2015 BENEFITS
OPEN
ENROLLMENT
GUIDE
Benefits and Health Fair
Thursday, October 16, 2014
9 a.m.–4 p.m.
Ida Noyes Hall, 1212 E. 59th St.
Visit our fair to access information and resources that can enhance your well-being. Learn from experts about ways to enrich your life through better nutrition, exercise, and stress reduction.Maroon Savings Choice Plan and Health Savings
Account Information Sessions
Thursday, October 16, 2014 • 10 a.m.–11 a.m.
• 1 p.m.–2 p.m.
Ida Noyes Hall, 3rd Floor
Explore how
to be healthier,
stronger, fitter,
Dear University of Chicago Colleagues,
Open Enrollment for 2015 is Friday, October 3, through Friday, October 17, 2014. Annual Open Enrollment is the time of year when all eligible University of Chicago colleagues can re-evaluate their benefit needs and review current plan elections to ensure they continue to meet their needs and those of their families. Now is the time to make changes to all 2014 elections or enroll for the first time for the 2015 calendar year. Any new elections and all changes will become effective January 1, 2015, and continue through December 31, 2015.
In an effort to continue to offer benefit choices that fit the diverse needs of the University population, a new medical plan will be offered for 2015, the Maroon Savings Choice, which will include a Health Savings Account. This guidebook includes helpful information for evaluating your benefit options, including the new medical plan. Additionally, the University has established a helpful on-line tool called The Choice Is Yours. Using this tool, you can answer a few questions about your medical benefit needs to find a medical plan that is right for you based on your responses. Refer to pages 4–5 and 10–13 for more information about the Maroon Savings Choice health plan and The Choice Is Yours web-based tool.
The University will continue to focus on providing access to high quality health care while supporting the health and wellness of all University colleagues. Plan options are designed to ensure choice to University colleagues while maintaining a high level of coverage and financial protection.
Similar to last year, this guidebook includes the required 2015 Summaries of Medical Benefits and Coverage (SBC) and a Glossary of Health Coverage and Medical Terms in the back pocket. The SBC booklet summarizes important information about all of your medical plan options to help you compare your choices before enrolling and understand your coverage after
enrollment. The glossary defines some of the most common medical and insurance terms. I encourage you to please carefully review and consider the information provided in the 2015 Benefits Open Enrollment Guide. I look forward to seeing you at the University Benefits and Health Fair on October 16, 2014, at Ida Noyes Hall. At the Benefits and Health Fair you can learn about your benefit options and ask questions of the benefits staff and vendors.
Should you have questions on any of the plan options or need assistance related to the Open Enrollment process, our benefit counselors are eager to assist you. Counselors can be reached Monday through Friday from 8:30 a.m. to 4:30 p.m. by phone at 773.702.9634 or email at benefits@uchicago.edu.
Sincerely,
Michael F. Knitter Assistant Vice President
Benefits and Human Resources Operations The University of Chicago
Campus &
Student Life
DO YOUR PART TO BE FLU SMART.
Please get your flu vaccination.
Benefits
and Health Fair
Thursday, October 16, 2014
9 a.m.–4 p.m.
Ida Noyes Hall
1212 East 59th Street
What Do I Need to Do?
Open Enrollment is an opportunity for you to review your current health plan elections to
ensure they continue to meet your needs and those of your family.
2015 BENEFITS
OPEN ENROLLMENT GUIDE
4 WHAT’S NEW FOR 20156 ENROLLMENT PROCESS
10 HEALTH & WELLNESS
10 Medical Plans 14 Dental Plans 16 Vision Plan
18 GROUP LIFE, PERSONAL ACCIDENT, LONG–TERM DISABILITY, AND LONG–TERM CARE INSURANCE
18 Basic, Supplemental, and Voluntary Life Insurance 19 Personal Accident Insurance
19 Long–Term Disability Insurance 19 Long–Term Care Insurance
24 HEALTH AND DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS AND COMMUTER BENEFITS
26 SUPPLEMENTAL RETIREMENT AND DEFERRED COMPENSATION PLANS 27 OTHER BENEFITS
29 NOTICES
32 CONTACT INFORMATION
WHAT BENEFITS REQUIRE RE-ELECTION?
If you want to participate in the health care and/or dependent care flexible spending accounts (FSA) or the 457(b) Deferred Compensation Plan during calendar year 2015, you must complete new enrollment elections. Even if you participated in these plans during calendar year 2014, your deductions will default to $0 for 2015 unless you re-enroll. For more information, see page 24 for flexible spending accounts and page 26 for the 457(b) Plan.
NO CHANGES TO YOUR CURRENT ELECTIONS?
If you do not want to make any changes to your current medical, dental, vision, supplemental life, dependent life, personal accident, long-term disability, long-term care, commuter, or supplemental retirement elections, you do not need to do anything. Your 2014 elections for these benefit plans will automatically continue for calendar year 2015.
WHAT IF I WANT TO CHANGE MY CURRENT ELECTIONS OR ENROLL FOR THE FIRST TIME?
If you want to change your elections or enroll for the first time in the medical, dental, vision, supplemental life, dependent
life, personal accident, long-term disability, long-term care, commuter, or supplemental retirement plans, you must access Employee Self Service at ess.uchicago.edu/ess from any computer beginning October 3, 2014, through October 17, 2014. Once you have completed your changes, it is important that you print the confirmation statement for your records. Any changes you make during Open Enrollment will take effect on January 1, 2015. Decisions made during Open Enrollment are binding through December 31, 2015, unless you have a qualified life event, such as a marriage or birth of a child.
WHAT IF I EXPERIENCE A QUALIFIED LIFE EVENT IN 2015?
Dependents who become eligible during the year can be added to your coverage within 31 days of the qualified life event. Eligible dependents are your legal spouse, same-gender University-registered domestic partner, civil union partner, and children. Adopted, foster, and stepchildren are also eligible for coverage. Documentation will be required when you add a dependent. Contact Human Resources at 773.702.9634 within 31 days of the qualified life event to enroll.
MAROON SAVINGS CHOICE PLAN
Effective January 1, 2015, the University will be offering the Maroon Savings Choice Plan. This medical plan will give you greater control and flexibility on how your health care dollars are spent. It will also provide access to a University-funded, tax advantaged Health Savings Account (HSA).
Highlights of the Maroon Savings Choice Plan
When you elect the Maroon Savings Choice Plan:
Q
Q The network will be a preferred provider organization
(PPO) administered by BlueCross BlueShield of Illinois. This plan will offer the same broad network of physicians and care providers currently available in the Maroon Plan.
Q
Q Like all University medical plans, preventive care is covered
at 100%. This means when you receive annual physicals, mammograms, colonoscopies, and well-child care, there is no deductible or coinsurance.
Q
Q All non-preventive care will require you to meet 100% of your
annual deductible before the plan will provide coverage. The annual deductible forthis plan is:
•
$2,000 in-network/$4,000 out-of-network for those enrolled as an individual
•
$4,000 in-network/$8,000 out-of-network for those enrolled with a spouse and/or children. The family deductible must be satisfied before coverage begins for any one family member (often referred to as a “true family” deductible).Q
Q You pay the full cost of prescription drugs until your
deductible is met unless it is a preventive drug. Once your annual deductible has been met, then the cost will be the appropriate copay. For preventive drugs, you will only be responsible for the copay before and after your deductible is met. The 2015 copays will be exactly the same as the current Maroon Plan.
Remember to have the pharmacy apply all CVS Caremark network discounts prior to submitting payment.
Q
Q Once you meet your annual out-of-pocket maximum, the
Maroon Savings Choice Plan will pay 100% of eligible medical and prescription drug expenses. The out-of-pocket maximum for this plan is:
•
$3,000 in-network/$6,000 out-of-network if enrolled as an individual
•
$6,000 in-network/$12,000 out-of-network if enrolled with a spouse and/or childrenQ
Q Additional plan features can be found on the Medical Plan
Comparison Chart on pages 12 and 13.
Health Savings Account
The Maroon Savings Choice Plan will include a health savings account (HSA) administered by HSA Bank, a division of Webster Bank, an FDIC-insured institution. For calendar year 2015, the University will contribute $500 to the HSA for those enrolled as individuals or $1,000 for those enrolled with a spouse and/ or children. You have the option to contribute additional funds through pre-tax payroll deductions, but contributions are not mandatory. For 2015 you can contribute up to an additional $2,850 if you are enrolled as an individual or $5,650 if you are enrolled with a spouse and/or children through payroll deductions on a pre-tax basis. If you are age 55 or older, you can contribute an additional $1,000 regardless of your coverage tier. You can also contribute by check/money order or transfer/ rollover funds directly to HSA Bank.
You can use this account to pay for qualified health expenses, including deductibles, coinsurance, dental, vision, and
prescription drug expenses. Since the HSA is a bank account that you own, you will be issued a debit card. As the account holder, you will be responsible for all banking fees such as replacement of a debit card or ordering checks. You can use your debit card or check to directly pay for your eligible out- of-pocket health expenses to providers.
Any unused funds will roll over, allowing you to build tax-free savings for future health care needs, including funds for medical expenses during retirement years. You can also grow your HSA savings through TD Ameritrade and Devenir self-directed investment options (through HSA Bank’s internet banking). There is no minimum requirement to begin investing. Important Information to Know If You Choose to Enroll
Q
Q Eligibility:
•
IRS rules state that participants cannot be covered in any other Traditional Health Plan, Health Care Reimbursement Account (HRA), Health Care Flexible Spending Account (FSA), Tricare, and/or VA benefits.•
You cannot be claimed as a dependent on another person’s tax return (excluding your spouse’s).•
You cannot be enrolled in Medicare.•
You are responsible for informing HSA Bank if you are not eligible for an HSA.WHAT’S NEW
New for 2015
Generic Retail/Mail Order $8/$16 $8/$16 after deductible Preferred-Brand Retail/ $20/$40 $20/$40 after deductible Mail Order
Non-Preferred-Brand Retail/ $35/$70 $35/$70 after deductible Mail Order Preventive (Before and After Deductible) Non-Preventive Medications (Participant pays 100% until deductible is met)
Q
Q Health Care Flexible Spending Accounts:
•
If you enroll in the HSA, you are not eligible to enroll in a Health Care Flexible Spending Account (FSA) for the 2015 Plan Year; however, many of the qualified expenses under a Health Care FSA would be reimbursable under an HSA.•
You are not eligible to participate in the 2014 Plan Year grace period. If you are enrolled in a Health Care Flexible Spending Account for 2014, any balance not used by December 31, 2014, will be forfeited.Q
Q Health Savings Account:
•
The University will automatically open an HSA account for you and deposit either $500 or $1,000. These funds will be available on January 1, 2015.•
Your HSA will operate just like a bank account. Once your account is opened, you will be required to maintain the account, including making updates to your address and marital status, directly with HSA Bank.•
Some states (California, Alabama, and New Jersey) will apply state taxes to contributions.•
You are not required to provide proof that an HSA distribution was used exclusively for an eligible pocket health expense; however, you will want to maintain records showing that payments were for qualified health care expenses in the event of an IRS audit.•
Investment accounts are not bank guaranteed or FDIC insured and are the sole responsibility of theaccount holder.
•
HSA Bank will provide monthly account statements, a year-end status report, and IRS Forms 5498-SA and 1099-SA to report contributions and distributions on your tax returns.Additional information about the new Maroon Savings Choice Plan can also be found online in the
“Changes for 2015” section of the Benefits website at humanresources.uchicago.edu/benefits.
NEW MEDICAL PLAN DECISION TOOL— THE CHOICE IS YOURS
Need help choosing a medical plan? Answer a few simple questions about your medical benefit needs. Then in just a few minutes, The Choice Is Yours will suggest the medical plan that is right for you based on your responses. Your responses are anonymous and you can use the tool multiple times. Visit www.decisionsupportsuite.com/uchicago to find your choices.
NEW HMO ILLINOIS VISION CARE BENEFITS
All HMO Illinois medical plan participants have access to vision care benefits through Davis Vision. Effective January 1, 2015, these benefits will include a $75 allowance toward the purchase price of eyeglasses/contacts every 24 months. Plan participants will still continue to receive coverage for one eye examination every 12 months at no cost and discounts on the purchase of eyeglasses and contact lenses.
Remember, these benefits are only available from a Davis Vision network provider and are separate from the benefits offered through the Vision Service Plan.
NEW UNIVERSITY OF CHICAGO HEALTH PLAN ID CARDS
All University of Chicago Health Plan (UCHP) participants will receive new ID cards in mid-December for use beginning January 1, 2015. We ask that you discard your current card when you receive the new ID card.
NEW WOMEN’S HEALTH FRIENDS AND FAMILY PROGRAM
Effective January 1, 2015, all Maroon Plan, Maroon Savings Choice Plan, and UCHP participants can begin receiving care from top specialists in women’s health through the University of Chicago’s Women’s Health Friends and Family Program. This program will offer convenient, quality obstetric and gynecologic care. Visits will be centrally located at the Duchossois Center for Advanced Medicine. To get started, call 773.834.7999 or email ucmfamily@uchospitals.edu.
HEALTH CARE FLEXIBLE SPENDING ACCOUNT CHANGE
As a health care flexible spending account (FSA) participant, please keep receipts for all purchases made with your Conexis debit card. Per IRS regulations, Conexis requires itemized receipts to verify debit card purchases. Failure to submit proper documentation within 90 days of the transaction date will result in the deactivation of your Conexis debit card. Once your card has been deactivated, you must clear all of the unresolved card transactions to reactivate your card. Additional information can be found on page 25.
WHAT’S NEW
Advantages of an HSA
(Health Savings Account)
• You own the account and it goes with you when you retire or leave. • In addition to University-provided funds, you can also
contribute to the account up to certain limits. • Your dollars can be invested and grow tax-free.
• Your funds roll over every year—no use it or lose it requirements! • Withdrawals are tax-free when used for eligible
Enrollment Process
The Online Benefits Enrollment Center gives you the ability toupdate your dependent and beneficiary data, and make benefit choices. It is important that you print the confirmation statement for your records.
All of your current health and welfare benefit elections can be viewed on the Employee Self Service (ESS) web page. We encourage you to review them to ensure they continue to meet your needs.
Choose your medical, dental, vision, and flexible spending account benefits carefully, as you will not be able to make changes after October 17, 2014, unless you experience a qualified life event. Changes made must be consistent with the type of life event. Proof of the life event is required and must be submitted within 31 days of the change effective date.
The benefit elections you make during this open enrollment period will become effective January 1, 2015, and are binding through December 31, 2015.
To begin your 2015 enrollment process, access Employee Self Service at ess.uchicago.edu/ess from any computer beginning October 3, 2014, through October 17, 2014.
Q
Q Enter your CNet ID and password. Q
Q The first screen you will see is the personalized welcome page. Q
Q Select Benefits. Q
Q Select Current Year Coverage to review your 2014 elections. Q
Q Select Next Year Enrollment to begin your 2015 elections.
If you leave the enrollment system before submitting your elections, your choices will not be saved. Remember to print your confirmation statement for your records.
To add a dependent, select the Add Dependent button. An Add Dependent form will appear in a separate window.
Q
Q Provide the person’s full name. Q
Q Select a reason for this entry from those listed. If no reason
fits, simply select No Reason Given.
Q
Q Select Relationship. Only individuals whose relationship is spouse,
civil union partner, same-gender domestic partner, or child will be allowed enrollment into the medical, dental, and vision plans.
Q
Q Provide the Social Security number and date of birth. Q
Q If your dependent child is a twin or triplet, enter a birth order
number (one, two, or three) in the Birth Order field.
Q
Q Provide a telephone number where the person resides. Q
Q Enter disabled or veteran in the Special Status field if
applicable to your dependent.
Q
Q When you have completed the information, select the
SAVE button.
A confirmation message asks that you verify the Social Security number, date of birth, and special status. Select Cancel if you want to double check. If you save and these are not correct, you will need to contact the Benefits Office for any corrections. A second message reminds you that if you plan to provide coverage for this dependent, you will need to submit verification of relationship to the Benefits Office by November 30, 2014. Your new dependent is now added to your list. You can continue entering additional dependents by selecting the
ADD DEPENDENT button.
The dependents you enter will also be included in your list of beneficiaries. If you need to add other people to your beneficiary list, use the Beneficiary Update option on the left menu.
You can insert as many other beneficiaries as you wish. Use the same method as you did in adding dependents. Just select the ADD BENEFICIARY button and complete the form.
When you have finished entering your dependents and beneficiaries, select the Begin Election entry.
MEDICAL, DENTAL, AND VISION COVERAGE
Q
Q Separately select the medical, dental, and vision coverage
level you want.
Q
Q Separately select the medical and dental plans that best
meet your needs.
Q
Q The rates for each medical, dental, and vision plan and
coverage level are shown.
Q
Q If you elect the Maroon Savings Choice medical plan and want
to contribute to your Health Savings Account, click on the link next to it. This link will take you to the Health Savings Account enrollment page where you will enter the annual amount you want to contribute.
Q
Q If there is a physician or medical group ID link next to
the medical plan you select, an ID number is required for enrollment into this plan. These links will take you to the corresponding websites for looking up the ID numbers. If you do not wish to select a physician or group, you can select the box to allow the carrier to make a selection for you. You can always change this option later through the provider.
Q
Q Separately select the dependents you wish to enroll in the
medical, dental, and vision plans.
Q
Q When you are finished, select SAVE. Q
Q Verification of relationship for each dependent is required. You
only have to provide this information once for enrollment into medical, dental, or vision plans.
The enrollment process is the same as last year.
ENROLLMENT
PERSONAL ACCIDENT INSURANCE
Q
Q Select the coverage level you want. Q
Q Select your beneficiary(ies) and benefit percentage amount. Q
Q Then select whether you want the person to be a primary or
contingent beneficiary.
Q
Q If you are only selecting one primary or contingent beneficiary,
allocate 100% of the benefit to him or her.
Q
Q If you are selecting two or more primary or contingent
beneficiaries, you will need to split the 100% allocation between them.
Q
Q When you are finished, select the SAVE button.
LONG–TERM DISABILITY
Q
Q Select the long–term disability plan that best meets
your needs.
Q
Q Evidence of insurability is required for a new election into
the Optional Plan. You will be contacted through US mail by Prudential.
Q
Q Coverage will not become effective until evidence
of insurability is approved by Prudential.
Q
Q After you have made your selection, select the
SAVE button.
SUPPLEMENTAL LIFE INSURANCE
Q
Q Select your desired coverage level based on your current
coverage election.
Q
Q Evidence of insurability may be required. If required, you will
be contacted through US mail by Prudential.
Q
Q Coverage will not become effective until evidence of
insurability is approved by Prudential.
Q
Q Choose primary and contingent beneficiaries using the same
method as with personal accident insurance. They may be, but do not have to be, the same designations as your personal accident insurance selections.
Q
Q You do not necessarily have to allocate the same way, but
your allocations have to add up to 100%.
Q
Q When you are finished, select the SAVE button.
VOLUNTARY DEPENDENT CHILD LIFE INSURANCE
Q
Q Select a coverage level of group life insurance for
your children.
Q
Q When you are finished, select the SAVE button.
VOLUNTARY SPOUSE OR SAME-GENDER DOMESTIC PARTNER LIFE INSURANCE
Q
Q Select a coverage level of life insurance for your spouse,
same-gender domestic partner (registered with the University), or civil union partner.
Q
Q Evidence of insurability is required. You will be contacted
through US mail by Prudential.
Q
Q Coverage will not become effective until evidence of
insurability is approved by Prudential.
Q
Q When you are finished, select the SAVE button.
HEALTH SAVINGS ACCOUNT
Q
Q Enrollment in the Maroon Savings Choice is required to
contribute to the Health Savings Account.
Q
Q For calendar year 2015, the University will contribute $500 to
your account if enrolled as individuals or $1,000 if enrolled with a spouse and/or children.
Q
Q Enter the annual amount you want to contribute. Q
Q If enrolled as an individual, you can contribute an annual
maximum of $2,850. If enrolled with a spouse and/or children, you can contribute an annual maximum of $5,650.
Q
Q Any unused funds will roll over to next year. Q
Q When you are finished, select the SAVE button.
HEALTH AND DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS
Q
Q If you enroll in the Maroon Savings Choice medical plan, you
are not allowed to enroll in the Health Care FSA.
Q
Q IRS regulations require re-enrollment into the FSAs each year.
If you are enrolled in a health and/or dependent care FSA during calendar year 2014, your elections will not automatically be continued for calendar year 2015.
Q
Q Enter the annual amount you want to contribute. Q
Q For health care, you can contribute an annual minimum of
$250 and maximum of $2,500, if you are not enrolling in the Maroon Savings Choice medical plan.
Q
Q For dependent care, you can contribute any amount up to an
annual maximum of $5,000. (Highly compensated employees can only contribute a maximum of $1,900.)
Q
Q These election amounts will be available January 1, 2015,
through March 15, 2016. All claims must be submitted by June 30, 2016. Any balance not used by March 15, 2016, will be forfeited; you cannot receive the balance.
Q
Q When you are finished, select the SAVE button.
RETIREMENT PLANS
If you would like to enroll in the Supplemental Retirement
Program (SRP) and, if eligible, the 457(b) Deferred Compensation Plan [457(b) Plan] for 2015, you will be directed to the SRP/457(b) online enrollment site. If you already are enrolled in the SRP, you may change your contribution rate and your percentage allocation between TIAA-CREF and Vanguard online during the open enrollment period.
If you are eligible and wish to participate in the 457(b) Plan, you must enroll online for 2015 even if you participated in the 457(b) Plan in 2014.
COMMUTER BENEFITS
If you would like to enroll in the Commuter Benefits (Qualified Transportation Program), you will need to contact Conexis at 877.822.9091 or visit mybenefits.conexis.com.
LONG–TERM CARE INSURANCE
If you would like to enroll in long–term care insurance, you will need to contact Genworth at 800.416.3624 or visit genworth.com/groupltc, and enter group id: UChicago and code: groupltc.
ENROLLMENT
Enrollment Process,
(continued)
ELECTRONIC SIGNATUREOnce you have selected your health and welfare benefits for 2015, ESS will request an electronic signature. You can sign the online document by selecting the I AGREE button. By selecting the I AGREE button, you certify that:
Q
Q You authorize the University of Chicago to deduct from your
earnings the required contributions, if any, toward the cost of the plan(s); and
Q
Q You cannot change any of your elections for medical,
dental, vision, or health and/or dependent care flexible spending accounts until the next open enrollment period, unless you have a qualified life event. Proof of the life event is required and must be submitted within 31 days of the life event effective date.
Remember:
Q
Q All new benefit elections will become effective January 1, 2015. Q
Q If any of your benefit elections require the completion of the
evidence of insurability (EOI) process, new benefit elections will be effective when you have completed the EOI process and Prudential has approved your new benefit election(s).
Q
Q If you are adding dependents to your medical, dental, or
vision plans for the first time during Open Enrollment, verification of relationship documentation must be submitted by November 30, 2014. If documentation is not received, coverage elections for unverified dependents will not be effective January 1, 2015. Your next opportunity for enrollment will be in the fall of 2015 for coverage effective January 1, 2016.
CONFIRMATION SCREEN
UNIVERSITY OF CHICAGO BENEFIT ENROLLMENT 01/01/2015 thru 12/31/2015 CONFIRMATION STATEMENT FOR EMPLOYEE ID: *****2697
Election Entry signed: Aug 28, 2014 9:34 PM SONIA ALMANZA
3621 S. DAMEN CHICAGO, IL 60609
This statement is a confirmation of your benefit elections for the Jan. 1, 2015, plan year. Remember to print a copy of this statement for your records. If you have any questions, please contact the Benefits Office by phone at (773) 702-9634 or email at benefits@uchicago.edu.
PRE-TAX BENEFIT ELECTIONS Plan Name Dollar Amount Pre-Tax
Medical Maroon You + Fami ly $441.00
Dental MetLife Co-Pay You + Fami ly $66.87
Vision VSP Vision Cov You + Chil d(ren) $16.44
Health Care FSA $2,500.00 $208.33
Dependent Care FSA $5,000.00 $416.67
Total Pre-Tax Amount $1,149.31
** Please note if you have a same-gender domestic partner, a portion of your deductions will be pre-tax and a portion will be after-tax.
AFTER-TAX BENEFIT ELECTIONS Plan Name Dollar Amount After-Tax
Personal Accident $100,000 Yourself and Family $2.30
Long Term Disability Base $11.66
Group Life Insurance $492,000.00 $16.73
Child Life Insurance $10,000 $1.00
Spouse Life Insurance $150,000 $5.10
Total After-Tax Amount $36.79
DEPENDENTS:
Our records indicate the following information for your dependents.
Please Note: If you add your same-gender domestic partner, he or she must be registered with and approved by
the University before coverage will take effect. If you have added dependents to your medical, dental, or vision plan for the first time during Open Enrollment, verification of relationship documentation must be submitted by November 30, 2014 to finalize their enrollment. If documentation is not received, coverage elections for unverified dependents will not be effective January 1, 2015. Your next opportunity to enroll will be in fall of 2015.
Name SSN Birth Date Relationship Gender Medical Dental Vision
JAVIER B. ALMANZA ...-6768 Apr07,1976 Spouse Male Yes Yes No ANGELA M. ALMANZA ...-9872 Jul23,2002 Child Female Yes Yes Yes XAVIER ALMANZA ...-9925 Dec12,2005 Child Male Yes Yes Yes LILIANA G. ALMANZA ...-3058 Sep03,2008 Child Female Yes Yes Yes
BENEFICIARIES:
Our records indicate the following information for your beneficiaries Personal Accident Group Life Insurance Name SSN Birth Date Relationship Beneficiary Percent Beneficiary Percent
JAVIER B. ALMANZA ...-6768 Apr07,1976 Spouse Primary 100 Primary 100 ANGELA M. ALMANZA ...-9872 Jul23,2002 Child Contingent 34
XAVIER ALMANZA ...-9925 Dec12,2005 Child Contingent 33
LILIANA G. ALMANZA ...-3058 Sep03,2008 Child Contingent 33
Page 1 of 2
Confirmation Statement
9/3/2014
https://ess-test.uchicago.edu/ess/ben/igbms25.jsp?ref=99325&linkOrg=&tempid=66926&sv...
Once you have verified your elections, it is important that you print the confirmation statements for your records. Just select the PRINT button.
ENROLLMENT NAME ADDRESS 1 ADDRESS 2 XXXXXXXX DATE NAME 1 XXX-XX-XXX XX/XX/XXX XXXX XXXX XXXX XXXX XXXX NAME 1 XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX NAME 2 XXX-XX-XXX XX/XX/XXX XXXX XXXX XXXX XXXX XXXX NAME 2 XXXX XXXX XXXX XXXX XXXX NAME 3 XXX-XX-XXX XX/XX/XXX XXXX XXXX XXXX XXXX XXXX NAME 3 XXXX XXXX XXXX XXXX XXXX NAME 4 XXX-XX-XXX XX/XX/XXX XXXX XXXX XXXX XXXX XXXX NAME 4 XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX XXXX
Health & Wellness
Medical Plans
The University of Chicago offers two different types of medical plans: two preferred provider
organization (PPO) plans and three health maintenance organization (HMO) plans.
HEALTH & WELLNESS
MEDICAL PLANS OFFERED
The University of Chicago offers five medical insurance plans, all of which provide coverage for pre-existing conditions, prescription drugs, mental health, and substance abuse with no lifetime maximum. Choosing and personalizing your benefits depends on your specific health care needs, doctor preferences, budget, and the type of plan you prefer. Use the comparison chart on pages 12 and 13 to determine which of the following plans best suits your medical needs.
Q
Q Maroon Plan (PPO) Q
Q Maroon Savings Choice (PPO) Q
Q University of Chicago Health Plan (HMO) Q
Q Humana Illinois Platinum HMO Q
Q HMO Illinois (BlueCross BlueShield)
COST OF COVERAGE
You and the University of Chicago share the monthly cost for medical coverage. The University pays the majority of the costs. Your cost is based on
Q
Q The plan you choose; Q
Q The coverage level you choose (yourself only; yourself +
spouse/partner; yourself + child(ren); yourself + family)
Q
Q Your annual salary; and Q
Q Whether you are a full-time or part-time employee.
HEALTH MAINTENANCE ORGANIZATION (HMO)
An HMO is a managed care group that provides services and supplies through its own network of doctors, hospitals, and other health care facilities. It covers your expenses only if you go to a health care provider within its network of providers (unless it’s a life-threatening emergency).
When you enroll in an HMO plan, you will be required to select a primary care physician (PCP), who manages your care using the HMO network’s physicians and facilities. You will need approval from your PCP before seeing a specialist.
HMOs provide health care within specific geographic areas called service areas. An HMO’s service area may include all or part of a particular county. To be a member of an HMO, you must live in its service area (Illinois and Indiana). Except for emergencies, you must use doctors in your HMO’s network and within your service area.
With an HMO:
Q
Q There is NO deductible Q
Q There are NO claims to file. Q
Q You pay a fixed copayment for each office visit, emergency
room visit, and hospital stay.
PREFERRED PROVIDER ORGANIZATION (PPO)
A PPO gives you freedom of choice and greater flexibility than an HMO. You are not required to choose a primary care physician and do not need a referral to see a specialist. The PPO offers a large network of contracting doctors and hospitals to choose from when care is needed. When a contracting network provider is used, the care is considered “in-network,” out-of-pocket costs will be less, and the highest level of benefits is received. If a doctor outside the network is used, the care is considered “out-of-network” and coverage is still provided, but the out-of-pocket costs will be significantly higher. In addition, PPO members have access to care anywhere they live, work, or travel, across the country and around the world.
With a PPO:
Q
Q There is an annual deductible Q
Q You pay a percentage of the charge after you have met your
deductible for each office visit, emergency room visit, and hospital stay.
Q
Q There is a Health Savings Account (with the Maroon
Savings Choice Plan only)
WHICH PLAN IS RIGHT FOR YOU?
The best medical plan for you depends on a number of factors:
Q
Q What are your anticipated medical expenses for 2015? Q
Q Do you want to participate in a Health Savings Account
or a Flexible Spending Account?
Q
Q What can you afford to pay out-of-pocket (in terms of
deductibles and copayments) if you or a covered dependent needs medical care?
Q
Q Do you have other medical coverage (for example, through
your spouse’s employer)?
Q
Q Do you have a doctor whom you want to keep seeing, or
would you be willing to switch to a network doctor, if necessary, to pay less for coverage?
Q
Q Do you travel often or are you away from the University of
Chicago often?
Q
Q Do any of your dependents need routine medical care in an
out-of-state location?
The Choice Is Yours
Find the medical plan that is right for you by answering a few questions about your medical needs. Visit www.decisionsupportsuite.com/uchicago to find your choices.
Monthly Medical Rates for Part-Time Employees
If your salary is: Under $45,000 $45,000 – $74,999 $75,000 – $99,999 $100,000 – $174,999 $175,000 or more
Maroon Plan
Yourself Only $176 $233 $261 $413 $435 Yourself + Spouse/Partner $315 $428 $534 $653 $675 Yourself + Child(ren) $293 $407 $480 $533 $608 Yourself + Family $399 $533 $662 $818 $848
Maroon Savings Choice Plan
Yourself Only $80 $104 $126 $149 $173 Yourself + Spouse/Partner $168 $216 $264 $312 $362 Yourself + Child(ren) $144 $186 $227 $269 $309 Yourself + Family $240 $309 $378 $447 $516 UCHP Yourself Only $69 $110 $165 $186 $192 Yourself + Spouse/Partner $150 $234 $345 $410 $435 Yourself + Child(ren) $138 $218 $327 $360 $375 Yourself + Family $189 $288 $410 $503 $525
Humana Illinois Platinum HMO
Yourself Only $71 $114 $168 $215 $221 Yourself + Spouse/Partner $170 $273 $375 $495 $507 Yourself + Child(ren) $153 $258 $357 $405 $420 Yourself + Family $215 $333 $474 $593 $615 HMO Illinois Yourself Only $62 $102 $141 $165 $177 Yourself + Spouse/Partner $146 $222 $300 $402 $417 Yourself + Child(ren) $132 $203 $285 $323 $345 Yourself + Family $185 $275 $405 $495 $510
Monthly Medical Rates for Full-Time Employees
If your salary is: Under $45,000 $45,000 – $74,999 $75,000 – $99,999 $100,000 – $174,999 $175,000 or more
Maroon Plan
Yourself Only $117 $155 $174 $275 $290 Yourself + Spouse/Partner $210 $285 $356 $435 $450 Yourself + Child(ren) $195 $271 $320 $355 $405 Yourself + Family $266 $355 $441 $545 $565
Maroon Savings Choice Plan
Yourself Only $53 $69 $84 $99 $115 Yourself + Spouse/Partner $112 $144 $176 $208 $241 Yourself + Child(ren) $96 $124 $151 $179 $206 Yourself + Family $160 $206 $252 $298 $344 UCHP Yourself Only $46 $73 $110 $124 $128 Yourself + Spouse/Partner $100 $156 $230 $273 $290 Yourself + Child(ren) $92 $145 $218 $240 $250 Yourself + Family $126 $192 $273 $335 $350
Humana Illinois Platinum HMO
Yourself Only $47 $76 $112 $143 $147 Yourself + Spouse/Partner $113 $182 $250 $330 $338 Yourself + Child(ren) $102 $172 $238 $270 $280 Yourself + Family $143 $222 $316 $395 $410 HMO Illinois Yourself Only $41 $68 $94 $110 $118 Yourself + Spouse/Partner $97 $148 $200 $268 $278 Yourself + Child(ren) $88 $135 $190 $215 $230 Yourself + Family $123 $183 $270 $330 $340
Medical Plan Comparison Chart
Your medical-related needs and considerations are unique, and so are your family’s.That’s why the University offers you the opportunity to select the plan option that works best for you.
PLAN FEATURE Maroon Plan Maroon Savings Choice Plan University of Chicago Health Plan Humana Illinois Platinum HMO HMO Illinois Inside BCBSIL (BlueCross
BlueShield) Network
Outside BCBSIL Network Inside BCBSIL (BlueCross BlueShield)
Network
Outside BCBSIL Network
Choice of doctor Limited to BCBSIL network Any provider Limited to BCBSIL network Any Provider Limited to network Limited to network Limited to network Deductible Individual — $250
Family — up to $600
Individual — $250 Family — up to $600 Additional $200 per hospital admission Individual — $2,000 Family — $4,000 Individual — $4,000 Family — $8,000 Additional $200 per hospital admission
None None None
Benefit payment percentage You pay 20%;
Plan pays 80% of covered expenses
You pay 35% ***; Plan pays 65% of the costs
You pay 20%;
Plan pays 80% of covered expenses
You pay 35% ***;
Plan pays 65% of the costs
You pay nothing or a minimal copayment; Plan pays 100%
You pay nothing or a minimal copayment; Plan pays 100%
You pay nothing or a minimal copayment; Plan pays 100% Out-of-pocket maximum $2,000/Individual
$4,000/Family $3,000/Individual $6,000/Family $6,000/Individual $12,000/Family $1,500/Individual $3,000/Family $1,500/Individual $3,000/Family $1,500/Individual $3,000/Family
Health Savings Account
(University contribution)
None $500/Individual $1,000/Family
None None None
Physician office visits You pay 20%; Plan pays 80% of covered expenses for “non-preventive services.” Preventive services, including preventive office visits, are covered at 100%.
You pay 35% ***;
Plan pays 65% of the costs
You pay 20%; Plan pays 80% of covered expenses for “non- preventive services.” Preventive services including preventive office visits, are covered at 100%.
You pay 35% ***;
Plan pays 65% of the costs
You pay a $10 copayment for a PCP* visit and $20 for a specialist visit; Plan covers the remainder
You pay a $10 copayment for a PCP* visit and $20 for a specialist visit; Plan covers the remainder
You pay a $10 copayment for a PCP* visit and $20 for a specialist visit; Plan covers the remainder
Hospital: Inpatient You pay 20%; Plan pays 80% of covered expenses
You pay 35%*** (after $200 deductible); Plan pays 65% of the costs
You pay 20%;
Plan pays 80% of covered expenses
You pay 35%*** (after $200 deductible); Plan pays 65% of the costs
You pay $250 copayment per admission; Plan covers the remainder
You pay up to $300 copayment per admission ($100 per day for up to three days); Plan covers the remainder
You pay $250 copayment per admission; Plan covers the remainder
Hospital: Outpatient You pay 20%;
Plan pays 80% of covered expenses
You pay 35%***; Plan pays 65% of the costs
You pay 20%;
Plan pays 80% of covered expenses
You pay 35%***; Plan pays 65% of the costs
Provided in full Provided in full Provided in full
Preventive care/wellness Provided in full Provided in full $0 copay $0 copay $0 copay
Ongoing therapy, occupational therapy, physical therapy, and speech therapy
20 visits maximum per condition 20 visits maximum per condition Limit of 60 combined treatments per calendar year
PCP* and any consulting
physician must determine that the member’s condition can improve significantly within 2 months
Limit of 60 combined treatments per calendar year; $10 copayment per visit
Hearing services Not covered Not covered Exam provided in full; no coverage for
hearing aids
Exam provided in full; no coverage for hearing aids
$10 PCP*/$20 specialist; no coverage for hearing aids Vision services Contact Davis Vision at 877.393.8844. Contact Davis Vision at 877.393.8844. Contact the Plan at 773.834.0900 Contact EyeMed Vision Care at
888.289.0595
Contact Davis Vision at 877.393.8844
Prescriptions
(generic/preferred brand-name/ non-preferred brand-name)
Covered under a separate prescription drug plan administered by CVS Caremark
Retail (30-day supply): $8/$20/$35 copayment Mail Service (90-day supply): $16/$40/$70 copayment
Covered under a separate prescription drug plan administered by CVS Caremark; Retail (30-day supply): $8/$20/$35 copayment; Mail Service (90-day supply): $16/$40/$70
copayment. You are responsible for the full cost of non-preventive drugs until the plan deductible has been met, after the deductible copays apply.
Retail (30-day supply): $5/$15/$30 copayment; 50% copayment for maintenance medications after 2nd refill; Mail service at DCAM** Pharmacy (90-day supply): $10/$30/$60 copayment; Mail service (90-day supply) with CVS Caremark: $15/$45/$90 copayment
Retail (30-day supply): $5/$15/$30 copayment; Mail service (90-day supply): $10/$30/$60 copayment
Retail (34-day supply): $5/$15/$30 copayment; $50 self-injectables Mail service & select retail pharmacies (90-day supply): $10/$30/$60 copayment; $50 copay for self-injectables
Emergency room You pay 20%;
Plan pays 80% of covered expenses
You pay 20%***;
Plan pays 80% of the costs
You pay 20%;
Plan pays 80% of covered expenses
You pay 20%***;
Plan pays 80% of the costs
$75 copayment; waived if admitted $75 copayment; waived if admitted
$75 copayment; waived if admitted
Mental health: Outpatient You pay 20%; Plan pays 80% of covered expenses
You pay 35%***;
Plan pays 65% of the costs
You pay 20%;
Plan pays 80% of covered expenses
You pay 35%***;
Plan pays 65% of the costs
$10 copayment per visit (waived for initial visit)
$20 copayment per visit $10 copayment per visit HEALTH & WELLNESS
PLAN FEATURE Maroon Plan Maroon Savings Choice Plan University of Chicago Health Plan Humana Illinois Platinum HMO HMO Illinois Inside BCBSIL (BlueCross
BlueShield) Network
Outside BCBSIL Network Inside BCBSIL (BlueCross BlueShield)
Network
Outside BCBSIL Network
Choice of doctor Limited to BCBSIL network Any provider Limited to BCBSIL network Any Provider Limited to network Limited to network Limited to network Deductible Individual — $250
Family — up to $600
Individual — $250 Family — up to $600 Additional $200 per hospital admission Individual — $2,000 Family — $4,000 Individual — $4,000 Family — $8,000 Additional $200 per hospital admission
None None None
Benefit payment percentage You pay 20%;
Plan pays 80% of covered expenses
You pay 35% ***; Plan pays 65% of the costs
You pay 20%;
Plan pays 80% of covered expenses
You pay 35% ***;
Plan pays 65% of the costs
You pay nothing or a minimal copayment; Plan pays 100%
You pay nothing or a minimal copayment; Plan pays 100%
You pay nothing or a minimal copayment; Plan pays 100% Out-of-pocket maximum $2,000/Individual
$4,000/Family $3,000/Individual $6,000/Family $6,000/Individual $12,000/Family $1,500/Individual $3,000/Family $1,500/Individual $3,000/Family $1,500/Individual $3,000/Family
Health Savings Account
(University contribution)
None $500/Individual $1,000/Family
None None None
Physician office visits You pay 20%; Plan pays 80% of covered expenses for “non-preventive services.” Preventive services, including preventive office visits, are covered at 100%.
You pay 35% ***;
Plan pays 65% of the costs
You pay 20%; Plan pays 80% of covered expenses for “non- preventive services.” Preventive services including preventive office visits, are covered at 100%.
You pay 35% ***;
Plan pays 65% of the costs
You pay a $10 copayment for a PCP* visit and $20 for a specialist visit; Plan covers the remainder
You pay a $10 copayment for a PCP* visit and $20 for a specialist visit; Plan covers the remainder
You pay a $10 copayment for a PCP* visit and $20 for a specialist visit; Plan covers the remainder
Hospital: Inpatient You pay 20%; Plan pays 80% of covered expenses
You pay 35%*** (after $200 deductible); Plan pays 65% of the costs
You pay 20%;
Plan pays 80% of covered expenses
You pay 35%*** (after $200 deductible); Plan pays 65% of the costs
You pay $250 copayment per admission; Plan covers the remainder
You pay up to $300 copayment per admission ($100 per day for up to three days); Plan covers the remainder
You pay $250 copayment per admission; Plan covers the remainder
Hospital: Outpatient You pay 20%;
Plan pays 80% of covered expenses
You pay 35%***; Plan pays 65% of the costs
You pay 20%;
Plan pays 80% of covered expenses
You pay 35%***; Plan pays 65% of the costs
Provided in full Provided in full Provided in full
Preventive care/wellness Provided in full Provided in full $0 copay $0 copay $0 copay
Ongoing therapy, occupational therapy, physical therapy, and speech therapy
20 visits maximum per condition 20 visits maximum per condition Limit of 60 combined treatments per calendar year
PCP* and any consulting
physician must determine that the member’s condition can improve significantly within 2 months
Limit of 60 combined treatments per calendar year; $10 copayment per visit
Hearing services Not covered Not covered Exam provided in full; no coverage for
hearing aids
Exam provided in full; no coverage for hearing aids
$10 PCP*/$20 specialist; no coverage for hearing aids Vision services Contact Davis Vision at 877.393.8844. Contact Davis Vision at 877.393.8844. Contact the Plan at 773.834.0900 Contact EyeMed Vision Care at
888.289.0595
Contact Davis Vision at 877.393.8844
Prescriptions
(generic/preferred brand-name/ non-preferred brand-name)
Covered under a separate prescription drug plan administered by CVS Caremark
Retail (30-day supply): $8/$20/$35 copayment Mail Service (90-day supply): $16/$40/$70 copayment
Covered under a separate prescription drug plan administered by CVS Caremark; Retail (30-day supply): $8/$20/$35 copayment; Mail Service (90-day supply): $16/$40/$70
copayment. You are responsible for the full cost of non-preventive drugs until the plan deductible has been met, after the deductible copays apply.
Retail (30-day supply): $5/$15/$30 copayment; 50% copayment for maintenance medications after 2nd refill; Mail service at DCAM** Pharmacy (90-day supply): $10/$30/$60 copayment; Mail service (90-day supply) with CVS Caremark: $15/$45/$90 copayment
Retail (30-day supply): $5/$15/$30 copayment; Mail service (90-day supply): $10/$30/$60 copayment
Retail (34-day supply): $5/$15/$30 copayment; $50 self-injectables Mail service & select retail pharmacies (90-day supply): $10/$30/$60 copayment; $50 copay for self-injectables
Emergency room You pay 20%;
Plan pays 80% of covered expenses
You pay 20%***;
Plan pays 80% of the costs
You pay 20%;
Plan pays 80% of covered expenses
You pay 20%***;
Plan pays 80% of the costs
$75 copayment; waived if admitted $75 copayment; waived if admitted
$75 copayment; waived if admitted
Mental health: Outpatient You pay 20%; Plan pays 80% of covered expenses
You pay 35%***;
Plan pays 65% of the costs
You pay 20%;
Plan pays 80% of covered expenses
You pay 35%***;
Plan pays 65% of the costs
$10 copayment per visit (waived for initial visit)
$20 copayment per visit $10 copayment per visit
Use this chart to help you make a decision.It’s a good idea to think through how you might use the plan in the coming year. Do you want a plan that offers you more access to providers? Are you looking for a plan with lower costs? Do you want to have one doctor to coordinate all your care? What kind of coverage do you want? Do you want to have access to a Health Savings Account? REMEMBER: All medical plans provide emergency care anywhere in the world. Before you enroll in a new plan, make sure the doctor you want is accepting new patients.
HEALTH & WELLNESS
*PCP = Primary Care Physician
**DCAM = Duchossois Center for Advanced Medicine at the University of Chicago Medicine ***You are also responsible for 100% of the charges in excess of the prevailing fee schedule
Dental Plans
The University of Chicago offers two different types of dental plans: a preferred provider
organization (PPO) plan and a copay plan through MetLife.
DENTAL PLANS OVERVIEW
Regular visits to the dentist may do more than just brighten your smile—they can be important to your overall health. Many diseases produce oral signs and symptoms. Both of the University of Chicago dental insurance plans provide coverage for preventive care, basic care, major care, and orthodontia. Choosing and personalizing your benefits depends on your specific dental care needs, budget, and the type of plan you prefer. Under both plans, you are free to visit any licensed dentist you choose. The dental plans offer a large network of contracting providers to choose from when dental care is needed.
When a contracting network provider is used, the care is considered “in-network,” out-of-pocket costs will be less, and the highest level of benefits is received. If a provider outside the network is used, the care is considered “out-of-network” and coverage is still provided, but the out-of-pocket costs will be significantly higher.
USING YOUR DENTAL BENEFIT IS EASY.
Q
Q To find a preferred provider, visit metlife.com or call
800.942.0854. Reference the “PDP Plus” network.
Q
Q At your appointment, tell them you have MetLife. There’s
no ID card necessary.
COST OF COVERAGE
You pay the full cost for your dental coverage based on:
Q
Q The plan you choose and Q
Q The coverage level you choose
WHICH PLAN IS RIGHT FOR YOU?
Although the plans utilize the same provider network, your costs associated with the plans will vary. Use the Dental Plan Comparison Chart to determine which plan suits your dental needs. Copay Plan approximated coinsurance amounts are for comparison purposes. Fee schedules apply to all in-network services.
The best dental plan for you depends on a number of factors:
Q
Q What are your anticipated dental expenses for 2015? Q
Q What can you afford to pay out-of-pocket (in terms of
deductibles and copayments) when dental care is needed?
Q
Q Do you have other dental insurance?
Copay Plan PPO Plan
Monthly MetLife Dental Rates
Yourself only $25.28 $45.41
Yourself + spouse or domestic/civil union partner $41.88 $81.35 (without a child/children)
Yourself + child/children $48.43 $102.15
(without a spouse or domestic/civil union partner)
Yourself + family $66.87 $161.04
(with a spouse or domestic/civil union partner and child/children)
HEALTH & WELLNESS
Dental Plan Comparison Chart
HEALTH & WELLNESS
PLAN FEATURE COPAY PLAN
Inside MetLife Network Out of MetLife Network
PPO PLAN
Inside MetLife Network Out of MetLife Network Choice of Dentist
Deductible Annual Maximum
The most coverage that the Plan will provide you in one year. You are responsible for all dental costs after you reach your annual maximum benefit.
Preventive Care
Basic Care Major Care Orthodontia
(Adult and Child)
Limited to MetLife Network
None
Per individual: $5,000
You pay approximately 10%; Plan pays approximately 90%
You pay approximately 30%; Plan pays approxi-mately 70%
You pay approximately 60%; Plan pays approximately 40% You pay 60%; Plan pays 40%
Lifetime maximum per individual: $1,500 Any dentist Per individual: $75* Per family: Up to $225* Per individual: $1,000 You pay 30%***; Plan pays 70% You pay 60%***; Plan pays 40% You pay 70%***; Plan pays 30% You pay 60%***; Plan pays 40%
Lifetime maximum per individual: $500
Limited to MetLife Network Any dentist
Per individual: $60** Per individual: $1,500 Per family: Up to $3,000 You pay 0%; Plan pays 100% You pay 20%; Plan pays 80% You pay 50%; Plan pays 50% You pay 50%; Plan pays 50% You pay 0%***; Plan pays 100% You pay 20%***; Plan pays 80% You pay 50%***; Plan pays 50% You pay 50%***; Plan pays 50%
* Waived for orthodontia
** Waived for preventive care and orthodontia
*** You are also responsible for 100% of the charges in excess of the reasonable and customary charge.
Two visits per calendar year
Lifetime maximum per individual: $1,000 One visit in a six month period
VISION PLAN OVERVIEW
The University of Chicago’s separate vision plan offers
comprehensive coverage, including eye exams and discounts on eyewear. With open access to see any eye care provider, you can see the one who is right for you.
Eye exams are an important part of overall health care for the entire family. The summary on the next page may help you decide if you need or your family needs a separate vision plan. The Vision Service Plan (VSP) offers a large network of contracting providers to choose from when vision care is needed. When a contracting network provider is used, the care is considered “in-network,” out-of-pocket costs will be less, and the highest level of benefits is received. If a provider outside the network is used, the care is considered “out-of-network” and coverage is still provided, but the out-of-pocket costs will be significantly higher.
USING YOUR VSP BENEFIT IS EASY.
Q
Q To find a VSP doctor or an affiliate provider, visit vsp.com or
call 800.877.7195. Reference the “choice” network to find an “in-network” VSP doctor.
Q
Q At your appointment, tell them you have VSP. There’s no ID
card necessary. If you would like a card, you can visit vsp.com and print your personalized member vision card.
COST OF COVERAGE
You pay the full cost for this vision coverage. Your cost is based on the coverage level you choose.
Vision Plan
The University of Chicago offers a separate vision plan, through the Vision Service Plan.
Vision Service Plan
Monthly Vision Rates
Yourself only $7.49
Yourself + spouse or domestic/civil union partner $14.98 (without a child/children)
Yourself + child/children $16.44 (without a spouse or domestic/civil union partner)
Yourself + family $26.27
(with a spouse or domestic/civil union partner and child/children)
HEALTH & WELLNESS
Benefit Description Copay Frequency Your Coverage with VSP Doctors and Participating Retail Chains*
Well Vision Exam Focuses on your eyes and overall wellness $0 Every calendar year
Prescription glasses $25
Frame Q $150 allowance for a wide selection of frames Q 20% off amount over your allowance
Included in Prescription Glasses
Every other calendar year Lenses Q Single vision, lined bifocal, and lined
trifocal lenses
Q Polycarbonate lenses for dependent children
Included in Prescription Glasses
Every calendar year
Lens options Q Standard progressive lenses Q Premium progressive lenses Q Custom progressive lenses
Q Average 20%–25% off other lens options
$55 $95–$105 $150–$175
Every calendar year
Contacts
(instead of glasses)
Q Contact lens exam (fitting and evaluation) Q $150 allowance for contacts
Up to $60
Copay does not apply
Every calendar year Extra savings and discounts Glasses and Sunglasses
Q 20% off additional glasses and sunglasses, including lens options, from any VSP doctor within 12 months of
your last Well Vision Exam Laser Vision Correction
Q Average 15% off the regular price or 5% off the promotional price; discounts only available
from contracted facilities
Summary of Vision Benefits
HEALTH & WELLNESS
* Coverage with a participating retail chain may be different. Visit vsp.com for details.
Exam Up to $45
Frame Up to $70
Single Vision Lenses Up to $30 Lined Bifocal Lenses Up to $50 Lined Trifocal Lenses Up to $65 Progressive Lenses Up to $50 Contacts Up to $105
Your Coverage with Other Providers
Group Life, Personal Accident,
Long-Term Disability, and
Long-Term Care Insurance
Life Insurance
The University of Chicago group life insurance plans provide your family (or beneficiary) with a lump sum payment in the event of death.
BASIC LIFE INSURANCE
All benefits-eligible employees have a life insurance coverage amount equal to one times their annual salary to a maximum benefit of $50,000. If you are a benefits-eligible employee, your basic life insurance was effective on your date of hire or benefits eligible date. Enrollment was automatic, as long as you were actively at work on that date. The University pays the full cost for this benefit.
SUPPLEMENTAL LIFE INSURANCE
The University of Chicago offers you the opportunity to purchase additional life insurance protection for yourself. Enrollment is voluntary and you decide how much to purchase.
If you are currently enrolled in supplemental life insurance, you have the option of increasing your coverage by 1x your annual base salary, up to $750,000. Evidence of insurability is not required, unless you have previously been denied coverage under the evidence of insurability process.
If you are not currently enrolled in supplemental life insurance, you have the option of selecting coverage equal to a multiple of your annual base salary (1x, 2x, 3x, 4x, 5x, 6x, 7x, or 8x), with evidence of insurability to an overall maximum of $1,500,000 (basic and supplemental life combined).
Any coverage requiring evidence of insurability will not become effective until approved by Prudential. You will be contacted directly by Prudential through US mail.
You, as the employee, pay the full cost of this coverage through after-tax payroll deductions. When you reach age 65, coverage is only available at a reduced percentage of your elected coverage amount.
VOLUNTARY SPOUSE, SAME-GENDER DOMESTIC PARTNER (REGISTERED WITH THE UNIVERSITY), OR CIVIL UNION PARTNER LIFE INSURANCE
The University of Chicago offers you the opportunity to purchase life insurance protection for your spouse, same-gender domestic partner (who is registered with the University), or civil union partner. Enrollment is voluntary and you decide how much to purchase.
Q
Q You may elect coverage for your spouse, same-gender
domestic partner (registered with the University), or civil union partner in $10,000 increments up to $150,000.
Q
Q During the Open Enrollment period, evidence of insurability is
required for all coverage elections.
Q
Q Coverage will not become effective until evidence of
insurability is approved by Prudential. You will be contacted directly by Prudential through US mail.
Q
Q You, as the employee, pay the full cost for this coverage
through after-tax payroll deductions.
Q
Q When your spouse, same-gender domestic partner, or civil
union partner reaches age 65, coverage is available at a reduced percentage of the elected coverage amount.
VOLUNTARY DEPENDENT CHILD(REN) LIFE INSURANCE
The University of Chicago offers you the opportunity to purchase life insurance protection for your child(ren). Enrollment is
voluntary and you decide how much to purchase.
Q
Q You may elect coverage for your eligible dependent child(ren)
(up to age 26) in $2,000 increments up to $10,000.
Q
Q You may cover one child or multiple children in your family.
You will only pay premium based on one level of coverage. So, if you choose the $2,000 level of coverage, you will only pay premium based on $2,000, yet you will have $2,000 worth of life insurance coverage on each eligible child in your family.
Q
Q There is no evidence of insurability required for children. Q
Q You, as the employee, pay the full cost for this coverage
through after-tax payroll deductions.
The monthly cost for supplemental and voluntary life insurance is based on the coverage amounts you elect. See page 20 to determine coverage costs.
Whether you’re just getting started or preparing for what’s next in life, someone is depending
on you. Adequate protection means your loved ones can pursue their plans and dreams, even
if something happens to you.
Personal Accident
Insurance
The University of Chicago offers personal accident insurance, which provides a benefit that helps protect you and your family from financial hardship if you or a covered family member dies or suffers a serious injury in an accident. You may elect up to $1,000,000 of personal accident insurance for you and your dependents (to a maximum of 10 x your annual salary). Participation is voluntary and you decide how much to purchase. Evidence of insurability is not required.
If family coverage is selected, all eligible dependents will be automatically covered by this voluntary personal accident insurance benefit. If both you and your spouse, same- gender University-registered domestic partner, or civil union partner are University employees, both of you cannot choose family coverage. You, as the employee, pay the full cost of this coverage through after-tax payroll deductions.
The cost for personal accident insurance is based on the coverage amounts you elect. See page 21 to determine coverage costs.
Long-Term Disability
Insurance
The University of Chicago offers long-term disability insurance (LTD), which provides supplemental income to allow you to focus on your recovery when you suffer an illness, injury, or disabling condition that prevents you from working for more than three months. You can choose from the base plan or the optional plan.
BASE PLAN
Under the Base Plan, you receive 60% of your monthly base salary, up to a maximum monthly benefit of $10,000, less any benefits you receive from other sources, such as Social Security. Under this plan, during the first 24 months, disability is defined as being unable to perform the material and substantial duties of your regular occupation or having a 20% or more loss in your monthly earnings, and being under the regular care of a doctor. After 24 months, disability is defined as being unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training, or experience, and being under the regular care of a doctor.
OPTIONAL PLAN
Under the Optional Plan, you receive 60% of your monthly base salary, up to a maximum monthly benefit of $20,000, less any benefits you receive from other sources, such as Social Security. Under this plan, disability is defined as being unable to perform the material and substantial duties of your regular occupation or having a 20% or more loss in your monthly earnings, and being under the regular care of a doctor. This plan also provides an annual 5% cost of living adjustment.
Evidence of insurability is required for participation in the Optional Plan. You will be contacted by Prudential, through US mail. Coverage will become effective on the date approved by Prudential.
The monthly cost for long-term disability coverage is based on your salary and the plan you elect. See page 22 to determine coverage costs.
Long-Term Care Insurance
The University of Chicago offers long-term care (LTC) insurance to provide support when needed due to a long-term illness, recovery from an accident or illness, or advanced aging. LTC support can include help getting dressed, eating, bathing, or self-administering medication. Skilled, intermediate, and custodial care in your home, an adult day care center, an assisted living facility, or a nursing home can be covered. LTC insurance will provide coverage for services when they are required for an extended period of time and are not associated with acute care or short-term illness.All benefits-eligible employees actively at work are eligible to apply. Also eligible are the employee’s spouse, same-gender domestic partner (registered with the University), or civil union partner and adult children between the ages of 18 and 79 years. All applicants must maintain a permanent United States residence. Enrollment is voluntary and you decide how much to purchase. Evidence of insurability is required for all coverage elections. Coverage will not become effective until evidence of insurability is approved by Genworth. You will be contacted directly by Genworth.
The cost for long-term care insurance is based on your age and the coverage amounts you select. If you would like to enroll, you will need to contact Genworth at 800.416.3624 or visit genworth.com/groupltc and enter group id: UChicago and code: groupltc.
Supplemental and Voluntary Life Insurance Rates
When it comes to life insurance, many families are underinsured. It can be difficult to know how much protection is needed in the event of an unexpected death. The Prudential Easy-to-Use Life Insurance Needs Estimator can help you estimate how much life insurance makes sense for your current situation. It’s faster and simpler than other similar tools you may have tried. It considers income, assets, mortgage or rent, and everyday expenses such as college tuition. To get started, visit prudential.com/EZLifeNeeds. Just answer six questions and click Continue to get an estimate of your current life insurance needs.
How to Calculate Your Monthly Rate for Supplemental Life
Step One
Take your annual salary and round it up to the next $1,000.
Step Two
Elect the level of coverage that you want.
Step Three
Multiply annual salary times the coverage that you elect.
Step Four
Divide the result in Step Three by $1,000.
Step Five
Multiply the result in Step Four by the applicable rate per $1,000.
Example
Sue is 38 and her annual salary is $34,482. Sue rounds that figure up to $35,000.
Sue wants to elect three times her annual salary.
3 X $35,000 = $105,000 $105,000 ÷ $1,000 = 105 105 X $0.034 = $3.57 per month Under 35 35 – 39 40 – 44 45 – 49 50 – 54 55 – 59 60 – 64 65 – 69* 70 – 74* 75 and over* $0.027 $0.034 $0.061 $0.103 $0.158 $0.293 $0.444 $0.820 $1.506 $1.506 Under 35 35 – 39 40 – 44 45 – 49 50 – 54 55 – 59 60 – 64 65 – 69* 70 – 74* 75 and over* $0.027 $0.034 $0.061 $0.103 $0.158 $0.293 $0.444 $0.820 $1.506 $1.506 All Eligible Children $0.200
Your Age Age Age Monthly Cost per $1,000 of Coverage Monthly Cost per $1,000 of Coverage Monthly Factor per $2,000 of Coverage
* Reduction in coverage applies. Employee
Spouse, Same-Gender Domestic Partner
(Registered with the University),
or Civil Union Partner Child(ren)
$50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000 $0.70 $1.40 $2.10 $2.80 $3.50 $4.20 $4.90 $5.60 $6.30 $7.00 $1.15 $2.30 $3.45 $4.60 $5.75 $6.90 $8.05 $9.20 $10.35 $11.50
Principal Amount Cost of Individual Coverage Cost of Family Coverage (Yourself Only) (Yourself and Your Family)
The table below shows some examples of monthly Personal Accident Insurance contribution rates for various coverage levels:
Personal Accident Insurance Rates
How to Calculate Your Monthly Rate for Personal Accident Insurance
Step One
Choose the amount of coverage you want.
Step Two
Divide the amount of your total coverage (your principal amount) by $10,000.
Step Three
Multiply the result by the appropriate rate:
Q $0.14 if you have coverage for yourself only
Q $0.23 if you have coverage for yourself and your family
This gives you your monthly contribution rate.
Example
Jane wants to know what it would cost if she chooses coverage equal to $80,000 for herself only or for herself and family.
$80,000 ÷ $10,000 = 8
8 x $0.14 = $1.12
Jane will pay $1.12 per month for coverage for herself. or
8 x $0.23 = $1.84
Jane will pay $1.84 per month for family coverage.
