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Benefits Guide
Your Health
Your Decision
2016 - 2017
Plan Year
2 Overview
Table of Contents Page
Overview 2 - 3
Core Group Benefits 4
Medical 5 - 6
Dental 7
Basic Term Life Insurance & Supplemental Term Life 8
LTD 9
STD 10
Vision 11
Trustmark Voluntary Benefits 12 - 13
LifeLock Iden-ty The/ Protec-on 14
Important Contacts 15
Who is eligible?
Employees working at least 30 hours each work week and their eligible dependents.
When can I Enroll? New hire ini-al enrollment and annual open enrollment allows for employees of the Diocese to enroll or
make changes in any of the plans without a qualifying event.
In order to make changes outside of your ini-al or annual enrollment period, there would need to be a
qualifying event such as the birth of a child, change in marital status, death, or loss of coverage due to no
fault of your own. You must make your requested changes on the Benefits website and you must send the
required documenta-on to the Diocese Benefits Office within thirty-one (31) days of the qualifying event in
order for coverage to be effec-ve. No changes will be authorized un-l the suppor-ng documenta-on has
been provided to the Benefits Office. Ques-ons may be directed to the Benefits Office.
WELCOME TO ENROLLMENT
FOR YOUR 2016 - 2017 BENEFITS!
The Diocese of Palm Beach offers you and your eligible family members a comprehensive and valuable
benefits program. We encourage you to take the -me to educate yourself about your op-ons and choose
the best coverage for you and your family.
Annual Enrollment
Online Benefit Enrollment System open:
May 2nd - May 13th
DO I NEED TO ENROLL IN BENEFITS?
If you need to make changes to your benefits or if you would
like to review your current elec-ons you can log in to our
online benefits enrollment system from any computer,
tablet or smartphone:
Explainmybenefits.biz/diocese
If you have ques-ons regarding the enrollment system or benefits call the
Explain My Benefits Enrollment Center:
321– 296-8060; Op-on 1
Monday - Friday, 9:00am - 5:00pm
3 Overview
Who is Eligible? Employees working at least 30 hours each work week and their eligible dependents. Some benefits are restricted offer-
ings. Eligibility will be indicated for each benefit.
Dependents An individual who meets the eligibility criteria specified below is an Eligible Dependent and is eligible for coverage
under this Booklet:
1. The Covered Employee’s Spouse*.
2. The Covered Employee’s natural, newborn, Adopted, Foster, or step child(ren) (or a child for whom the Covered
Employee has been court-appointed as legal guardian or legal custodian) who has not reached the end of the Cal-
endar Year in which he or she reaches age 26 (or in the case of a Foster Child, is no longer eligible under the Foster
Child Program), regardless of the dependent child’s student or marital status, financial dependency on the Covered
Employee, whether the dependent child resides with the Covered Employee, or whether the dependent child is
eligible for or enrolled in any other health plan.
3. The newborn child of a Covered Dependent child who has not reached the end of the Calendar Year in which he or
she becomes 26. Coverage for such newborn child will automa-cally terminate 18 months a/er the birth of the
newborn child.
Note: If a Covered Dependent child who has reached the end of the Calendar year in which he or she becomes 26 obtains a
dependent of their own (e.g., through birth or adop�on) such newborn child will not be eligible for this coverage and the Covered
Dependent child will also lose his or her eligibility for this coverage. It is the Covered Employee’s sole responsibility to establish that
a child meets the applicable requirements for eligibility.
*SPOUSE shall mean for all purposes of the Trust and each Plan of the Trust, the individual to whom the Member Par-
-cipant is civilly married under a marriage covenant between a man and a woman as described in Canon 1055 of the
Code of Canon Law (Codex Iuris Canonici) for the La-n Rite of the Catholic Church.
Medical and Vision - Dependent children up to age 26 regardless of financial dependency, residency, student status,
employment or marital status. Coverage ends the last day of the year the child turns 26.**
**A Covered Dependent child may con-nue coverage beyond the age of 26 (Medical & Vision ONLY), provided he or
she is:
1. unmarried and does not have a dependent;
2. a Florida resident or a full--me or part--me student;
3. not enrolled in any other health coverage policy or plan; and
4. not en-tled to benefits under Title XVIII of the Social Security Act unless the child is a
Handicapped dependent child.
This eligibility shall terminate on the last day of the Calendar Year in which the dependent child reaches age 30.
Dental & Supplemental Term Life- Dependent children up to age 19 or 25, if a full-5me student. Coverage ends the
last day of the year the child turns 19 or 25.
4 Overview of Core Group Benefits
Plans BCBS Standard BCBS Premium
In Network Out-of-Network In Network Out-of-Network
Deduc5ble
Individual $400 $600 $300 Combined w/ In-Network
Family $1,200 $1,800 $900 Combined w/ In-Network
Coinsurance 20% 50% 10% 30%
Out of Pocket Maximum (Includes Deduc5ble, Coinsurance, Co-pays, PAD and Rx)
Individual $3,500 Combined w/ In-Network $2,500 Combined w/ In-Network
Family $7,000 Combined w/ In-Network $7,500 Combined w/ In-Network
Preven5ve Care
Office Visit Covered 100% 50% Coinsurance Covered 100% 30% Coinsurance
Mammograms Covered 100% Covered 100% Covered 100% Covered 100%
Colonoscopy Covered 100% 50% Coinsurance Covered 100% 30% Coinsurance
Physician Office Visit
Primary Care $25 Co-pay 50% a/er Ded. $25 Co-pay 30% a/er Ded.
Specialist $50 Co-pay 50% a/er Ded. $50 Co-pay 30% a/er Ded.
Diagnos-c Labs 20% Coinsurance 50% a/er Ded. 10% Coinsurance 30% a/er Ded.
Complex Imaging $50 Co-pay 50% a/er Ded. $50 Co-pay 30% a/er Ded.
Hospital Services, Urgent Care & Walk-In Clinics
In-Pa-ent Hospital
Services (Out of Network
PAD Applies)
20% a/er Ded. 50% a/er Ded. +
$500 PAD 10% a/er Ded.
30% a/er Ded. +
$300 PAD
Outpa-ent Surgery 20% a/er Ded. 50% a/er Ded. 10% a/er Ded. 30% a/er Ded.
Emergency Room
(PVD Applies)
20% a/er Ded. +
$100 PVD
20% a/er Ded. +
$100 PVD
10% a/er Ded. +
$50 PVD
10% a/er Ded. +
$50 PVD
Urgent Care $25 Co-pay 50% a/er Ded. $25 Co-pay 30% a/er Ded.
Prescrip5ons
Pharmacy Deduc-ble
Per Rx Max Out of Pocket
$100
$50 per Rx Full cost at purchase and
must file a claim for
reimbursement
$100
$50 per Rx
Generic
Preferred Brand
Non-Preferred Brand
Rx Ded. + Greater of $5 or 30%
Rx Ded + Greater of $35 or 30%
Rx Ded + Greater of $50 or 50%
Rx Ded. + Greater of $5 or 30%
Rx Ded. + Greater of $30 or 30%
Rx Ded. + Greater of $45 or 50%
Specialty Drugs 20%
$375 Max per Rx Not Covered
Rx Ded. + 10%
$225 Max per Rx Not Covered
Full cost at purchase and
must file a claim for
reimbursement
5 Group Benefits - Medical
Go to www.floridablue.com to locate a network provider. Please note that your out-of-pocket costs will be more if you
choose to go to an out-of-network provider.
Coverage Tier BCBS Standard Plan BCBS Premium Plan
Employee Only $9.00 $28.00
Employee & Spouse $260.50 $299.50
Employee & Child (1 Child) $260.50 $299.50
Employee & Children $357.00 $400.50
Family $357.00 $400.50
Semi-Monthly (24 Pay Period) Rates
Coverage Tier BCBS Standard Plan BCBS Premium Plan
Employee Only $10.80 $33.60
Employee & Spouse $312.60 $359.40
Employee & Child (1 Child) $312.60 $359.40
Employee & Children $428.40 $480.60
Family $428.40 $480.60
20 Pay Period Rates
6 Group Benefits - Medical Rates
Go to www.floridablue.com to locate a network provider. Please note that your out-of-pocket costs will be more if you
choose to go to an out-of-network provider.
Good oral care enhances overall physical health, appearance and mental well-being. Problems with the teeth and
gums are common and easily treated health problems. Keep your teeth healthy and your smile bright with the Diocese
of Palm Beach dental benefit plan.
Go to www.deltadentalins.com to locate a network PPO provider. Please note that your out-of-pocket costs may be
more if you choose to go to an out-of-network provider.
*When you receive services from an Out of Network Den-st, the percentages in this column indicate the por-on of Delta Dental’s
Out of Network Den-st Fee that will be paid for those services. The Out of Network Den-st Fee may be less than what your den-st
charges and you are responsible for the difference.
***Dependents ages 19 and under can be covered with no requirements and age 25 if a full �me student. Coverage terminates
at the end of the calendar year in which the dependent turns 19 or 25.
7 Group Benefits - Dental
Plan Delta Dental PPO
In-Network
Delta Dental PPO
Out of Network*
Calendar Year Deduc5ble $100 per person $100 per person
Annual Maximum $1,500 per person $1,500 per person
Preventa5ve Services
Oral examina-ons, rou-ne cleanings, x-rays,
fluoride treatment, space maintainers
Plan pays 100%
Deduc-ble waived
Plan pays 100%
Deduc-ble waived
Basic Services
Fillings, sealants, denture repairs,
endodon-cs, periodon-cs, oral surgery
80% Covered 80% Covered
Major Services
Crowns, inlays, onlays, cast restora-ons,
bridges, dentures
50% Covered 50% Covered
Deduc5ble Applies
Coverage Tier Semi-Monthly (24 Pay Period) Rates 20 Pay Period Rates
Employee Only $0.00 $0.00
Employee & Spouse $46.00 $55.20
Employee & Child (1 child) $46.00 $55.20
Employee & Children $59.00 $70.80
Family $59.00 $70.80
** Coverage reduces by 50% at age 70
8 Group Benefits - Term Life Insurance
COSTS FOR VOLUNTARY SUPPLEMENTAL LIFE AND
ACCIDENTAL DEATH & DISMEMBERMENT
Age Band Employee & Spouse Life
Monthly Rate per $1,000 Age Band
Employee & Spouse Life
Monthly Rate per $1,000
00-29 $0.070 50-54 $0.410
30-34 $0.080 55-59 $0.700
35-39 $0.110 60-64 $1.010
40-44 $0.170 65-69 $1.540
45-49 $0.230 70-100 $2.900
$2,000 $0.24
$4,000 $0.48
$6,000 $0.72
$8,000 $0.96
$10,000 $1.20
CHILD LIFE
MONTHLY RATES
Coverage Amount
$50,000
# of Units/$1,000
(Coverage Amt./1,000)
50
Monthly Rate per $1,000
from rate table above
.110
Total Monthly Premium
$ 5.50
Example: A 36 year old employee wants to
purchase $50,000 of term life insurance.
Coverage Amount
_______________
# of Units/$1,000
(Coverage Amt./1,000)
_______________
Monthly Rate per $1,000
from rate table above
_______________
Total Monthly Premium
_______________
Employee Worksheet
Basic Term Life and AD&D The Diocese of Palm Beach provides Basic Life and AD&D Insurance for all eligible employees at no cost to the
employee. The Basic Life benefit is $25,000 and AD&D insurance benefit is $25,000.
Voluntary Supplemental Term Life You also have the opportunity to purchase supplemental Term Life coverage for yourself, spouse and dependent
children. Please note that dependent children include unmarried adopted, natural or stepchildren age 14 days to age
19 (25 if full--me student).
You may elect Voluntary Life Insurance in increments of $10,000 to a maximum of $100,000. You may elect Voluntary
Life Insurance on your dependents: spouse in increments of $10,000 to a maximum of $50,000, not to exceed 100% of
your Op-onal Term Life coverage amount and children in increments of $2,000 to a maximum of $10,000, not to
exceed 50% of your Op-onal Term Life coverage.
Guaranteed Issue Amount
$50,000 employee / $20,000 spouse / $10,000 children
Guaranteed Issue is only for employees enrolling within the ini5al eligibility enrollment period.
EOI is required for enrollment / changes a/er the ini-al enrollment period.
Available to Laity employees
Laity employees of the Diocese of Palm Beach are provided, at no cost to you, Long Term Disability (LTD) coverage,
aGer one full year of employment with the Diocese. LTD coverage supplements your lost wages should you be
unable to work due to an illness or injury. LTD coverage begins a/er missing the specific elimina-on period below due
to a medically cer-fied reason. Benefits are payable up to the specific benefit dura-on period below. Benefits may be
offset by deduc-ble sources of income - please see your policy for details.
Elimina5on Period for sickness, accident or pregnancy: 90 Days
Monthly Benefit: 60% of your monthly earnings to a maximum benefit of $3,000
Maximum Benefit Period: Under age 61 to normal re-rement age*, but not less than 60 months
Age 61 to normal re-rement age*, but not less than 48 months
Age 62 to normal re-rement age*, but not less than 42 months
Age 63 to normal re-rement age*, but not less than 36 months
Age 64 to normal re-rement age*, but not less than 30 months
Age 65 24 months
Age 66 21 months
Age 67 18 months
Age 68 15 months
Age 69 and over 12 months
*Your normal re�rement age is your re�rement age under the Social Security Act where re�rement age depends on
your year of birth.
Pre-Exis5ng Condi5on: LTD benefits will not be paid for a disability that begins within 12 months of your coverage
effec-ve date and due to a pre-exis-ng condi-on.
LONG TERM DISABILITY
9 Group Benefits - Disability Insurance
As an employee of the Diocese of Palm Beach, you are able to enroll in Short Term Disability (STD) coverage at your
own expense. STD coverage supplements your lost wages should you be unable to work due to an illness, injury or
pregnancy. STD coverage begins a/er missing the specific elimina-on period below due to a medically cer-fied reason.
Benefits are payable up to the specific benefit dura-on period below.
Elimina5on Period for sickness, accident or pregnancy: 14 Days
Maximum Benefit Period: 11 weeks
Weekly Benefit: 60% of your weekly earnings to a maximum benefit of $1,500
Cost per unit of weekly benefit: $.017
Pre-Exis5ng Condi5on: STD benefits will not be paid for a disability that begins within 12 months of your coverage
effec-ve date and due to a pre-exis-ng condi-on.
SHORT TERM DISABILITY
Step 1 Indicate your weekly earnings $1,000.00
Step 2 Mul-ply your weekly earnings by 60% $600.00
Step 3 If the amount in Step 2 is greater than $1,500, indicate
$1,500. Otherwise, indicate the amount from step 2. $600.00
Step 4 Mul-ply the amount in Step 3 by the rate of $0.017 to
obtain your total STD monthly cost. $10.20
Calcula5on for Total Monthly STD Cost
Example: Employee has a $52,000 annual salary and wants to purchase short
term disability.
10 Group Benefits - Disability Insurance
Available to Laity only. Available only for those in their ini5al eligibility period.
Regular eye examina-ons cannot only determine your need for correc-ve eyewear, but also may detect
general health problems in their earliest stages. Protec-on for your eyes should be a major concern to
everyone.
*Dependent eligibility rules for
the Vision Plan are on Page 4.
Go to www.vsp.com to locate a network provider. Please note that your out-of-pocket costs may be more if
you choose to go to an out-of-network provider.
11 Group Benefits - Vision Insurance
Available to all employees
WellVision Exam � Focuses on your eyes and overall wellness $10 Every plan year**
Prescrip5on Glasses $25 See frames and lenses
Frame
� $150 allowance for a wide selec-on of frames
� $170 allowance for featured frame brands
� 20% off amount over your allowance
Included in
Prescrip-on
Glasses
Every other plan year
Lenses � Single vision, lines bifocal, and lined trifocal lenses
� Polycarbonate lenses for dependent children
Included in
Prescrip-on
Glasses
Every plan year
Lens Op5ons
� Standard progressive lenses
� Premium progressive lenses
� Custom progressive lenses
� Average 20-25% off other lens op-ons
$55
$95 - $105
$150 - $175
Every plan year
Contacts
(instead of glasses)
� $150 allowance for contacts; copay does not apply
� Contact lens exam (fiUng and evalua-on) Up to $60 Every plan year
Diabe5c Eyecare Plus
Program
� Services related to diabe-c eye disease, glaucoma and age-
related macular degenera-on (AMD). Re-nal screening for
eligible members with diabetes. Limita-ons and coordina-on
with medical coverage may apply. Ask your VSP doctor for
details.
$20 As needed
Extra Savings and
Discounts
Glasses and Sunglasses: 20% off addi-onal glasses and sunglasses, including lens op-ons, from any VSP
doctor within 12 months of your last WellVision Exam.
Re5nal Screening: Guaranteed pricing on re-nal screening as an enhancement to your WellVision Exam.
Laser Vision Correc5on: Average 15% off the regular price or 5% off the promo-onal price; discounts only
available from contracted facili-es.
Your Coverage with Other Providers
Visit vsp.com for details, if you plan to see a provider other than a VSP doctor.
Exam……….up to $45 Single Vision Lenses……..up to $30 Lined Trifocal Lenses……..up to $65 Contacts……..up to $105
Frame……..up to $70 Lined Bifocal Lenses……..up to $50 Progressive Lenses……....up to $50
*Coverage with a retail chain affiliate may be different. Once your benefit is effec5ve, visit vsp.com for details. **Plan year begins in August
Coverage Tier Semi-Monthly (24 Pay Period) Rates 20 Pay Period Rates
Employee Only $2.81 $3.37
Employee & Spouse $5.61 $6.73
Employee & Children $6.01 $7.21
Family $9.60 $11.52
TRUSTMARK ACCIDENT PLAN A plan that helps pay for the unexpected expenses that can result from an accident.
• On and off-the-job coverage = 24 hours per day, 7 days a week
• Family coverage available
• Sports related injuries covered also
Money is paid directly to you for (please see brochure for a complete list of benefits and details):
• Ini-al Doctor’s Office Visit: $200 • Fractures: up to $15,000
• Hospitaliza-on: $3,200 admission, $500 per day • Disloca-ons: up to $12,000
Wellness Benefit Included: A wellness benefit is paid for all rou-ne physicals, vaccines, and health screen-
ing tests for each covered person. There is a 60-day wai-ng period, a/er ini-al enrollment, for this benefit.
This benefit pays $50 per test per person, twice each year (maximum of $100 annually per insured).
Examples of Health Screenings include:
• Low-dose Mammogram • Pap Smear
• Serum Cholesterol • Fas-ng blood glucose test
• Prostate Specific An-gen (PSA)
• Stress Test on a bicycle or treadmill
*Dependents up to age 26
can be covered regardless
of student status.
What are Voluntary Benefits? Voluntary Benefits are offered to strengthen your overall benefits package. You customize the benefit based
on your needs and affordability. Available to all employees.
• Ownership – Policies are fully portable and belong to you if you leave the Diocese, price and plan benefits
remain the same
• Benefits are payroll deducted
• Cash benefits are paid directly to you, not to a hospital or to a doctor
• Benefits are paid regardless of any other coverage you may have
• Level premiums—Rates do not increase with age
• Guaranteed Renewable
• Designed to provide addi-onal cash flow to assist with out of pocket medical costs and other bills
The Voluntary Benefits offered are Accident and Universal Life with Long Term Care through Trustmark.
12 Voluntary Individual Benefits
Coverage Tier Semi-Monthly (24 Pay Period) Rates 20 Pay Period Rates
Employee Only $7.87 $9.44
Employee & Spouse $11.41 $13.69
Employee & Children $15.24 $18.28
Family $18.78 $22.54
Trustmark Universal Life with Long Term Care
Universal Life with Long Term Care includes both a death benefit and a living benefit.
• Trustmark Universal Life with Long Term Care is a permanent life insurance policy that is designed to
match your needs throughout your life-me. It pays a higher death benefit during your working years
when expenses are high and you need maximum protec-on.
• The Universal Life with Long Term Care policy is priced to remain the same cost to you un-l age 100.
• The death benefit reduces at age 70 when the need for life insurance typically decreases.
• The Living Benefit, Long Term Care never reduces and is 4% of the original death benefit per month for up
to 25 months.
• If you use the Long Term Care benefit, your death benefit amount does not reduce due to the Benefit
Restora5on feature included.
• Coverage available for spouse and children as well.
Special Underwri�ng at Ini�al Offering
Guaranteed Issue (Employee Only)
The lesser of the face amount purchased by $18 per week or $200,000
Rates
This benefit is customized by each employee so rates vary, but can start as liYle as a few dollars a week.
13 Voluntary Individual Benefits
Iden-ty the/ in the United States is a major problem that con-nues to be on the rise. Professional
protec-on and assistance have become important tools in figh-ng the iden-ty the/ epidemic.
Thieves today can get a hold of your personal informa-on from trash cans, dumpsters, stolen mail, and even
shoulder surfing. Once thieves have your informa-on, it’s a simple maYer to open new fraudulent accounts
and make purchases in your name.
When you enroll in LifeLock, you can be confident knowing that they are available 24 hours a day, 7 days a
week, and commiYed 100% to helping protect your informa-on as if it were their own.
LifeLock offers Proac5ve Protec5on:
• LifeLock Iden-ty Alert System
• eRecon
• TrueAddress
• WalletLock
• Reduc-on in Pre-Approved Credit Card offers
• 24-Hour Customer Service
• Offered through payroll deduc5on at a 15% discount off retail rates
$1 Million Total Service Guarantee
LifeLock’s proac-ve approach works to help stop iden-ty the/ before it happens.
As a LifeLock member, if you become a vic-m of iden-ty the/ because of a failure
in their service, they will help fix it at their expense, up to $1,000,000.
*Employee & Children and Family Tiers: You may enroll up to 8 children with 4 of those children between the ages of 18 and 26.
14 LifeLock Iden-ty The/ Protec-on
Coverage Tier Semi-Monthly (24 Pay Period) Rates 20 Pay Period Rates
Employee Only $4.25 $5.10
Employee & Spouse $8.50 $10.20
*Employee & Children $7.44 $8.93
*Family $11.69 $14.03
Vendor Phone Website
Medical
Florida Blue 800-352-2583 www.floridablue.com
Pharmacy
RxEDO Pharmacy Benefits 888-879-7339 www.rxedo.com
Dental
Delta 800-521-2651 www.deltadentalins.com
Life / STD / LTD
Pruden-al
Contact the Benefits office at the
Diocese:
Sandy Maulden: 561-995-9574
Ana Jarosz: 561-995-9525
smaulden@diocesepb.org
anaj@diocesepb.org
Vision
VSP 800-877-7195 www.vsp.com
Voluntary Benefits
Trustmark 800-918-8877 www.trustmarksolu-ons.com
Iden5ty TheG Protec5on
LifeLock 800-543-3562 www.lifelock.com
Trustmark Claims Help
Explain My Benefits 321-296-8060, Op-on 2 service@explainmybenefits.biz
Sandy Maulden
561-775-9574
smaulden@diocesepb.org
Ana Jarosz
561-775-9525
anaj@diocesepb.org
Fax: 561-775-9575
For other ques5ons please contact the Diocesan Benefits Office:
Or go to the website at:
hYp://www.explainmybenefits.biz/diocese
15 Important Contacts
Benefit Guide Descrip5on
Please Note: This Employee Benefit Brochure is designed to provide a brief overview of the benefit plans that are provided for and made
available to employees of the Diocese of Palm Beach and their families. Please refer to the Diocesan Benefits website and your plan
booklets for full details.
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