Employee Guide for 2016. Welcome Open Enrollment October 21, 2015 - November 6, 2015 Plan Year January 1, 2016—December 31, 2016 Enrollment Elections

Employee Guide for 2016

Welcome

Open Enrollment

October 21, 2015 - November 6, 2015

Plan Year January 1, 2016—December 31, 2016

Enrollment Elections are Effective 1/1/16

General Information for All Employees. Please Read Thru the Entire Packet.

Health and/or Dental Insurance Benefits

-ACTION is REQUIRED! – If you are eligible for benefits according to your employment agreement, you must enroll or decline (opt-out) even if you currently have benefits with the District. If you work for the District on average 30 hours or more per week or 130 hours per month, even in a combination of duties, you are eligible for health coverage. For determining eligibility, a month to month method or a look back measurement method is used based on your employee group. The measurement period is from November 1, 2014 thru October 31, 2015. Please enroll or decline the coverage thru your employee access of Skyward.

If you are eligible for benefits with a District contribution, but do NOT enroll or decline (opt-out) in the District’s Health Plan, you will be automatically enrolled in the District’s Single High Deductible Health Plan (HDHP). However, being auto enrolled does not qualify to receive the HRA contribution. See Automatic Enrollment Language in contracts or work agreements for further information.

Health Flexible Spending Account (FSA)

Prescription & medical/dental out of pocket expenses

YES you need to enroll every year if you want to have pre-tax dollars taken out of your paycheck for health expense reimbursement. You must enroll if you want to participate.

YES you need to enroll every year if you want to have pre-tax dollars taken out of your paycheck for dependent care expenses. You must enroll if you want to participate.

Dependent Care Account Plan (DCAP)

Designed for employees who need daycare to be able to work

IMPORTANT INFORMATION

1. You are responsible for Insurance Services receiving your election by November 6th.

2. Open Enrollment elections cannot be changed after the deadline. Reminder: Elections are based on the Plan Year.

3. On-line enrollment is done through your Skyward Employee Access. Additional information is available at www.rochester.k12.mn.us/insurance

4. 2015 Health and/or Dental Benefits will not be carried over into 2016. You must ENROLL during this Annual Open Enrollment!

http://www.rochester.k12.mn.us/insurance

Table of Contents

Benefit Choices 2

Tax Benefits 3

When Benefits Can Be Changed 4

Medical Plans 5-9

Dental Plan 10

Medical and Dental Premiums 11

Flexible Spending Accounts 12-15

Life Insurance 16

Long Term Disability 17

Employee Assistance Program 18

457 and 403(b) Plans 19

Notice of Privacy Practices 20-24

COBRA Continuation Notice 25-28

Marketplace Notice 29-30

Annual Notifications 31-34

Contacts 35

1

MAKING CAREFUL CHOICES

The annual enrollment period is the only time you can change benefit plans or add/drop dependents during a plan year, unless you have a qualified life event. Qualified life events include a birth, death, marriage, divorce, adoption, ineligibility of a dependent, unpaid leave of absence. Reference page 4 of the guide for qualified life events. Please choose your benefits carefully.

2

YOUR BENEFIT CHOICES

Rochester Public Schools provides a wide variety of benefits. Some are provided automatically at no cost to you. Other benefits are available if you choose them. Check the following guide to see which benefits you need to make a successful program designed just for you.

Rochester Public Schools Health and Welfare Benefits Plan offers you and your family affordable comprehensive benefits that are designed to maintain your health and protect your income in case of illness or injury. You have the flexibility to choose the benefits that make the most sense for you and your family.

Benefit Choices

BENEFITBENEFIT AUTOMATICALLY AUTOMATICALLY ENROLLEDENROLLED

YOU CAN ENROLL YOU CAN ENROLL NOWNOW

WHO PAYS THE COSTWHO PAYS THE COST

*Medical Coverage District &/or Employee

Dental Coverage District &/or Employee

Flexible Spending Accounts

Health Care Dependent Care

EmployeeEmployee

Life and Accidental Death & Dismemberment (AD&D) Insurance

District &/or Employee

Long Term Disability (LTD)

District &/or Employee

Supplemental Long Term Disability (IDI)

Employee

Employee Assistance Program (EAP)

District

*See Automatic Enrollment Provision on Page 6

3

PRE-TAX AND AFTER TAX BENEFITS

Pre-Tax Benefits

To provide you with an allowable tax benefit, your payroll deductions for some benefits are made on a pre-tax basis. Pre-tax benefits are paid for with the money deducted from your paycheck before taxes are withheld. You do not pay federal income tax, FICA (Social Security and Medicare), and in most cases state taxes on the contributions you make for before-tax benefits. The federal government also imposes restrictions on benefits that are paid on a pre-tax basis, such as how often you can change your benefits. In exchange for the advantage of pre-tax benefits, Section 125 of the IRS Code requires you to keep your pre-tax benefit choices the same for the entire plan year. However, your pre-tax benefit choices may be changed during the plan year if you have a qualifying life event. (See page 4 for a definition of qualifying life event.)

Eligible pre-tax benefits include:

Medical

Dental

Flexible Spending Account

After-Tax Benefits

After-tax benefits are benefits for which payroll deductions are taken out of your paycheck after taxes have been withheld.

If not enrolled during your first 30 days of being hired, you may apply for late enrollment throughout the year, however, you must submit satisfactory evidence of good health before being considered by the carrier to be approved for coverage.

Eligible after-tax benefits include:

Life and AD&D

Long Term Disability

Supplemental Long Term Disability

Tax Benefits

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Any change in your employment status, or your spouse’s or qualified dependent’s employment status, that results in a significant change to your benefits, such as start or end of employment, change from full-time to part-time employment, or start or end of an unpaid leave of absence

Dependent satisfies or ceases to satisfy eligibility

Change in worksite or residence for you, your spouse or your qualified dependent, if that change affects your benefits

To make a change, you must contact Insurance Services within 30 days of the qualifying life event. If you do not change coverage within 30 days of the above qualifying life event, your next opportunity to change options will be during next annual open enrollment period for 2017.

If you experience a qualifying life event, the changes you make to your benefits must be consistent with your change in status. For example, if you get married, you can add your spouse to your health care coverage. However, you cannot change from one plan to another (e.g. from $500 deductible plan to $1,500 HDHP).

WHO TO CONTACT FOR HELP

If you have questions on the health and welfare benefits programs, contact Insurance Services at (507) 328-4280. Also visit the Insurance Services website at www.rochester.k12.mn.us/insurance.

WHEN BENEFITS CAN BE CHANGED

The benefit selections you make now cannot be changed until the next annual Open Enrollment period (unless you have a qualifying life event). The benefit selections you make during this election period will remain in effect through December 31, 2016. However, you may make changes during the year if you experience any of the following changes in status, known as a “qualifying life event”:

Marriage, divorce or legal seperation

Birth or adoption of a dependent, or placement of a child with you for foster care or adoption

Death of a spouse or qualified dependent

When Benefits Can Be Changed


MEDICAL COVERAGE

At Rochester Public Schools we are committed to providing comprehensive, affordable health care coverage. The District offers two medical plans so you can choose a coverage option best suited to your needs. Rochester Public School has determined that the following plans will offer choice, yet remain cost effective.

Medical Plans:

$500 Deductible Plan$1,500 High Deductible Plan (HDHP)

A comparison chart of the medical plans can be found beginning on page 7. Review your choices carefully. Once you choose your plan during open enrollment, your election will be in effect January 1, 2016 thru December 31, 2016.

Is your doctor in the network?

1) Visit the networks section of www.ccstpa.com

Choose networks Choose search our networks Choose CCStpa networks for in Minnesota or PHCS for outside the Minnesota

area

2) Call Rochester Public Schools Insurance Services at (507) 328-4280 or 1-888-940-7427 for PHCS providers.

Why is it important to see network providers?

If you see a provider that is not in your network, your costs could be significantly higher because your share of the cost will be based on the provider’s full charges rather than the discounted rate negotiated with in-network providers. Using a network provider will save you and the plan money.

Medical Benefits

5

Health Reimbursement Arrangement (HRA)

According to most employment contracts and work agreements, if you are eligible for a District contribution toward health premiums, and elect to participate in the High Deductible Health Plan (HDHP) during open enrollment you will be enrolled in the HRA where the District contributes $750 to a health reimbursement account if you have elected single coverage or $1,500 if you have elected family coverage. HRA participation does require you to actively elect the HDHP. Being auto enrolled does not qualify to receive the HRA contribution.

http://www.ccstpa.com/

Medical Benefits

6

Automatic Enrollment Provision

If you are eligible for medical coverage with a District contribution toward the premium and do not enroll during the annual open enrollment period in one of the medical plans indicated on page 5, you will be automatically enrolled with single coverage in the High Deductible Health Plan. This automatic enrollment provision does NOT give access to receiving a Health Reimbursement Arrangement District contribution.

Summary of Benefits & Coverage

The Affordable Care Act (ACA) requires Rochester Public Schools to distribute a Summary of Benefits and Coverage (SBC) to provide standard information that assist you to compare and understand you medical plan options. You can also find a copy of the SBC for each health plan under www.rochester.k12.mn.us/insurance, Summary Plan Documents.


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MEDICAL BENEFIT SUMMARY $500 Deductible

This is a brief summary only. Certain restrictions and exclusions apply. For exact terms and conditions, please refer to your summary plan description.

$500 DEDUCTIBLE PLAN

Partial Listing of Covered Services

Summary of Benefits Rochester Public Schools

January 1, 2016

Annual Deductible(Deductible carryover applies)

$500 per member$1,500 per family

Annual Out-of-Pocket Maximum

Annual Prescription Drug Out-of-Pocket Maximum(Prescription drug copays are applied toward the prescription out-of-pocket maximum)

$2,500 per member$5,000 per family

$1,500 per person$3,000 per family

Lifetime Maximum Unlimited

Preventive Care•Routine Physical & Eye Exams•Immunizations, Well Child Care and Cancer Screenings

The deductible does not apply to these services.100%100%

Office Visits•Illness or Injury•Chiropractic Care (20 visit maximum)•Physical, Occupational & Speech Therapy•Mental Health and Substance Abuse

80% after $30 copayment80% after deductible80% after deductible

80% after $30 copayment

Prescription DrugsUp to a 30-day supply per prescription

Generic: 100% after $12 copaymentRxF Preferred Brand: 100% after $30 copaymentNon-preferred Brand: 100% after $55 copayment

Specialty: 100% after $60 Copayment

Inpatient Hospital Services 80% after deductible

Outpatient Hospital Services 80% after deductible

Lab and Pathology 80% after deductible

X-Ray and Other Imaging 80% after deductible

Urgent or Emergency Care•Urgent Care Center•Hospital Emergency Room•Emergency Ambulance

80% after $30 copayment$50 copayment, then 80% after deductible

80% after deductible

Durable Medical Equipment and Prosthetics


Home Health CareLimited to a maximum of 60 visits per calendar year


Medical Benefits

Medical BenefitsMEDICAL BENEFIT SUMMARY $1,500 Deductible (HDHP)


$1,500 DEDUCTIBLE PLAN

Partial Listing of Covered Services

Summary of Benefits Rochester Public Schools

January 1, 2016

Annual Deductible(Deductible carryover applies)


Annual Out-of-Pocket MaximumAll providers combined (including prescription drugs)

Annual Prescription Drug Out-of-Pocket Maximum(Prescription drug copays are applied toward the presciption out of pocket maximum)


$1,500 per person$3,000 per family

Lifetime Maximum Unlimited

Preventive Care•Routine Physical & Eye Exams•Immunizations, Well Child Care and Cancer Screenings

The deductible does not apply to these services.100%100%

Office Visits•Illness or Injury•Chiropractic Care (20 visit maximum)•Physical, Occupational & Speech Therapy•Mental Health and Substance Abuse

80% after deductible80% after deductible80% after deductible


Prescription DrugsUp to a 30-day supply per prescription Generic: 100% after $12 copayment

RxF Preferred Brand: 100% after $30 copaymentNon-preferred Brand: 100% after $55 copayment

Specialty: 100% after $60 Copayment

Inpatient Hospital Services 80% after deductible

Outpatient Hospital Services 80% after deductible

Lab and Pathology 80% after deductible

X-Ray and Other Imaging 80% after deductible

Urgent or Emergency Care•Urgent Care Center•Hospital Emergency Room•Emergency Ambulance

80% after deductible80% after deductible80% after deductible

Durable Medical Equipment and Prosthetics


Home Health CareLimited to a maximum of 60 visits per calendar year


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Medical Benefits

9

Prenatal Support for moms and babiesTo promote a healthy pregnancy, the Prenatal Support program matches moms-to-be with a registered nurse with obstetric experience who delivers personal and ongoing support by phone. Participants who complete the program receive a $50 gift card. You also get a prenatal self-care guide book and helpful educational materials.

Call toll free at 1-866-938-9743 to get started.

Proven Stop-Smoking SupportStop-Smoking Support has helped thousands of people. It provides one-on-one phone counseling and tools and strategies to help you quit in your own way, at your pace. Call toll free at 1-888-662-Quit (7848) to get started.

Fitness Program pays you back monthlyEligible members can earn up to a $20 credit each month toward your fitness center dues by working out at least 12 days a month at a participating fitness center.

Step 1: To find a participating fitness center visit http://ccstpa.com/Member/FitnessDiscount. At the bottom of the webpage, click on Find Center.

Step 2: Enroll at your participating fitness center. Present your medical member ID card with the fitness symbol and tell them you want to enroll into the Fitness Center Discount Program.

Step 3: If you have worked out 12 days in a month the fitness center will submit this record for you. You will receive up to a $20 credit directly to your bank account (will take up to 60 days) as reimbursement. You can receive up to $40 per household for qualifying adults over age 18 covered under your plan. Your visits are tracked and submitted by your fitness center. As long as you are eligible for the discount and you meet the minimum number of workout sessions per month, you will get the discount.

Call Insurance Services at 507-328-4280 with any questions.

http://ccstpa.com/Member/FitnessDiscount

Rochester has designed your dental plan so it is easy to use and gives you and your family maximum flexibility and unparalleled commitment to service and peace of mind. Rochester Public Schools encourages you to visit the dentist and help ensure your basic dental needs are met in a timely, cost-effective manner. Your dental plan and your medical plan are separate plans.


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Benefit

Calendar Year Deductible(Deductible carryover applies)Orthodontic Services Deductible

$25 Single / $75 Family

$50 one-time lifetime

1st Diagnostic/Preventive visit of calendar year (applies to bitewings, flouride treatment, prophylaxis and office visit or oral evaluation charge)

100% no deductible applied

Diagnostic & Preventive 80% after deductible

Basic Services 80% after deductible

Endodontics 50% after deductible

Periodontics 50% after deductible

Oral Surgery 80% after deductible

Major Restorative 50% after deductible

Prosthetics Repairs & Adjustments 80% after deductible

Prosthetics 50% after deductible

Annual Benefit Maximum $1,200

Orthodontics –waiting period applied 50%

Orthodontic Lifetime Maximum - dependent children ages 8 through 18 after a 1 year waiting period of the dependent being enrolled in the dental plan

Orthodontic Lifetime Maximum - members over the age of 18 after a 3 year waiting period of being enrolled in the dental plan

$1,500

$1,000

DENTAL COVERAGE

Dental Benefits

2016 Health & Dental Premiums

Health

Teachers

Copay PlanEmployee Cost

Per Month

Copay PlanDistrict Cost Per Month

HDHP Employee Cost

Per Month

HDHP District Cost Per Month

Employee Only $23 $756 $0 $648

Family (Employee + Dependent coverage)

$296.54 $1,286.46 $17.54 $1286.46

DentalEmployee Cost Per

MonthDistrict Cost Per

Month

Employee $0 $39.00

Family (Employee + Dependent Coverage

$0 $97.00

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Health

All Staff other than Teachers

Copay PlanEmployee Cost

Per Month

Copay PlanDistrict Cost Per Month

HDHP Employee Cost

Per Month

HDHP District Cost Per Month

Employee Only $62 $717 $0 $648

Family (Employee + Dependent Coverage)

$357.80 $1225.20 $78.80 $1225.20

Actual premiums are determined by employee contract and spousal surcharge provision of the health and dental plans. If spousal surcharge rules apply, you are responsible for 100% of the premium cost for dependent coverage.

The Co-Pay Health Plan premiums are: $779/month for Single Coverage, $1583/month for Family Coverage.If the spousal surcharge applies under the Co Pay Plan, the dependent premium is $804/month.

The HDHP premiums are: $648/month for Single Coverage, $1304/month for Family Coverage.If the spousal surcharge applies under the HDHP, the dependent premium is $$656/month.

Spousal Surcharge provision may apply to both health plans and dental plan

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Rules and Regulations

Plan your annual FSA contribution amounts carefully; the election you make when you enroll is binding for the entire plan year (January 1 to December 31) unless you have a qualifying life event. Additionally, the IRS imposes some rules and restrictions on the way you can use FSAs:

• You must incur eligible expenses during the plan year.

• You can’t transfer money from one account to another; money in your Health Care FSA can’t be used for dependent care expenses, and money in your Dependent Care FSA can’t be used for health care expenses.

•If you incur fewer expenses for Dependent Care than you expected, you forfeit any money remaining in your FSAs at the end of the year; you can’t roll money over from one plan year to the next.

• If you participate in a HRA and a FSA, your FSA must be exhausted before seeking reimbursement from you HRA.

• You can only make changes during the year to your contribution amounts when you have a qualified life event and notify the Insurance Services office in writing of the event. See page 4 for qualifying life events.

Make the FSA Decisions That Are Best For YouFSAs can save you money on out-of-pocket health care and dependent care expenses. But

before you sign up, there are a few things you should consider: Is a Health Care FSA Right for You? If you are married, are you covered by your spouse’s health care benefits, too? If so, the

other plan may pay the part of your expenses that your benefit plans do not cover. Expenses that are covered by any benefit plan or insurance cannot be reimbursed by an FSA.

Do you or any of your family members need special health care supplies or equipment that your medical plan does not cover?

Filing a Claim for ReimbursementTo be reimbursed you must mail, scan, fax, or email a completed claim form to:Rochester Public Schools District 535Insurance Services, 615 7th Street SWRochester, MN 55902Fax: 507-328-4213Email: [email protected]

Year End ClaimsYou may submit claims for expenses incurred in the previous plan year until March 31st of the following year.

Rochester Public School’s Health and Dependent Care Flexible Spending Accounts (FSAs) allow you to use tax-free dollars to reimburse yourself for a wide variety of health and/or dependent care expenses that aren’t covered through your other benefit plans. The annual amount you elect to contribute to each account will be divided into equal amounts and deducted from your paycheck before federal and, in most cases, state and local income taxes are withdrawn.


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THE HEALTH CARE FSA

Even though your insurance benefits may cover a large part of your health care expenses, you are likely to have expenses you will have to pay out of your pocket. Keep in mind that your eligible tax dependents’ health care expenses also count, even if the dependents are not enrolled in the Rochester Public Schools Health Insurance plan.

The amount you set aside in your FSA must be in a whole-dollar amount. The maximum amount you can contribute on an annual basis is $2,500.

The District has adopted the Carry-Over Provision, so you are able to carry over up to $500 into the following calendar year. Your current year election dollars are expensed first and then carry-over dollars are available. You do have the option to opt out of this provision when you enroll for Flex Spending 2016.

For more information about eligible health care expenses obtain a copy of Publication 502 from the IRS website at www.irs.gov. Please note that not all health care expenses listed in Publication 502 are reimbursable under the District’s Health Care FSA. THE DEPENDENT CARE FSA

This account lets you use pre-tax money to pay for eligible dependent care expenses that enable you and your spouse to work outside the home. Eligible dependents are:

Your dependent child who was under the age of 13 when the care was provided and for whom you can claim a federal tax exemption (if you are legally separated or divorced, special rules apply – see below)

A dependent of any age who is mentally or physically incapable of self-care (such as an elderly parent, who lives with you for at least 8 hours a day, and whom you can claim as a dependent on your federal tax return).

In addition, your dependent child must spend at least 8 hours a day in your home for you to obtain reimbursement for dependent care expenses for care provided outside your home. It is important to note that special rules apply if you are legally separated or divorced. Contact your local IRS office for a copy of Publication 503 or visit the IRS website at www.irs.gov for information about those special rules.

The amount you set aside in your FSA must be in a whole-dollar amount The maximum amount you can contribute to your FSA on an annual basis is:

•$5,000 ($2,500 if married and filing taxes separately).•Your (e.g., the employee’s) earned income for such taxable year, or•The earned income of your spouse for such taxable year.

Special rules apply if your spouse is a full-time student or is unable to care for an eligible dependent because of a disability.

You cannot use a Dependent Care FSA and take the Dependent Care Tax credit on your income taxes for the same expense. Consult with your tax advisor about which option is better for you.

If you use an FSA, you must report the name, address and tax ID (or Social Security number) of your day care provider to the IRS. Also, if you are married your spouse must work, be looking for work, be a full-time student, or be disabled.

For a more comprehensive list of eligible dependent care expenses, obtain a copy of Publication 503 form the IRS website at www.irs.gov.

http://www.irs.gov/

This worksheet will help you estimate medical expenses for the plan year. Do not include medical and dental premiums, spouse’s after-tax group medical or dental premiums nor any individual insurance premiums.

EXPENSES 2016 ESTIMATE

MEDICAL EXPENSES

Deductibles $

Co-Pays $

Co-Insurance $

Prescription Drugs $

Insulin/Syringes $

Birth Control Pills $

Allergy Shots $

Annual Physicals $

Chiropractic Treatments $

Orthopedic Shoes (excess over cost of normal shoes) $

Psychiatric/Psychologist Fees $

Smoking Cessation Programs $

Wheelchairs/Crutches $

Hearing Exams/Aids/Batteries $

Other $

DENTAL EXPENSES

Routine Exams $

Fillings $

Root Canals $

Crowns $

Bridges $

Dentures $

Orthodontia $

Other $

VISION EXPENSES

Annual Eye Exam $

Glasses $

Prescription Sunglasses $

Contact Lenses $

Corrective Eye Surgery $

Other $

TOTAL ANNUAL $

DIVIDED BY NUMBER OF PAY PERIODS $

PER PAY PERIOD PRE-TAX DEDUCTION $

THE DISTRICT’S FLEXIBLE SPENDING ACCOUNT DOES NOT ALLOW REIMBURSEMENT FOR THE FOLLOWING EXPENSES:

Cosmetic Medications and Procedures

Massage Therapy

Lamaze/Childbirth Classes

Health Club Memberships

Vitamins

Home Exercise Equipment

Marriage/Group/Family Counseling

Vision Service Contracts

Insurance Premiums

Payment of services not yet provided

ELIGIBLE MEDICAL EXPENSES:

This is a partial list of eligible reimbursable expenses. Refer to Insurance Services for a more complete list.

MEDICAL EXPENSES

DENTAL EXPENSES Deductibles, Co-Pays,

& Co-Insurance Routine Exams

Orthodontia Fillings Bridges Dentures Crowns Root canals

VISION EXPENSES Prescription Glasses Prescription

Sunglasses Contact Lenses Eye exams Corrective Eye Surgery

MEDICAL REIMBURSEMENT ACCOUNT WORKSHEET:

Deductibles, Co-Pays, & Co-Insurance

Prescription Drugs & Allergy Shots

Birth Control Pills Insulin/Syringes Hearing Exams Hearing Aids & Batteries Allergy Shots Fertility Treatments Annual Physicals Chiropractic Treatments Vasectomy

Alcoholism/ Drug Addiction Treatment

Psychiatric/Psychologist Fees

Smoking CessationPrograms

Wheelchairs/Crutches Ambulance Services Nursing Services Laboratory Services Physical & Speech

Therapy Well-Baby Care &

Immunizations

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DEPENDENT CARE REIMBURSEMENT ACCOUNT WORKSHEET:

This worksheet will help estimate dependent care expenses. Consider the following when estimating expenses:

Dependent Care expenses may fluctuate during individual vacations or holidays

If the dependent is a student, expenses may be different when school is not in session. The child may be starting school or may be increasing time spent at school during the plan year.

Consider each spouse’s work schedule when considering total expenses.

MONTH COST # OF WEEKS TOTAL

JAN. $ x = $

FEB. $ x = $

MAR. $ x = $

APR. $ x = $

MAY $ x = $

JUNE $ x = $

JULY $ x = $

AUG. $ x = $

SEPT. $ x = $

OCT. $ x = $

NOV. $ x = $

DEC. $ x = $

Total Annual $

Divided by # of Pay Periods $

Per Pay Period Deduction $

REIMBURSABLE DEPENDENT CARE EXPENSES:

After-school Care

Daycare Center (complies with state & local laws)

Nanny

Elder Care

THE DISTRICT’S PLAN DOES NOT ALLOW REIMBURSEMENT FOR THE FOLLOWING EXPENSES:

Activity Fees/Educational Fees

Supplies/Materials

Registration Fees

Overnight Camps

Payment of services not yet provided

Transportation Costs

Food, Clothing

Reservation Fees

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Life Insurance

Life Insurance and Accidental Death & Dismemberment Insurance (AD&D) is offered by Madison National Life Insurance to employees only and enrollment is voluntary and not automatic. Coverage, premium share, and initial eligibility is determined by your employment contract. Please refer to your contract for further information.

COVERAGE PREMIUM

Employee $0.11 Per $1,000.00 of coverage

New Enrollment:

New employees have 30 days to enroll from employment start date (which is determined by the Office of Human Resources). If elected, enrollment will be the employment start date.

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Late Enrollment:

An employee is considered to be a late enrollee when:

•Insurance Services Office does not receive initial enrollment application from the employee within 30 days

•Enrollment was declined by the employee and now they wish to enroll outside of their initial 30 day enrollment window

Employee must request a late enrollment application from the Insurance Services Office

•Application must be returned to the Insurance Services Office once completed

•Enrollment is not guaranteed – late enrollment acceptance is granted at the discretion of Madison National Insurance

Long Term Disability

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Long Term Disability insurance is offered by Madison National Life Insurance to actively working employees only and enrollment is voluntary and not automatic. Premium share and initial eligibility is determined by your employment contract, please refer to your contract for further information.

COVERAGE PREMIUM BENEFIT

Employee$.27 per $100.00 of employee’s annual salary

66 2/3% of employee’s salary after a 90 day calendar waiting period

New Enrollment:

New employees have 30 days to enroll from employment start date (which is determined by the Office of Human Resources). If elected, enrollment will be the employment start date.

Late Enrollment:

An employee is considered to be a late enrollee when:

•Insurance Services Office does not receive initial enrollment application from the employee within 30 days

•Enrollment was declined by the employee and now they wish to enroll outside of their initial 30 day enrollment window

•Employee must request a late enrollment application from the Insurance Services Office

•Application must be returned to the Insurance Services Office

•Enrollment is not guaranteed – enrollment is granted at the discretion of Madison National Insurance

Supplemental Long Term Disability

Supplemental Long Term Disability is offered by Madison National Life Insurance Company to employees only. Enrollment is voluntary and you may enroll at any time as long as you are enrolled in Long Term Disability Insurance.

COVERAGE PREMIUM BENEFIT

Employee$.21 per $100.00 plus $.27 per $100.00 of employee’s annual salary

85% of employee’s salary after a 90 day calendar waiting period

You must request an application from the Insurance Services Office, complete the application and return to the Insurance Services Office. Enrollment is not guaranteed – enrollment is granted at the discretion of Madison National Life. If approved, enrollment will be the date of approval given by Madison National Life.

Employee Assistance Program

What is the Employee Assistance Program or EAP?

•Employee Assistance Programs are private, confidential and free opportunities for employees to discuss any issues, concerns or problems. Your EAP provider is The Center for Effective Living, 507-288-5675.

If it is free, who pays?

•The District pays for one session per year with an EAP counselor.

Why would the District pay for me to see an EAP counselor?

•We know that when you are feeling good, you do a better job. Also, if you are stressed out or have problems you can’t shake, it is hard to do your work.

How do I use my EAP?

•Call The Center for Effective Living, (507) 288-5675, at anytime. Indicate that you want to use your EAP and would like to make an appointment. During the day, a staff member will help you. At night, staff will either answer your call or call you back.

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Address:

The Center for Effective Living

Suite 1, Lexington Building

1027 7th Street NW

(507) 288-5675

457 and 403(b) Plans

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457 Deferred Compensation Plan

The 457 deferred compensation plan is an additional supplemental retirement plan option you can elect to make voluntary employee contributions in addition to the district sponsored 403(b) plan. You can elect to participate in both the 403(b) and 457 plans simultaneously if you wish. The 457 plan is non-qualified tax advantaged deferred-compensation retirement plan that is available to employees of Rochester Public Schools. Rochester Public Schools has provided the plan and you the employee can elect to defer a percentage of your W-2 compensation into it on a pre-tax basis. For the most part the plan operates similarly to a 401(k) or 403(b) plan. The key difference is that unlike with a 401(k) and 403(b) plan, there is no 10% penalty for withdrawal before the age of 59½ (although the withdrawal is subject to ordinary income taxation). The maximum amount of deferred compensation you can defer into your 457 deferred compensation plan is set each year by the Internal Revenue Service after taking inflation into account. For the year 2015, you can contribute up to $18,000 as an elective deferral to Rochester Public School’s 457 deferred compensation plan. Participants age 50 or older can contribute an additional $6,000 as a catch-up contribution. The district sponsored 457 plan is just another savings vehicle available to you and your family to help assist you in meeting your long-term savings objectives. Authorization forms to sign up for this plan are available from the Payroll Office or on their website. Elections and/or changes received after the 10th of the month will impact the following month’s paycheck.

403(b) Universal Availability Notice for Rochester ISD #535

The Employer (the “District”) offers a 403(b) plan for eligible employees of the District. Employees are eligible to participate as described below: All employees are eligible to participate in the 403(b) plan **Note: Possible employer matching contributions are determined by the employee’s employment contract or work agreement with the District.

A 403(b) plan is a tax-deferred retirement program that permits an employee to reduce his or her compensation on a pre-tax basis (a “deferral”) and have the deferral deposited into a 403(b) account that the employee sets up with a 403(b) vendor. Amounts deferred into a 403(b) account, and any earnings on those deferrals, are generally not taxed until the employee makes a withdrawal from his or her 403(b) account following separation from service with the District. The District maintains a list of approved 403(b) vendors found in the payroll office or website. Employees should contact each vendor for information about the 403(b) products and services it offers. To enroll in the 403(b) plan, an employee must complete a salary reduction agreement (“SRA”). The SRA will only apply to amounts earned after enrolling in the plan. This contribution will continue unless it is modified or revoked in the future. The District has established policies that enable you to increase or decrease your contribution, stop your contribution or change from one authorized 403(b) vendor to another. Employees may get the necessary enrollment forms from the payroll office or website. Additional information on District policies and other 403(b) plan rules can be obtained with the enrollment materials. . Disclosure to employees: The District has no liability for any employee’s election to participate in the 403(b) plan, choice of 403(b) vendor(s), or expected tax consequences resulting from participating in the 403(b) plan. The District does not provide tax, legal or investment advice and recommends that employees seek advice from professionals who specialize in these areas.

Notice of Privacy Practices

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COBRA Continuation Notice

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IMPORTANT INFORMATION ABOUT YOUR COBRA CONTINUATION COVERAGE RIGHTS

What is continuation coverage?

Federal law and Minnesota law require that most group health plans give employees and their families the opportunity to continue their health care coverage when there is a qualifying event that would result in a loss of coverage under an employer’s plan. Depending on the type of qualifying event, qualified beneficiaries can include the employee (or retired employee) covered under the group health and/or dental plan, the covered employee’s spouse, and the dependent children of the covered employee. Continuation coverage is the same coverage that the Plan gives to other participants or beneficiaries under the Plan who are not receiving continuation coverage. Each qualified beneficiary who elects continuation coverage will have the same rights under the Plan as other participants or beneficiaries covered under the Plan, including HIPAA Special Enrollment Rights.

How long will continuation coverage last?

In the case of a loss of coverage due to end of employment or reduction in hours of employment, coverage generally may be continued for up to a total of 18 months. In the case of losses of coverage due to an employee’s death, divorce or legal separation, the employee’s becoming entitled to Medicare benefits or a dependent child ceasing to be a dependent under the terms of the plan, coverage may be continued for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. This notice shows the maximum period of continuation coverage available to the qualified beneficiaries.

Continuation coverage will be terminated before the end of the 18 month period if:

•any required premium is not paid in full on time,

•a qualified beneficiary elects to terminate continuation coverage

•a qualified beneficiary becomes covered, after electing continuation coverage, under another group health plan that does not impose any pre-existing condition exclusion for a pre-existing condition of the qualified beneficiary (note: there are limitations on plans’ imposing a preexisting condition exclusion and such exclusions will become prohibited beginning in 2014 under the Affordable Care Act),

•a qualified beneficiary becomes entitled to Medicare benefits (under Part A, Part B, or both) after electing continuation coverage, or

•employer ceases to provide any group health plan for its employees.

Continuation coverage may also be terminated for any reason the Plan would terminate coverage of participant or beneficiary not receiving continuation coverage (such as fraud).


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How can you extend the length of COBRA continuation coverage?

If a qualified beneficiary elects continuation coverage, an extension of the maximum period of coverage may be available if a qualified beneficiary is disabled or a second qualifying event occurs. The qualified beneficiary must notify Rochester Public Schools of a disability or a second qualifying event in order to extend the period of continuation coverage. Failure to provide notice of a disability or a second qualifying event may affect the right to extend the period of continuation coverage.

Disability

An 11-month extension of coverage may be available if any of the qualified beneficiaries is determined by the Social Security Administration (SSA) to be disabled. The disability has to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. Each qualified beneficiary who has elected continuation coverage will be entitled to the 11-month disability extension if one of them qualifies. If the qualified beneficiary is determined by SSA to no longer be disabled, you must notify the Plan of that fact within 30 days after SSA’s determination.

Under Minnesota State law, the employee is considered disabled for the first 24 months if he or she is unable to perform their regular duties, even without a Social Security Administration disability determination. After 24 months, a disabled employee may stay on the plan as long as they are unable to engage in any paid employment. While only the employee’s disability is considered, eligible dependents may also continue coverage.

Second Qualifying Event

An 18-month extension of coverage will be available to spouses and dependent children who elect continuation coverage if a second qualifying event occurs during the first 18 months of continuation coverage. The maximum amount of continuation coverage available when a second qualifying event occurs is 36 months or longer for fully insured plans under Minnesota law. Such second qualifying events may include the death of a covered employee, divorce or separation from the covered employee, the covered employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both), or a dependent child’s ceasing to be eligible for coverage as a dependent under the Plan. These events can be a second qualifying event only if they would have caused the qualified beneficiary to lose coverage under the Plan if the first qualifying event had not occurred. You must notify the Plan within 60 days after a second qualifying event occurs if you want to extend your continuation coverage.

How can you elect COBRA continuation coverage?

To elect continuation coverage, you must complete the Election Form and furnish it according to the directions on the form. Each qualified beneficiary has a separate right to elect continuation coverage. For example, the employee’s spouse may elect continuation coverage even if the employee does not. Continuation coverage may be elected for only one, several, or for all dependent children who are qualified beneficiaries. A parent may elect to continue coverage on behalf of any dependent children. The employee or the employee’s spouse can elect continuation coverage on behalf of all of the qualified beneficiaries.

In considering whether to elect continuation coverage, you should take into account that you have HIPAA Special Enrollment Rights under federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the qualifying event listed above. You will also have the same HIPAA Special Enrollment Rights at the end of continuation coverage if you get continuation coverage for the maximum time available to you.


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How much does COBRA continuation coverage cost?

Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The amount a qualified beneficiary may be required to pay may not exceed 102 percent (or, in the case of an extension of continuation coverage due to a disability, 150 percent) of the cost to the group health plan (including both employer and employee contributions) for coverage of a similarly situated plan participant or beneficiary who is not receiving continuation coverage. An employee who continues under the disability provisions of Minnesota law may be charged up to the cost to the employer only. The required payment for each continuation coverage period for each option is described in this notice.

When and how must payment for COBRA continuation coverage be made?

First payment for continuation coverage

If a qualified beneficiary elects continuation coverage, they do not have to send any payment with the Election Form. However, the first payment for continuation coverage must be made no later than 45 days after the date of their election. (This is the date the Election Notice is post-marked, if mailed.) If the first payment for continuation coverage is not paid in full no later than 45 days after the date of their election, the qualified beneficiary will lose all continuation coverage rights under the Plan. The qualified beneficiary is responsible for making sure that the amount of your first payment is correct. They may contact Insurance Services to confirm the correct amount of your first payment.

Periodic payments for continuation coverage

After the first payment is made for continuation coverage, you will be required to make periodic payments for each subsequent coverage period. The amount due for each coverage period for each qualified beneficiary is shown in this notice. The periodic payments can be made on a monthly basis. Under the Plan, each of these periodic payments for continuation coverage is due on the 10th of each month. If a periodic payment is made on or before the first day of the coverage period to which it applies, the coverage under the Plan will continue for that coverage period without any break. The Plan will not send periodic notices of payments due for these coverage periods.

Grace periods for periodic payments

Although periodic payments are due on the dates shown above, the qualified beneficiary will be given a grace period of 30 days after the first day of the coverage period to make each periodic payment. Their continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment.

If you fail to make a periodic payment before the end of the grace period for that coverage period, you will lose all rights to continuation coverage under the Plan.

The qualified beneficiary’s first payment and all periodic payments for continuation coverage should be sent to: Rochester Public Schools Insurance Services – Edison Building- 615 7th St. SW Rochester MN 55902.


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For more information

This notice does not fully describe continuation coverage or other rights under the Plan. More information about continuation coverage and your rights under the Plan is available in your summary plan document or from the Claims Administrator. If you have any questions concerning the information in this notice, your rights to coverage, or if you want a copy of your summary plan document, you should contact Rochester Public Schools Insurance Services - Edison Building- 615 7th St. SW Rochester MN 55902.

For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, visit the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) website at www.dol.gov/ebsa or call their toll-free number at 1-866-444-3272 For more information about health insurance options available through a Health Insurance Marketplace, visit www.healthcare.gov.

Keep Your Plan Informed of Address Changes

In order to protect your and your family’s rights, you should keep the Claims Administrator informed of any changes in your address and the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Claims Administrator.

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately four minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of the Chief Information Officer, Attention: Departmental Clearance Officer, 200 Constitution Avenue, N.W., Room N-1301, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0123.

OMB Control Number 1210-0123 (expires 10/31/2016)

Marketplace Notice

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New Health Insurance Marketplace CoverageOptions and Your Health Coverage

PART A: General Information

When key parts of the health care law took effect in 2014, there is now a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new marketplace and employment-based health coverage offered by your employer.

What is the health Insurance Marketplace?The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers “one-stop shopping” to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2015 for coverage starting as early as January 1, 2016. Can I Save Money on my Health Insurance Premiums in the Marketplace?You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn’t meet certain standards. The savings on your premium that you’re eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer’s health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the “minimum value” standard set by the Affordable Care Act, you may be eligible for a tax credit.

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution-as well as your employee contribution to employer-offered coverage-is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information?For more information about your coverage offered by your employer, please check your summary plan description on the District’s web page or contact the Insurance Services office at 507-328-4280. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

Marketplace Notice

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PART B: Information About Health Coverage Offered by Your EmployerThis section contains certain information about any health coverage offered by your employer. If you decide to complete an application for coverage in the marketplace, you will be asked to provide this information. This information is numbered to correspond to the marketplace application.

3. Employer name 4. Employer Identification number (EIN) Rochester Public School District #535 41-60028035. Employer address 6. Employer phone number 615 7th Street SW 507-328-42807. City 8. State 9. Zip code Rochester Minnesota 55902 10. Who can we contact about employee health coverage at this job?

Total Rewards Division of the Human Resource Department11. Phone number 12. Email address507-328-4280 [email protected]

Here is some basic information about health coverage offered by this employer:As your employer, we offer health coverage to eligible employees. Eligible employees are employees who work for the District on average 30 hours or more per week or 130 hours per month in accordance with contract language and the Affordable Care Act. With respect to dependents:We do offer coverage. Eligible dependents are: 1.a spouse (married as recognized under Minnesota law), 2.dependent children to age 26•-natural-born, legal wards, and/or legally adopted children•-Stepchildren who reside with you•-children that are eligible to be covered as an employee under any health plan sponsored by their employer are not eligible•Children that are covered as an employee under any health plan sponsored by their employer are not eligible•Grandchildren who are financially dependent on you and reside with you continuously from birth•Children who are required to be covered by reason of a Qualified Medical Child Support Order (QMCSO) as defined in Minnesota statute 518.171.3. Children who become disabled prior to reaching age 27 if:•They are primarily dependent upon you and are incapable of self-sustaining employment because of physical and/or mental disability•For whom application for extended coverage as a disabled dependent child is made within 30 days after reaching the age limit. A Disable Dependent Application must be completed every 2 years.

This coverage offered by the District does meet the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee’s wages. ** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example your wages vary from week to week, if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount through the Marketplace. If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process and can assist you in determining if you can get a tax credit to lower your monthly premiums.

Women’s Health and Cancer Rights Act

Under the federal Women’s Health and Cancer Rights Act of 1998, you are entitled to the following services:

1. reconstruction of the breast on which the mastectomy was performed;

2. surgery and reconstruction of the other breast to produce a symmetrical appearance; and

3. prosthesis and treatment for physical complications during all stages of mastectomy, including swelling of the lymph glands (lymphedema).

Services are provided in a manner determined in consultation with the physician and patient. Coverage is provided on the same basis as any other illness.

Rights Under Newborns and Mothers Health Protection Act

Under the Newborns and Mothers Health Protection Act (NMHPA) passed by Congress, group health plans offering group health insurance coverage, generally may not, under federal law, restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider obtain authorization from the plan for prescribing a length of stay not in excess of the above periods. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).

Rights Under Family and Medical Leave Act

The Family and Medical Leave Act (FMLA) passed by Congress in 1993 requires that some employers provide employees up to twelve (12) weeks of unpaid, job-protected leave for certain family and medical reasons. The employer must maintain coverage to employees and dependents for the duration of the FMLA leave, subject to payment of any required contributions. Human Resources should be contacted for more information about the FMLA.

Annual Notifications

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Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). _________________________________________________________________________________________ If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of July 31, 2015. Contact your State for more information on eligibility –


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To see if any more States have added a premium assistance program since July 31, 2015, or for more information on special enrollment rights, you can contact either:

U.S. Department of Labor U.S. Department of Health and Human ServicesEmployee Benefits Security Administration Centers for Medicare & Medicaid Serviceswww.dol.gov/ebsa www.cms.hhs.gov1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

CONTACT INFORMATION

Rochester Public Schools, in partnership with the following carriers, strives to meet your benefit needs. If you have any questions regarding your benefits, please contact the corresponding carrier listed below or Insurance Services.

CARRIERCUSTOMER SERVICE

PHONE #WEBSITE

Rochester Public Schools Insurance Services

(507) 328-4280 Phone(507) 328-4213 Fax

Email: [email protected]

s

www.rochester.k12.mn.us/insurance

Madison National Life Insurance Company(Life Insurance)(Long Term Disability)

1-800-356-9601 www.madisonlife.com

Mid America(HRA Support)

(800) 430-7999 Phone(838) 688-4200 Fax www.midamerica.biz

Contacts

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Notes