Employee Benefits
Effective January 1, 2012
About this site
Welcome to your Online Benefits Dashboard, a customized SingleSource platform for your employee benefits program brought to you by William Gammon Insurance. Through your site, you can access benefit summaries, enrollment forms, provider search tools, plan contacts, and other important employee benefit resources. Please contact your HR Department or William Gammon Insurance if you have any questions.
Coverage
You may select the following coverage(s) for you and your eligible dependents, unless stated otherwise. View the 2012 Open Enrollment presentation.
- Medical Insurance with Prescription Drug Coverage
- Dental Insurance
- Vision Insurance
- Basic Group Life and Accidental Death & Dismemberment Insurance
- Long Term Disability Insurance
- Optional Short Term Disability Insurance (employee only)
- Optional Life Insurance
- Optional AD&D Insurance (employee only)
- Health Care Savings Account
- Health Care Flexible Spending Account
- Dependent Care Flexible Spending Account
Semi-Monthly Insurance Deductions
Medical
HSA Plan
- 100/70 HSA Plan
- $2,500 (2X Family) Calendar Year Deductible
- UnitedHealthcare ChoicePlus provider network
- 100% for Preventive Care Services
- Full Medical Summary of Benefits
PPO Plan
- 100/70 PPO Plan
- $2,500 (3X Family) Calendar Year Deductible
- $25 Primary Care Physician Office Visit CoPay
- $50 Specialist Physician Office Visit CoPay
- $10/$30/$50 Prescription Drug CoPays
- 100% for Preventive Care Services
- Full Medical Summary of Benefits
Health Savings Account
Plan, save and pay for medical expenses tax-free* with an HSA.
Each year, more people are choosing a medical plan with a health savings account (HSA). In fact, more than a million people are covered by a UnitedHealthcare DefinitySM Health Savings Account Plan.
- The medical plan covers you and your family and helps pay health care costs once you have met your plan's deductible.
- The HSA allows you to save money tax free to pay for eligible medical expenses today, tomorrow and in the future - even in retirement.
HSA Advantages
- The account is yours to keep - even if you change jobs or medical plans. There is no "use it or lose it" rule. Plus, you get triple tax advantages with an HSA:
- Money you deposit into an HSA is exempt from federal income taxes.
- Interest in your account grows tax free.
- You don't pay income taxes on withdrawals used to pay for eligible medical expenses.
- Anyone can contribute to your account - you (by contributions you make or payroll deductions, if available), your employer and/or any other person.
- If you would like more information about HSAs, click here.
* To be eligible to open and contribute to an HSA, you must:
- You are covered by a qualified single or family high-deductible health plan (HDHP).
- You are not covered by any other non-HDHP health plan, such as a spouse's plan, that provides any benefits covered by your HDHP plan. Exceptions include permissible coverage, such as specific injury insurance or accident, disability, dental, vision or long-term care insurance.
- You are not enrolled in Medicare.
- You are not enrolled in the TRICARE or TRICARE for Life military benefits program.
- You have not received Veterans Administration (VA) benefits within the past three months.
- You cannot be claimed as a dependent on another person's tax return.
- You are not covered by a health care flexible spending account (FSA) for the tax year in which you will claim your HSA deposits as tax deductions.
HSA funds used for non-eligible medical expenses are taxed and subject to a 10% penalty if HSA holder is less than 65 years of age. After age 65, HSA funds used to pay for non-eligible medical expenses are taxed but not penalized. Please consult a tax professional for personal advice on qualifications, tax treatment and restrictions.
Dental
- Calendar Year Benefit Maximum: $1,500
- Calendar Year Deductible Amount: $50 (3 per family)
- Full Dental Summary of Benefits
- Dental Providers
Preventive Services:
- Paid at 100% (deductible waived)
- Diagnostic Services
- Periodic Oral Evaluations
- Radiographs
- Lab and Other Diagnostic Tests
- Dental Prophylaxis (Cleanings)
- Sealants (for children under age 16)
- Space Maintainers (for children under age 16)
Basic Services:
- Paid at 80%
- Restorative (Amalgam or Composite)
- General Services (Including Emergency Treatment)
- Simple Extractions
Major Services
- Paid at 50%
- Oral Surgery (includes surgical extractions)
- Periodontics
- Endodontics
- Inlays/Onlays/Crowns
- Dentures and other Removable Prosthetics)
- Fixed Partial Dentures (Bridges)
Orthodontic Services
- Paid at 50% (deductible waived)
- Diagnose or correct misalignment of teeth or bite.
- $1,500 Lifetime Maximum
- Available to Dependent Children under age 19
Vision Insurance
- $10 Exam Copay
- $25 Materials CoPay
- Discounts on other services
- Frequency Limits
Comprehensive Exam: Every 12 Months
Lenses: Every 24 Months
Contact Lenses: Every 12 Months - Vision Providers
Contact Lens Exam/Fitting Fee:
Most providers charge a fee for the fitting of contact lenses. This fee is separate from the eye examination and will vary depending on the provider’s fee structure policies. It will also vary due to circumstances or complexities involving the physiological condition of the eyes, the lens prescription, and the type of lenses used. The contact lens exam/fitting fee may be included in the contact lens allowance.
Employees who elect coverage cannot change coverage until the open enrollment period after the first plan year, except for “coverage category” as a result of a qualifying family status change. Employees who do not elect coverage cannot enroll until the next open enrollment period.
Discount SVP8-20
- 20% Discount for Add-on charges to the covered pair of lenses.
Additional Purchases
- 30% Discount for Prescription eyeglass lenses
- 30% Discount for Eye frames
- 20% Discount for Add-on charges to basic lenses
- 20% Discount for Contact lenses, standard hard or soft
- 10% Discount for Disposable contact lenses
- 20% Discount for All other prescription materials
- Discounts are available for additional purchases of eyewear and contact lenses. Discounts are provided by Superior Vision Services contracted providers identified in the Provider Directory with a “DP”. These discounts do not apply to the insured benefit plan underwritten by ReliaStar Life Insurance Company.
How to Use the Plan
Procedure when using a Superior Vision Plan in-network provider:
- Identify yourself to the in-network provider as a member of the Superior Vision Plan. You can use your ID card for this purpose or simply give the provider your name, employer name, and your social security number. The provider will call SVS Member Services to verify your eligibility and obtain an authorization number. The I. D. card provided to you can be used for all covered family members.
- After eligibility is established, and an authorization number is received by the provider, services will be rendered. There is nothing else that you need to do except pay the provider directly for any appropriate copayments and charges above the covered benefits. The in-network provider handles all claims and paperwork.
Procedure when using a non-network provider:
- To receive services from a non-network provider, it is important that you first call Superior Vision Services Member Service Department at 800-507-3800 to receive your own authorization number. By doing so, you can be assured of your eligibility and reimbursement for money spent.
- After receiving services and paying in-full for the examination and/or materials (you do not pay a copayment to the non-network provider), submit your original itemized billing received from the provider, along with your authorization number, to the SVS Claims Administration office listed below.
- You will be reimbursed according to the schedule of allowances for non-network services, less any required copayments.
The Superior Vision Web Site www.superiorvision.com.
Superior Vision Plan Members have access to the following information from the Superior Vision web site:
- Review specific plan benefits and plan frequencies
- Verify individual and family enrollment
- Find a provider through a city/state or ZIP code accessing process
- Print a map to the provider’s location
Basic Group Life and AD&D Insurance
Basic Life
- Basic Life: 1X your base annual earnings not to exceed $300,000.
- Accidental Death & Dismemberment: 1X your base annual earnings not to exceed $300,000.
- Guarantee Issue: $300,000
- Note: for employees age 70+ the guarantee issue amount is $50,000.
- Disability Premium Waiver: Included
- Age Reduction: Included
- Conversion Privilege: Included
Optional Life Insurance
Employee
- $10,000 Increments to $300,000
- Not to exceed 5X your annual salary.
- Evidence of Insurability is required for initial amounts above $150,000.
- Evidence of Insurability is required on all "late" applicants (elections after the initial effective date).
- The maximum benefit for employees age 70 and over is $50,000.
- Benefits reduce by: 35% at age 65; 50% at age 70; 75% at age 75; and 85% at age 80.
Spouse
- 50% of employee amount to $150,000
- Employee coverage required.
- Benefit amount may not exceed 50% of the employee coverage amount.
- Evidence of Insurability is required for initial amounts above $50,000.
- Evidence of Insurability is required on all "late" applicants.
- Benefits reduce by: 35% at age 65; 50% at age 70; 75% at age 75; and 85% at age 80.
Children
- $5,000 or $10,000
- Employee coverage required.
- Evidence of Insurability is required on all "late" applicants.
- Coverage begins at 6 months from birth and ends at age 25 or 26 if full time student.
- $250 limit for children age 14 days to six months.
- Newborn children to age 14 days are not eligible.
Disability Insurance
Long Term Disability
Dunder Mifflin provides long-term disability (LTD) coverage at no cost to you. LTD protects your paycheck in the event of disability. If you have an illness or disability that lasts longer than 90 days, the LTD plan replaces 60% of your salary to a maximum of $10,000 per month. Benefits can be payable to age 65 in accordance with your SPD.
- Elimination Period: 90 Days
- Percentage of Salary: 60%
- Maximum Monthly Benefit: $10,000
- Benefit Duration: Benefits are payable to To Age 65 (You must be disabled to receive benefits)
Optional Short Term Disability
- Elimination Period: 1st day accident/8th day illness
- Percentage of Salary: 60%
- Maximum Weekly Benefit: $1,150
- Benefit Duration: 13 weeks (You must be disabled to receive benefits)
Eligibility
When Coverage Begins
Eligible employees, and their eligible dependents, are covered on the First of the Month following the employee's date of full-time employment.
When Coverage Ends
Medical, Dental, and Vision coverage ends on the last day of the month in which you, or your covered dependents, are no longer eligible for coverage under the plan.
Life and Disability coverage ends on your date of termination.
Employees
You are eligible for benefits as a full-time employee if you work at least 30 hours per week, and satisfy the new-hire waiting period.
Dependents
You may also enroll your eligible dependents under plans offered by The plan. Your eligible dependents are
Your legally-married spouse, or person with whom you have filed a Declaration of Informal Marriage;
Dependent children may participate on the Medical plan up to age 26. Dependent children include:
- Stepchildren, Adopted children, and Children for whom you are the legal guardian.
- Your grandchild under age 26, if the child qualifies and is claimed as your dependent for federal tax purposes; and
- Certain children over age 26, who are determined by the Plan to be medically incapacitated and are unable to provide their own support.
Your unmarried child(ren) up to age 25 on Dental, Vision, and Optional Life.
The plan may require supporting documentation when you request to add a dependent. You may be asked to provide copies of your marriage license, your children’s birth certificate(s), and/or appropriate adoption paperwork. This paperwork is required not only to support the coverage of eligible dependents but, in the case of marriage or the birth of a new child, to support a mid-year change of status.
Examples of dependents who are not eligible for coverage include
- Your common-law spouse, unless you have obtained a Declaration of Informal Marriage;
- Your same-sex partner;
- Your former spouse;
- Your child over age 26, if not medically incapacitated and unable to provide their own support;
- Foster children covered by another government program, unless required by law;
- Any child for whom you have Power of Attorney only;
- Any dependent who is active in the Armed Forces of any country.
Initial Period of Eligibility
You have 31 days from your hire date (initial period of eligibility) to complete enrollment in The plan. Employees moving from a non-benefits eligible status to a benefits eligible status also have 31 days from their new benefits eligible status (initial period of eligibility) to complete enrollment in The plan.
If elections are not made within the 31-day initial period of eligibility, you will be considered a "Late Applicant" and required to wait until the next Annual Enrollment or a qualified Change of Status event to make changes, including adding or dropping coverage.
Change of Status
Changes to your The plan may be made during Annual Enrollment each year or following a qualified Change of Status. You have 31 days from the date of the Change of Status event to notify your Plan Administrator and change your benefit selections. If you do not make your changes during the 31-day Status Change Period, your changes cannot be made until the next Annual Enrollment in December, to be effective the January 1st.
The list below includes common examples of qualified Changes of Status events:
- Marriage, divorce, annulment, legal separation, or spouse’s death
- Birth, adoption, medical child support order, or dependent’s death
- Significant change in residence if the change affects your or your dependents’ current plan eligibility
- Starting or ending employment, starting or returning from unpaid leave of absence, or a change of job status (e.g., from non-benefits eligible part-time to full-time)
- Change in dependent’s eligibility (e.g., marriage or reaching age 26)
- Change in coverage or cost of other benefit plans available to you and your family
Your benefit changes must be consistent with your Change of Status event. For questions regarding a qualified Change of Status, please contact your Plan Administrator.
Continuation of Group Medical and Dental Coverage (COBRA)
If you or your dependents lose eligibility for coverage, you may be eligible to continue your medical and dental coverage, generally for up to 18-months, under COBRA.
Dependents, losing coverage as a result of the death of an employee, may be eligible to continue medical and dental coverage for up to 36 months, pursuant to applicable COBRA provisions.
HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) imposes certain requirements on group health plans, including
- Limitations on pre-existing condition exclusion periods;
- Special enrollment periods for individuals (and dependents) losing other coverage;
- Prohibitions against discriminating against individual participants and beneficiaries based on health status;
- Standards relating to benefits for mothers and newborns;
- Parity in the application of certain limits to mental health benefits; and
- Protecting your privacy.
Flexible Spending Account
What is a FlexPlan?
Authorized by Internal Revenue Code Section 125, Cafeteria Plans, also called reimbursement accounts, flexible benefit plans or Flexible Spending Accounts (FSAs), provide a tax-advantaged way to pay certain out-of-pocket health care expenses, and work-related dependent care expenses.
The plans allow you to pay your expenses with “pre-tax” dollars, which means that you get a tax deduction for these expenses before you ever file your tax return. You don’t pay Federal income or Social Security taxes on this money and, in most states, you don’t pay state taxes either.
Please note, the latest health care reform bills, the Patient Protection and Affordable Care Acts, impact how over-the-counter (OTC) drugs and medicines are treated with respect to FlexPlans. Effective January 1, 2011 - OTC drugs and medicines will be considered ineligible unless you have a prescription from your physician.
Health Care FlexPlan
- Healthcare Contribution Limit: $3,000
- Eligible Health Care Expenses
- Savings Calculator
Dependent Care FlexPlan
- Dependent Care Contribution Limit: $2,500 ($5,000 if married filing jointly)
- Eligible Dependent Care Expenses
- Dependent Care Calculator
For more information, contact your Plan Administrator.