payment waived if admitted)

Non-‐Emergency

10% after $100 co-‐ payment (co-‐

payment waived if admitted)

30%2_{after $100 co-‐} payment (co-‐payment waived

if admitted)

20% after $150 co-‐ payment (co-‐

admitted)

No Cost after $75 co-‐ payment in-‐network only (co-‐payment waived if admitted)

Same as Urgent Care

(B)(C) Emergency Room Physician Charges/ Services:

Emergency 10% _10%2 _20% _20%2 _{Services Not Available} No Cost including out of

network services No Cost

Non-‐Emergency _{10% after deductible 30%}2_{after deductible 20% after deductible} _40%2_{after deductible} _{Services Not Available} No Cost in-‐network

services only Same as Urgent Care

Denotes services may be eligible for VikeHealth & Well-‐being points.

In-‐Network Only In-‐Network Only In-‐Network Only In-‐Network Only

Medical and Prescription Drugs

Deductibles (A) + Co-‐Insurance (B) + Co-‐Payments (C) = Maximum Out-‐of-‐Pocket (D) MMO Traditional

Single $250 $750 $5,600 $6,600

Family $500 $1,500 $11,200 $13,200

MMO Value

Single $750 $2,250 $3,600 $6,600

Family $1,500 $4,500 $7,200 $13,200

MetroHealth

Single $0 $0 $6,600 $6,600

Family $0 $0 $13,200 $13,200

HealthSpan

Single $1,000

Family $2,000

If you are enrolled in MMO or MetroHealth plans, you can receive certain health services at no cost at CSU Health & Wellness Services as described

below

Information contained in this booklet is in summary form. Certain benefits, limitations or exceptions may not be described in detail. If there are any discrepancies between the information presented and the actual plan documents, the plan documents will govern.

HealthSpan's maximum out-‐of-‐pocket is the same as the co-‐insurance maximum (includes co-‐insurance and co-‐payments)

Calendar Year (January 1 -‐ December 31)

Your Share of Costs

4_{Pre-‐authorization by MMO may be required for some services (e.g. surgical procedures, diagnostic tests, MRIs and scans) for which you are financially responsible. Refer to your}

2015-‐16 Maximum Out-‐of-‐Pocket $6,600 Single / $13,200 Family (D) =

In-‐network Deductibles (A) + In-‐network Co-‐insurance (B) + In-‐network Medical & Prescription Drug Co-‐payments (C) (Refer to illustration below)

Example: Maximum Out-‐of-‐Pocket (Applies to In-‐Network Employee Cost Share only)

JULY 1, 2015: To comply with Health Care Reform requirements, medical expenses including prescription drugs will be accumulated toward the new maximum out-‐of-‐pocket limit. Here is an illustration of the new limit:

3_{Evidence-‐based items or services that have a rating of (A) or (B) in effect in the current recommendation of the United States Preventive Services Task Force.}

$6,600 Single / $13,200 Family

2_{Allowed charges for non-‐network physicians or other professional providers are limited to the lesser of billed charges or the traditional amount. For non-‐contracting institutional}

providers, the non-‐contracting amount applies; non-‐contracting providers can balance bill.

Vike

Health

Well-Being

&

(9)

9

MEDICAL PLAN COMPARISON CHART July 1, 2015 -‐ June 30, 2016

The comparison chart has been updated to reflect your cost share for covered services

Plan Name MMO4_Traditional _MMO4_Traditional _MMO4_Value _MMO4_Value _{CSU Health & Wellness} _{MetroHealth Select} _HealthSpan

PPO In-‐Network Out-‐of-‐Network PPO In-‐Network Out-‐of-‐Network Services (Faculty & Staff only) EPO In-‐Network HMO In-‐Network MMO Tier Tier 2 Tier 3 Tier 2 Tier 3 Tier 1 (formerly Kaiser) Monthly Employee Pre-‐Tax

Payroll Contributions1

Full-‐time Faculty/Staff Single $120.54 Single $76.84 n/a Single $23.60 Single $70.20

Family $314.34 Family $200.54 n/a Family $61.70 Family $187.68

Part-‐time Staff Single $150.68 Single $128.08 Single $118.00 Single $117.00

(30-‐39 hours) Family $392.94 Family $334.24 Family $308.50 Family $312.78

1_{Note: IRS rules require that the value of any benefits provided to a same-‐sex domestic partner is taxable to the employee.}

Benefit Period

(A) Annual Deductible (Calendar Year) $250 / Single $750 / Single $750/ Single $1,500/Single No Deductible No Deductible No Deductible

$500 / Family $1,500 / Family $1,500/Family $3,000/Family

(Covered preventive care services are NOT subject to deductible)

(B)

Co-‐Insurance Maximum

(excludes co-‐payments and deductible except for

HealthSpan) $750 / Single $2,250 / Single $2,250 / Single $4,500 / Single Not Applicable Not Applicable $1,000 / Single

$1,500 / Family $4,500 / Family $4,500 / Family $9,000 / Family $2,000 / Family

(D)

Maximum Out-‐of-‐Pocket

(includes in-‐network co-‐ payments, co-‐insurance and deductible except for HealthSpan)

(C) Physician Office Visit $20 co-‐payment 30%2 after deductible $30 co-‐payment 40%2 after deductible No Cost $10 co-‐payment $25 co-‐payment

(C) Routine, Preventive & Wellness Services No Cost3 _30%2 _{No Cost}3 _40%2 _{Limited services at no cost} _{No Cost}3 _{No Cost}

(B) Laboratory & DiagnosticServices 10% after deductible 30%2 after deductible 20% after deductible 40%2 after deductible Limited services at no cost No Cost 10%

(C) Convenience Care Clinic $20 co-‐payment 30%2 after deductible $30 co-‐payment 40%2 after deductible Services Not Available Services Not Available Services Not Available

(C) Urgent Care Office Visit $35 co-‐payment 30%2 after deductible $50 co-‐payment 40%2 after deductible Limited services at no cost $10 co-‐payment in-‐network only $35 co-‐payment

(B) Inpatient Medical & Surgical Hospital Services 10% after deductible 30%2 after deductible 20% after deductible 40%2 after deductible Services Not Available No Cost 10%

(B)

Outpatient Medical, Surgical &

Hospital Services 10% after deductible 30%2 after deductible 20% after deductible 40%2 after deductible Limited services at no cost No Cost 10%

(B)(C) Institutional Charge for use of Emergency Room:

Emergency payment (co-‐payment 10% after $100 co-‐ waived if admitted)

10%2_{after $100 co-‐} payment (co-‐ payment waived if

admitted)

20% after $150 co-‐ payment (co-‐payment

waived if admitted)

admitted)

No Cost after $75 co-‐ payment including out-‐ of-‐network (co-‐payment

waived if admitted)

No Cost after $100 co-‐ payment (co-‐payment waived if admitted)

Non-‐Emergency

10% after $100 co-‐

payment (co-‐

30%2_{after $100 co-‐} payment (co-‐payment waived

if admitted)

20% after $150 co-‐

payment (co-‐

admitted)

No Cost after $75 co-‐ payment in-‐network only (co-‐payment waived if admitted)

Same as Urgent Care

(B)(C) Emergency Room Physician Charges/ Services:

Emergency 10% _10%2 _20% _20%2 _{Services Not Available} No Cost including out of

network services No Cost

Non-‐Emergency 10% after deductible 30%2_{after deductible 20% after deductible} _40%2_{after deductible} _{Services Not Available} No Cost in-‐network

services only Same as Urgent Care

Denotes services may be eligible for VikeHealth & Well-‐being points.

In-‐Network Only In-‐Network Only In-‐Network Only In-‐Network Only

Medical and Prescription Drugs

Deductibles (A) + Co-‐Insurance (B) + Co-‐Payments (C) = Maximum Out-‐of-‐Pocket (D) MMO Traditional

Single $250 $750 $5,600 $6,600

Family $500 $1,500 $11,200 $13,200

MMO Value

Single $750 $2,250 $3,600 $6,600

Family $1,500 $4,500 $7,200 $13,200

MetroHealth

Single $0 $0 $6,600 $6,600

Family $0 $0 $13,200 $13,200

HealthSpan

Single $1,000

Family $2,000

If you are enrolled in MMO or MetroHealth plans, you can receive certain health services at no cost at CSU Health & Wellness Services as described

below

Information contained in this booklet is in summary form. Certain benefits, limitations or exceptions may not be described in detail. If there are any discrepancies between the information presented and the actual plan documents, the plan documents will govern.

HealthSpan's maximum out-‐of-‐pocket is the same as the co-‐insurance maximum (includes co-‐insurance and co-‐payments)

Calendar Year (January 1 -‐ December 31)

Your Share of Costs

4_{Pre-‐authorization by MMO may be required for some services (e.g. surgical procedures, diagnostic tests, MRIs and scans) for which you are financially responsible. Refer to your}

2015-‐16 Maximum Out-‐of-‐Pocket $6,600 Single / $13,200 Family (D) =

In-‐network Deductibles (A) + In-‐network Co-‐insurance (B) + In-‐network Medical & Prescription Drug Co-‐payments (C) (Refer to illustration below)

Example: Maximum Out-‐of-‐Pocket (Applies to In-‐Network Employee Cost Share only)

JULY 1, 2015: To comply with Health Care Reform requirements, medical expenses including prescription drugs will be accumulated toward the new maximum out-‐of-‐pocket limit. Here is an illustration of the new limit:

3_{Evidence-‐based items or services that have a rating of (A) or (B) in effect in the current recommendation of the United States Preventive Services Task Force.}

$6,600 Single / $13,200 Family

2_{Allowed charges for non-‐network physicians or other professional providers are limited to the lesser of billed charges or the traditional amount. For non-‐contracting institutional}

providers, the non-‐contracting amount applies; non-‐contracting providers can balance bill.

Vike

Health

Well-Being

&

(10)

10 PRESCRIPTION DRUG COST SHARE PLAN

COMPARISON CHART

₂₀₁₅

-

₂₀₁₆

MMO Traditional PPO Express Scripts Network Pharmacy Tier 2 MMO Traditional Out-of-Network Tier 3 MMO Value PPO Express Scripts Network Pharmacy Tier 2 MMO Value Out-of-Network Tier 3 CSU Health and Wellness Services Tier 1 MetroHealth Select EPO Network (Administered

by MMO)2

HealthSpan (formerly Kaiser) HMO Network Pharmacy Non-Maintenance Retail Pharmacy Prescription Drugs (30-day Supply) • Mandatory Generic Rx dispensed

Generic $5

Brand:

formulary $20

Brand:

Non-formulary $40 Mandatory Mail

Order co-payment for maintenance medications doubles after three fills at a retail pharmacy

75% UCR3

Claim form required for reimbursement

Generic $10

Brand:

formulary $30 Brand:

Non-formulary $60 Mandatory Mail

Order co-payment for maintenance medications doubles after three fills at a retail pharmacy

75% UCR3

Claim form required for reimbursement Generally $5 Limited prescriptions available

Metro1_MM02 Generic $0 $10 Brand:

formulary $15 $30 Brand:

Non-formulary $30 $60

Generic $10

Brand $25

Pharmacy

Mail Order Generic $10

Brand:

formulary $40

Brand:

Non-formulary $80 (90-day supply)

N/A

Generic $20

Brand:

formulary $60

Brand:

Non-formulary $120 (90-day supply)

N/A

Service not

available Metro

1_MM02 Generic $10 $20 Brand:

formulary $30 $60 Brand:

Non-formulary $60 $120 (90-day supply)

Generic $10

Brand $25

(62-day supply)

1 _{MetroHealth Select Plan members pay lower co-pays when using MetroHealth pharmacies. Use an on-site MetroHealth pharmacy for a 30-day supply of any medication, or a} 90-day supply of maintenance medications. You may also use the MetroHealth Mail Order service for a 90-day supply of maintenance medications.

2 _{MMO/Express Scripts network pharmacies (non-Metro Pharmacy)}

3_{MMO out-of-network reimbursements are subject to allowable charges. Refer to your plan certificate for details.}

(11)

11 DENTAL PLAN

Cleveland State University’s Dental Coverage is Provided by Delta Dental of Ohio

With Delta Dental, you can visit any provider you choose; however, the highest benefit coverage and the lowest out-of-pocket costs will be through a Delta Dental participating provider. It is highly likely that your current dentist is already in the Delta Dental network. Services provided by a non-participating dentist are subject to a $50 deductible per person, per year.

You can check for participating dentists by visiting Delta Dental’s website at deltadentaloh.com and selecting Delta Dental Premier or by calling Delta Dental’s Customer Service Center toll free at (800) 524-0149. Customer Service representatives are available Monday through Friday from 8:30 a.m. until 8:00 p.m. (Eastern Time) to assist you.

If you are currently in treatment, then multiple-step services such as crowns, bridges, and dentures which are completed after the effective date of coverage should be billed to Delta Dental. Please have your dentist submit them to Delta Dental of Ohio for payment.

Payment for orthodontic treatment in progress begins the month coverage begins. Delta Dental will continue the payment obligation and ask the treating dentist to submit a new claim for payment.

Full-Time Faculty / Staff

Single: $2.86

(was $3.38)

Single Plus 1: $5.58

(was $6.62)

Family: $9.66

(was $10.14)

Part-Time Staff 30-39 Hours

Single: $7.14

(was $8.44)

Single Plus 1: $13.94

(was $16.56)

Family: $24.12

(was $25.34)

Delta Dental Participating Dentist

$1500 annual max per person Plan Pays

Nonparticipating Dentist

$1200 annual max per person Plan Pays*

DIAGNOSTIC AND PREVENTIVE

Diagnostic and Preventive Services – exams, cleanings, fluoride, sealants, x-rays, and space maintainers

100%* 100% BASIC SERVICES

Restorative Services – fillings and crowns 80% 80%

Endodontic Services – root canals 80% 80%

Periodontic Services – to treat gum disease 80% 80%

Oral Surgery Services – extractions and dental surgery 80% 80% MAJOR SERVICES

Prosthodontic Services – bridges, dentures, and implants 60% 60% ORTHODONTIC SERVICES

Orthodontic Services – braces; No Age Limit, $1200 lifetime maximum per person

60% 60%

* When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental’s Nonparticipating Dentist Fee that will be paid for those services. The Nonparticipating Dentist Fee may be less than what your dentist charges and you are responsible for that difference.

NEW ENHANCED DENTAL PLAN

BRUSH BIOPSY – for early detection of oral cancer

EVIDENCE BASED DENTISTRY - includes additional cleanings for at risk individuals

POSTERIOR COMPOSITE RESIN COVERAGE - Coverage for white filings on molars

(12)

12 VISION PLANS

Cleveland State University’s Vision Coverage is Provided by Vision Service Plan (VSP)

You have two Vision plan options from which to choose – the “Basic” plan and the “Enhanced”(Opt-up) Vision plan. Both plans are preferred provider

organizations (PPOs). VSP covered services are provided on an open access basis (in-network or out-of-network) for eye care examinations, frames and eye-glass or contact lenses.

The Basic Vision Plan provides covered services once in a 24-month period from the date of last service.

You may choose to enroll in the “Enhanced” (Opt-up) plan. This plan provides covered services once in a 12-month period from the date of last service.* .

Employee Monthly Vision Pre-Tax Premiums

Effective July 1, 2015

Basic Vision Plan Enhanced (Opt-up) Vision Plan Full-Time Faculty/Staff No premium contributions Single $5.98

Family $17.06

Part-Time Staff — 30-39 hours Single $.94

Family $2.70

Single $6.92 Family $19.76

Frequency of Coverage 24 months from date of last service 12 months from date of last service

Vision Summary of Benefits

In-Network

Open Access (Out-of-Network)

Vision Exam 100% after $15 Co-pay Up to $45 after $15 Co-pay

Prescription Glasses $25 Co-pay $25 Co-pay

Lenses** Single Vision, lined bi-focal, and trifocal lenses 100% Polycarbonate lenses for dependent children

Single Vision up to $30 Bifocal up to $50 Trifocal up to $65 Lenticular $100

Lens Options** _{Progressive: Covered in Full}Blended: Covered in Full _{Progressive: Up to $50}Blended: Up to $40

Frames Covered up to plan

allowance of $150 Up to $70

Contact Lenses

Up to $150, if elective; 100% covered if visually necessary * *VSP requires proof of visual necessity.

If elective, up to $105; If visually necessary, up to $210* *VSP requires proof of visual necessity.

Claims No claim form required Must file claim for reimbursement within _{6 months from date of service.}

* The Enhanced Plan also includes enhanced coverage for lenses for eyeglasses, including coverage for tints and photochromic or “transition” lenses.

** See VSP summary of coverage handout for coverage specifics and limitations for lenses.

Log in to your VSP account at www.vsp.com to:

• Choose a VSP network doctor • Print an ID card

• View your personal eyecare coverage • Find the latest eye health information

(13)

13 FLEXIBLE SPENDING PLAN

Cleveland State University’s Flexible Spending Account Plan is Administered by FlexSave

The Flexible Spending Account Plan (FSA) offers two types of accounts which allows you to set aside funds through pre-tax payroll deductions during the plan year for unreimbursed health care and/or dependent day care expenses. Eligible out-of-pocket expenses are defined by the Internal Revenue Service (IRS). You determine how much money you want to contribute for the plan year up to the FSA limits. The amount you select is deducted through payroll and is based on the number of pay periods you have within the CSU plan year (July 1 – June 30). You are reimbursed for eligible expenses from your FSA account as you incur and submit a claim for reimbursement.

FSA Account Limits and Enrollment Rules

CSU offers two types of Flexible Spending Accounts under the plan–Health Care FSA and a Dependent Day Care FSA. The plan year minimum contribution for each account is $24/year. In accordance with Health Care Reform guidelines, the maximum amount for a Health Care Spending Account is $2,550. The Dependent Day Care Account limit is $5,000.

To participate in an FSA, you must make an election during your new hire enrollment period or the annual benefits open enrollment period, unless you have a qualified change in status which allows for a mid-year election change. (Refer to Change in Status Rules on page 3 of this booklet or on the Human Resources web page of myCSU.) Enrollment is required each year during the annual employee open enrollment period to

participate or continue participation in the FSA plan. Note: Contributions to a Dependent Day Care account

may be further limited based on your marital status, how you file your income taxes, and if your spouse works or attends school full-time. You should consult with your tax advisor as to how a FSA Dependent Day Care Account impacts your personal situation.

FSA Plan Use It or Lose It Rule

The Internal Revenue Service (IRS) requires a “Use It or Lose It” rule for FSA accounts. If expenses are not incurred and/or filed for reimbursement within the

allowable time periods, funds remaining in your account are forfeited. You should carefully calculate the amount you contribute to a FSA each plan year. Details of the CSU Flexible Spending Plan are included in your packet and available on the Human Resources web page of myCSU, or contact FlexSave at (800) 525-4252.

FSA Debit Card

A FSA debit card (the Take Care® Visa Card) will be issued to each plan participant. Based on your account balance/election, the debit card will allow you to

immediately pay for eligible FSA expenses where debit cards are accepted. When using your debit card, you should continue to maintain receipts in the event you

are asked by FlexSave to submit receipts for review. Details of the plan are available on the Human Resources benefits web page.

FlexSave Online Account Access

FlexSave offers online access to your flexible spending accounts at www.MyFlexOnline.com. Participants can view their account, validate debit card swipes, order additional cards, repay non-qualified expenses and have internet claims entry. You will establish your own user name and password to access your account.

You must re-enroll

each plan year to

continue participation

in a FSA.

2015-2016 Plan Year Deadlines

Payroll Contributions

FSA elections made during new hire election period will be deducted on a pre-tax basis according to your pay periods remaining through June 30, 2016

or May 15, 2016 for facutly paid over nine months.

Plan year period to incur eligible expenses _{date enrolled in plan(s) through September 15, 2016 (which includes a 60-day grace period).}Participants enrolling for the 2015–2016 plan year must incur expenses from

Claim Filing Deadline

All eligible claims incurred during the plan year period must be filed with FlexSave no later than September 30, 2016. If you separate/retire from the University, you have 60 calendar days from your separation date to file your claims which were incurred prior to your last day of

employment. Refer to claim filing instructions located on the Human Resources benefits web page of myCSU or at the FlexSave website at www.myflexonline.com.

(14)

14 VIKEHEALTH & WELL-BEING PROGRAM

At Cleveland State University, we believe that your health and well-being are important priorities because they help you enjoy a better quality of life at work, at home, and when retired. The fourth year of the VikeHealth & Well-Being Program starts July 1, 2015. The program provides a wide range of wellness resources, services and support intended to help you and our CSU community Get Well, Be Well & Live Well – together! You can significantly improve your ability to enjoy a better quality-of-life by using the support of your colleagues, family members and health resources.

The University offers incentives for your voluntary participation in the VikeHealth & Well-Being Program. We are in the process of implementing a new portal, new incentive structure and exciting new resources to support your health and well-being.

Look for emails and more details to come regarding the launch of our new portal and new offerings. Once ready, employees who are benefits eligible will be able to access the VikeHealth & Well-Being Program from myCSU under “For Faculty and Staff” or at http://vikewellbeing.csuohio.edu.

Important notes: Faculty and Staff must work 20 hours or more, and have a six month or more appointment, to qualify for the VikeHealth & Well-Being Program.

Weight Watchers Monthly Pass Program

As an eligible for the University’s VikeHealth & Well-Being Program, CSU faculty and staff can take advantage of a special 50% subsidy for the Weight Watcher’s Monthly Pass Program. Students, spouses, same-sex domestic partners, retirees and dependents are not eligible for the 50% subsidy. However, they can enroll under the special portal for students, spouses, same-sex domestic partners and retirees for a potential monthly pass discount. Faculty and staff should also inquire with their medical plan provider as to whether additional Weight Watcher benefits are available.

The Monthly Pass Program provides free eTools, weekly meetings, motivation and support. The monthly pass offers you the flexibility of participating on campus, in your community or a combination of both. Weight Watchers meeting attendance earns VikeHealth Points as well as maintains your eligibility for the CSU subsidy.

CSU is a Tobacco Free Campus

Out of respect for the health of others and the environment, Cleveland State University is a tobacco free campus. All forms of tobacco usage is prohibited anywhere on the campus grounds and facilities.

The tobacco free campus policy, FAQ’s about our policy, and tobacco cessation support services to help employees and students quit are available on the University website at www.csuohio.edu/tobaccofree.

Faculty and Staff can earn VikeHealth Points through CSU’s VikeHealth & Well-Being Program for being tobacco free or for completing a tobacco cessation program. For more details, go to the VikeHealth & Well-Being portal on myCSU under “For Faculty and Staff” and click on the “VikeHealth Rewards” page within the program tab of the home page.

Please be aware that employees and spouses/same-sex domestic partners enrolled in CSU’s Supplemental Life Insurance plans pay premiums based on tobacco or non-tobacco usage.

Support services available now to help employees be tobacco free:

Enrolled in the MMO Traditional PPO Plan, Value PPO Plan or the MetroHealth Select EPO Plan

SuperWell QuitLine: (866) 845-7702 (4-week supply of nicotine replacement patches) Hours: Monday through Friday: 9 a.m. to 11 p.m.

Saturday and Sunday: 10 a.m. to 6:30 p.m.

24-hour voicemail is also available. Leave a message and a Quitline coach will return your call. Enrolled in the HealthSpan (formerly Kaiser) HMO

Discuss any concerns regarding tobacco cessation with your HealthSpan PCP at no cost to you after office co-payment. HealthSpan offers certain tobacco cessation benefits at no charge.

IMPACT Solutions Employee Assistance Plan (EAP) and WorkLife Solutions

Call Impact Solutions EAP at (800) 227-6007 for up to five telephonic cessation counseling sessions at no cost to you. Quit Center and other resources are available on Impact’s website at www.myimpactsolution.com. Your member login is csu.

VikeHealth & Well-Being Program

• Free Telephonic Health Coaching through the VikeHealth & Well-Being Program

• While getting the support you need to quit using tobacco, you can also earn VikeHealth points! http://vikewellbeing.csuohio.edu

Vike

Health

Well-Being

&

Tobacco free attestation or cessation programs earn VikeHealth points

(15)

15 LIFE INSURANCE BENEFITS

Cleveland State University’s Life Insurance Plans are Administered by Minnesota Life

Insurance Company

Basic Life & AD&D Insurance

A benefit of two (2) times your base pay up to a maximum $150,000 is provided by the University for Life and Accidental Death & Dismemberment (AD&D) insurance. Basic Life Insurance coverage exceeding $50,000 is subject to imputed income tax. AD&D coverage is not subject to imputed income tax. (Imputed income is explained further in this section.)

Your Basic Life Insurance and Imputed Income

The IRS requires employers to add the premium value of the employer paid Basic Life Insurance coverage in excess of $50,000 to your income for Federal tax purposes each pay period. Accidental Death & Dismemberment (AD&D) and Employee Supplemental life coverage are not subject to imputed income tax.

Consequently, your Federal tax will increase depending on the premium value as determined by an IRS premium rate table, your age at the end of the year and the amount of insurance coverage you have over $50,000.

You can choose to waive the employer provided coverage over $50,000 to avoid the added tax. To obtain a waiver, visit http://mycsu.csuohio.edu/offices/hrd/benefits.html and click on Forms. The effective date for requests to waive Basic Life Insurance coverage over $50,000 is determined by Minnesota Life Insurance Company.

Supplemental Life Insurance

The University offers three Supplemental Life Insurance plans–employee, spouse/ same-sex domestic partner and dependent child life insurance. The maximum supplemental life coverage available for employees is $500,000 and $250,000 for a spouse/same-sex domestic partner. Dependent children are covered at $10,000 for each child. The rate chart on this page reflects the cost of supplemental life insurance for the employee, spouse or same-sex domestic partner based on their age. The spouse’s or same-sex domestic partner’s coverage cannot exceed 100 percent of the employee’s coverage up to Guarantee Issue limits.

If you wish to enroll in the supplemental plans (employee, spouse/same-sex domestic partner, and dependent child) for the first time, you may request coverage within 31-days of new hire date. A request for coverage of any amount after your new hire election period has expired is considered a late application and subject to review by Minnesota Life Insurance Company for Evidence of Insurability.

Evidence of Insurability requires completing and submitting a medical history statement to the insurance company. It is reviewed for a determination of approval or denial. Contact the Department of Human Resources at (216) 687-3636 to request a medical history statement. A form must be submited for each person that coverage is being requested.

Age Non-Tobacco User Tobacco User

< 25 $0.037 $0.075

25-29 $0.037 $0.075

30-34 $0.044 $0.087

35-39 $0.056 $0.112

40-44 $0.081 $0.162

45-49 $0.134 $0.267

50-54 $0.205 $0.409

55-59 $0.380 $0.760

60-64 $0.461 $0.922

65-69 $0.804 $1.607

70-74 $1.302 $2.604

75 and older $1.833 $3.667

Dependent Child Life Insurance: $.050 per month for all covered dependent children.

NOTE: Rates are based on the employee’s and spouse’s/same-sex domestic partner’s age and tobacco user status. Monthly premium amount is divided between the first two paychecks of each month.