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ALASKA CONFERENCE OF CATHOLIC BISHOPS
2018
Health Insurance
Special Open Enrollment Lay Employee Plans
Nov 15, 2017 through Dec 20, 2017
(For Policies effective January 1 through June 30, 2018)
(Medical, Dental, & Vision)
Guide to your Health Care
Enrollment Letter (important information) ……………………….1
Health Insurance Meetings Notice! ……………………….2
Health Insurance Coverages ……………………….3
Medical Plan Overviews 3a
Dental Plan Overview 3b
Vision Plan Overview 3c
Prescription Drug Program 3d
Other Health Resources ………………………4
Online Health Management 4a
Doc Find (Medical) 4b
Doc Find (Dental) 4c
Vision Assistance Online 4d
Teledoc 4e
What is an HSA? 4f
Understanding Payment of benefits 4g
Benefit Pricing $$$ Explanation ………………………5
Enrollment/Change form ………………………6
(Please remove the last page to complete and turn in to your location administrator)
Enrollment Letter- Important Information
ALASKA CONFERENCE OF CATHOLIC BISHOPS 1
1
Dear Employee,
Your Employer participates in a cooperative group called the Alaska Conference of Catholic Bishops, or ACCB,
in order to provide Quality Health Benefits to our employees and their families. Our Health plans are administrated
by Christian Brothers Services, a Catholic Healthcare Trust.
ACCB is providing this packet to help you make informative decisions regarding your personal healthcare, and
options available for your dependents. Your Healthcare choices can only be adjusted during the “Open Enrollment”
period, unless there is a “qualified event” during the year.
Every eligible employee MUST “Re-Enroll” or “Waive” during this time to continue coverage.
This Special “Mid Year” - Open Enrollment begins November 15, 2017 and ends December 20, 2017
During the Open Enrollment period, you will have the opportunity to add, change or drop your health plan for
yourself or your dependents. This includes adding family members who are not currently enrolled in our group
insurance program, as well as increasing coverage for those members already participating.
Any change to benefits will be effective January 1, 2018.
The Open Enrollment period will close December 20, 2017. No exceptions. If you have any questions, please
contact the appropriate person in your parish, school or agency, or call Lalena Kruckeberg @ (907)297-7778
Eligibility
An employee must work 30 hours or more per week (on average over a 6 month period) in order to be
eligible for health insurance benefits.
A benefit eligible person may not waive insurance in lieu of additional compensation in wages, nor may an
employer make such an offer.
The option for a non-benefit eligible employee to purchase our insurance plan is not available.
Employee benefits are effective the first day of the month following a 30 day waiting period from their date
of hire. (ie: if hire date= May 28 (+ 30 days)= June 28 then the insurance effective date is July 1)
Spouse/Dependent coverage is available for purchase. Dependents qualify until the age of 26, married or
unmarried. If adding spouse or dependents, documentation must be provided. (Marriage Certificate
(spouse), and/or Birth certificate(s) for dependent(s))
Health Plan choices:
Medical - “Default” Higher Deductible Health Plan ($2,700 deductible) 85% coverage in network
Medical - “Buy-up” Lower Deductible Health Plan ($500 deductible) 75% coverage in network
Dental PPO - $1,500 allowance /$50 deductible
Vision-VSP Choice Plan - $10 Exam/$25 Eyeglasses
Life/Ltd (Long Term Disability) Insurance:
Life insurance coverage is $50,000 (decreased benefit amounts at age 65 & 70)
Employee only plans – a “Benefit Eligible” employee cannot waive these insurances.
Employee must enroll when eligibility requirements are met.
Informational Meetings!
Representatives from Christian Brothers Services and ACCB will be hosting the following “in person” informational meetings regarding your Health Care and employee benefits on the following dates and locations.
Please try to attend!
Juneau - St Ann’s Parish Hall- December 4th , 2017 – 9:00am Anchorage - St. Elizabeth Ann Seton – December 5th– 3:45pm Anchorage - Archdiocese Pastoral Ctr. –December 6th – 10am Anchorage - Lumen Christi/St. Benedict – December 6th– 2:45pm Fairbanks - Diocese of Fairbanks – December 7th – 10am Fairbanks - Catholic Schools of Fairbanks – December 7th – 3pm
ALASKA CONFERENCE OF CATHOLIC BISHOPS
~HSA Qualified ~
The "Default High Deductible Health Plan" is an "HSA" Qualified Plan. This allows you to set up a special "Health Savings Account". Your employer will not be administrating 'pre-tax' contributions, but you may contribute your 'after tax' dollars and claim an income deduction on your annual taxes.
Dental P 3 / Ortho 1000
Christian Brothers Employee Benefit Trust Dental Plan
DEDUCTIBLE $50 / Individual - $150 / Family
YEARLY MAXIMUM $1,500
PREVENTIVE DENTAL: Oral exam each 6 months Emergency exam X-rays with frequency limits Prophylaxis (Cleaning) each 6 months Fluoride each 6 months for children under 16 Sealants each 24 months for children under 16
100 % No Deductible
PREVENTIVE (Special provisions with Medical Necessity) Prophylaxis (Cleaning) Fluoride
The Plan may allow up to 3 cleanings and fluoride treatments per year if you are being treated for a serious medical condition. Your medical doctor must submit documentation to the Plan for pre-approval. Benefits will be paid at the Preventive Dental level of benefits.
BASIC DENTAL: Fillings Stainless steel crown for children Extraction of teeth Oral Surgery Periodontal services; each with frequency limits Endodontic services General anesthesia for complex oral surgery Repairs to bridges or dentures Relining of dentures with frequency limits
80 % After Deductible
MAJOR DENTAL: Gold inlays/onlays; replacements; limited to 5
years from last placement Crowns; replacements limited to 5 years from last
placement Implant Services Fixed bridges & full or partial dentures;
Initial placement limited to extractions while on the plan Replacements limited to 5 years from last placement
Temporomandibular Joint Disorders (TMJ)
50 % After Deductible
SOME SERVICES NOT COVERED (All Charges Subject to Prevailing Fees)
Cosmetic services, occlusal analysis or adjustments, oral hygiene instruction, services to alter vertical dimension, duplication or replacing lost or stolen prosthetics, temporary services, and orthodontics. Non-emergency service performed outside USA.
This Benefit Summary provides a brief outline of the services covered by CBEBT. THIS IS NOT A CONTRACT. The complete terms of the plan are contained in Your Employee Benefits booklet issued to members. For more information regarding benefits, please call Customer Service at 1.800.807.0400.
Dental P 3 / Ortho 1000
Christian Brothers Employee Benefit Trust Orthodontia
DEDUCTIBLE ( Separate from Dental Plan Deductible )
$50 / Individual - $150 / Family
LIFETIME MAXIMUM ( Separate from Dental Plan Maximum )
$1,000
ELIGIBILITY Covered Dependent Only Under Age 19
COVERED PROCEDURES:
Formal, full-banded retention and treatment X-rays Other diagnostic procedures Removable or fixed appliances for tooth or bony
structure guidance or retention.
50 % after Deductible
SOME SERVICES NOT COVERED Cosmetic services, implants, occlusal analysis, oral hygiene instruction, services to alter vertical dimension or restore occlusion (except for orthodontic related charges), duplication or replacing lost or stolen prosthetics, and temporary services.
This Benefit Summary provides a brief outline of the services covered by CBEBT. THIS IS NOT A CONTRACT. The complete terms of the plan are contained in Your Employee Benefits booklet issued to members. For more information regarding benefits, please call Customer Service at 1.800.807.0400.
Your VSP Vision Benefits SummaryALASKA CONFERENCE OF CATHOLIC BISHOPS and VSP provide you with anaffordable eye care plan.
VSP Coverage Effective Date: 07/01/2017 - 06/30/2018 06/30/2018
VSP Provider Network: VSP ChoiceFrequencyCopayDescriptionBenefit
Your Coverage with a VSP Provider
Every 12 months$10WellVision Exam Focuses on your eyes and overall wellness
See frame and lenses$25Prescription Glasses
Every 24 monthsIncluded inPrescription
GlassesFrame
$130 allowance for a wide selection of frames$150 allowance for featured frame brands20% savings on the amount over your allowance$70 Costco® frame allowance
Every 12 monthsIncluded inPrescription
GlassesLenses Single vision, lined bifocal, and lined trifocal lenses
Polycarbonate lenses for dependent children
Every 12 months$0
Lens EnhancementsProgressive lenses
$0Anti-reflective coatingAverage savings of 20-25% on other lens enhancements
Every 12 monthsUp to $60Contacts (instead ofglasses)
$130 allowance for contacts; copay does not applyContact lens exam (fitting and evaluation)
Glasses and Sunglasses
Extra Savings
Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12months of your last WellVision Exam.
Retinal ScreeningNo more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision CorrectionAverage 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
Your Coverage with Out-of-Network Providers
Get the most out of your benefits and greater savings with a VSP network doctor. Your coverage with out-of-network providers will be less or you’llreceive a lower level of benefits. Visit vsp.com for plan details.
Exam .............................................................................. up to $45Frame ............................................................................ up to $70Single Vision Lenses ........................................... up to $30
Lined Bifocal Lenses ........................................... up to $50Lined Trifocal Lenses ......................................... up to $65
Progressive Lenses ............................................. up to $50Contacts .................................................................... up to $105
Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between thisinformation and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc.,is the legal name of the corporation through which VSP does business.
Contact us. 800.877.7195 | vsp.com1. Brands/Promotion subject to change.2. Savings based on network doctor's retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Available only through VSP network doctors to VSPmembers with applicable plan benefits. Ask your VSP network doctor for details.
©2017 Vision Service Plan. All rights reserved.VSP, VSP Vision care for life, eyeconic.com, and WellVision Exam are registered trademarks, and "Life is better in focus." is a trademark of Vision Service Plan. Flexon is a registered trademark of MarchonEyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.
Vision Plan Summary (no changes) 3c
Prescription Drug Program
Instant Access to Express ScriptsWhen you register at mycbs.org/health and click on My Prescription Drugs, you will have instant access to:
• My Rx Choices®
• Prescriptions• Claims & Balances• Order Status• Locate a Pharmacy• Price a Medication• Bene�t Highlights• Forms and Cards• Learn About Formularies• Drug Information
Express ScriptsTrusts administered by Christian Brothers Services have chosen Express Scripts to manage the prescription drug bene�t for our members. Express Scripts has captured the No. 1 position in the Health Care: Pharmacy and Other Services sector on the Fortune World’s Most Admired Companies List, and it’s No. 2 in the world for Social Responsibility and Long-Term Investment. Of all companies surveyed globally, Express Scripts was ranked No. 5 in Innovation and No. 10 in People Management. With Express Scripts’s sophisticated dispensing technology and mail-order pharmacies, our Trust members are provided high-quality prescription drugs at discounted prices.
Express Scripts by MailIn the mail-order pharmacies, quality process activities as well as customer satisfaction are driven by performance measurement in four key areas: Compliance, Quality, Service, and Cost. Each of Express Scripts pharmacies adheres speci�cally to the requirements of the state in which it is located. In addition, Express Scripts and each of its mail-order pharmacies are fully accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and are diligent in adhering to all applicable standards of that organization.Each mail-order pharmacy has a Director of Pharmacy Practice who is a registered pharmacist. It is the Director of Pharmacy Practice who is responsible for all dispensing-related activities. Additional registered pharmacists supervise every activity in the dispensing process, including maintenance of dispensing records. All prescriptions are checked by registered pharmacists who are licensed in the state in which they practice.
Visit mycbs.org/health for more information
Contact Express Scripts at (800) 718-6601
8/2017
Other Resources Section 4
Helpful
Resources
Available!
Online Health Management 4a
Be sure to visit myCBS.org/health to “activate” your Health ID
Card! This site will provide valuable resources, health news,
access to your benefit information, and much more!
Online EOBs (explanation of benefits paid)
Medical plan summaries
Find Network providers
Current Health News
RX Drug information
www.myCBS.org/health
�e Simplest Way to Find a DoctorSelecting a doctor and other health care professionals for you and your family is important. �e Find a Provider online directory, available 24 hours a day, 7 days a week, makes it easy.
Find a Provider is the premier online search tool from Aetna. Up-to-date listings of participating doctors, medical professionals, and facilities are available at your �ngertips. With the easy-to-use format, you can search online by name, specialty, gender and/or hospital a�liation.
What Does Find a Provider Allow me to do? Choose the search option that works for you. Search by using a variety of criteria such as specialty, gender and/or hospital a�liation, or search using the health care professional’s name.
Make the informed choice. Find a Provider gives you easy access to information about health care professionals. �is includes information about medical school attended, board certi�cation status and gender, as well as information about the provider’s o�ce(s), such as handicapped access, etc.
Get up-to-date information. Find a Provider is typically updated daily, giving you access to the latest available information.
Review a list of transplant facilities and pediatric congenital heart surgery facilities in our Institutes of Excellence™ network.
To access Find a Provider, simply log on to mycbs.org/ppo-aetna.1) On the Aetna “Find a Provider” page, click on the “Medical” button. 2) Under the “What type of provider are you looking for?” heading, select one of the options for provider type. 3) Under the “Do you want to search by ZIP or state?” heading, enter the geographic information for the area where you wish to �nd a participating provider. Under the “Search by state” option, you can further narrow your selection by county and city. 4) You can run a search with the information you provided at this point or click on the “+ Advanced Search” link to open more options.NOTE: You must enter the information in steps 2 and 3 in order to access the Advanced Search options. Under the Advanced Search options, you can also narrow your search by doctor or facility name and/or specialty type or medical condition.5) If you already know the name of the provider or facility you are looking for, type the name in the “Doctor/Facility name” box. 6) Under “Specialty Type,” you may add up to �ve specialties by clicking on the list provided and clicking “Add.” If you want to change the specialty criteria, click on the “Remove” button. 7) You may also search for a specialist based on medical condition by clicking on the “Condition” button.8) Click “Search.”9) You will be presented with a list of providers matching your criteria. You can obtain additional information about each provider by clicking on the "More Details" link under the provider’s contact information.10) You can create a list of providers you are interested in by clicking on the yellow “Add to my list” button under the contact information. �ere is also a “Compare side by side” button to help you �nd the right provider.
Step-by-Step Instructions
Locate health care professionals and facilities using the criteria that’s best suited to your needs.
Visit mycbs.org/health for more information
Find a Provider Online Doctor Directory
7/2017
�e Simplest Way to Find a DentistSelecting a dentist for you and your family is important. �e Find a Provider online directory, available 24 hours a day, 7 days a week, makes it easy. Find a Provider is typically updated daily, providing access to the latest available information.
Find a Provider is the premier online search tool from Aetna providing up-to-date listings of participating dentists. With the easy-to-use format, you can search online by name, location, ZIP code or state, and up to �ve specialties. Find a Provider allows you to make an informed choice, and gives you easy access to information about dental care professionals, including information that is not available in paper directories. �is includes information about specialty/service type, gender, practice name, language(s) spoken, education, board certi�cation status and hospital a�liations. It also includes information on the provider’s o�ce(s), maps and driving directions, and the option to receive provider details and a map with directions through text or email.
You can use Find a Provider anywhere you have internet access. If you have questions while searching for a dentist, just click on the “Contact Us” link located at the bottom of any Find a Provider page to send a comment or question.
To access Find a Provider, simply log on to mycbs.org/ppo-aetna.
1) On the Aetna “Find a Provider” page, click on the “Dental” button.2) Under the “What type of provider are you looking for?” heading, choose a provider type: either Dentist-USA or Dentist-Mexico.3) Under the “Do you want to search by ZIP or state?” heading, enter the geographic information for the area where you wish to �nd a participating dentist. Under the “Search by state” option, you can further narrow your selection by county and city.4) You can run a search with the information you provided at this point or click on the “+ Advanced Search” link to open more options. NOTE: You must enter the information in steps 2 and 3 in order to access the Advanced Search options. Under the Advanced Search options, you can also narrow your search by name and/or specialties. 5) If you already know the name of the dentist you are looking for, type the name in the “Doctor/Facility name” box. 6) Under “Specialty Type,” you may add up to �ve specialties by clicking on the list provided and clicking “Add.” If you want to change the specialty criteria, click on the “Remove” button.7) Click “Search.”8) You will be presented with a list of dentists which match your criteria. You can obtain additional information about each provider by clicking on the "More Details" link under the provider’s contact information. 9) You can create a list of providers you are interested in by clicking on the yellow “Add to my list” button under the contact information. �ere is also a “Compare side by side” button to help you �nd the right provider.
Step-by-Step Instructions
Locate dental professionals and facilities using the criteria that’s best suited to your needs.
Visit mycbs.org/health for more information
Find a Provider Online Dental Directory
8/2017
Get access to the best in eye care andeyewear with ALASKA CONFERENCEOF CATHOLIC BISHOPS and VSP®
Vision Care.Why enroll in VSP? As a member, you’ll receive access to carefrom great eye doctors, quality eyewear, and the affordabilityyou deserve, all at the lowest out-of-pocket costs.
You’ll like what you see with VSP.Value and Savings. You’ll enjoy more value and the lowest out-of-pocketcosts.
High Quality Vision Care. You’ll get the best care from a VSP networkdoctor, including a WellVision Exam®—the most comprehensive examdesigned to detect eye and health conditions.
Choice of Providers. The decision is yours to make—choose a VSPnetwork doctor, a participating retail chain, or any out-of-network provider.
Great Eyewear. It’s easy to find the perfect frame at a price that fits yourbudget.
Using your VSP benefit is easy.Create an account at vsp.com. Once your plan is effective, review yourbenefit information.
Find an eye doctor who’s right for you. Visit vsp.com or call 800.877.7195.
At your appointment, tell them you have VSP. There’s no ID cardnecessary. If you’d like a card as a reference, you can print one onvsp.com.
That’s it! We’ll handle the rest—there are no claim forms to complete whenyou see a VSP provider.
Choice in EyewearFrom classic styles to the latest designer frames, you’ll find hundreds ofoptions. Choose from featured frame brands like bebe®, Calvin Klein,Cole Haan, Flexon®, Lacoste, Nike, Nine West, and more.1 Visit vsp.com tofind a Premier Program location that carries these brands. Plus, save up to40% on popular lens enhancements.2 Prefer to shop online? Check out allof the brands at eyeconic.com®, VSP's preferred online eyewear store.
Enroll in VSP today.You'll be glad you did.Contact us. 800.877.7195vsp.com
Life is better in focus. TM
Members enrolled for medical coverage in the trusts administered by Christian Brothers Services have 24/7 access to a panel of 16,000 physicians, 365 days a year through Teladoc. �e telemedicine bene�t o�ers accessible and convenient care, as well as providing patients and physicians a way to communicate, which bypasses the traditional o�ce visit yet provides excellent care through the use of technology. Members can talk with a doctor anytime, anywhere about non-emergent medical condi-tions via telephone, secure email, video or mobile app.
Teladoc’s network of board-certi�ed physicians can discuss symptoms, recommend treatment options, diagnose many common, minor and/or brief illnesses and prescribe medication, when appropriate. �e technology also features a content-rich member health portal, My Personal Health Manager, that combines 24/7 physician access with cutting edge health applications and empowers individuals and families to take an active role in health, prevention and disease management.
When to Use Teladoc? • Primary care doctor is not available or accessible • A�er normal business hours, evenings and weekends • When traveling for business or vacation • To request needed prescription (Rx) medication or re�ll • For non-emergent medical questions/advice • When seeking a second opinion • When seeking advice about an existing condition • To discuss lab results or wellness panel
Getting Started with Teladoc1) Set Up your Account Set up your account by:
Phone: Teladoc can help you register your account over the phone. Call 800.835.2362.
Online: Go to MyDrConsult.com and click “set up account.”
Mobile app: Visit teladoc.com/mobile to download the app. Click “Activate account.”
Text: Text “Get Started” to 469.844.5637 2) Provide Medical History Your medical history provides Teladoc doctors with the information they need to make an accurate diagnosis.
3) Request a Consult Once your account is set up, request a consult anytime you need care. You can talk to a doctor by phone, web or mobile app.
Teladoc saves time by avoiding waiting for an appointment or driving, sitting and waiting in a doctor’s office for hours. A doctor is always on call or a click away – 24/7. Additionally, members save money with the lower cost alternative to a doctor’s office, urgent care or emergency room. What’s more, this benefit is offered at no additional cost to participants.* Never wait for a doctor again!
Consult A Doctor 24/7Where the Doctor is Always In
* Due to the Internal Revenue Service (IRS) requirements of Health Savings Account (HSA) plans, in order to preserve the pre-tax status of your members’ HSA, an employee who has a HSA and uses Teladoc will now be required to pay a $40.00 up front consult fee. �is fee will then be processed (and/or reimbursed, if the member has reached their Out of Pocket Maximum) under the medical plan. * Please Note: Teladoc is not currently available in Arkansas. You may use Teladoc in Texas via phone only, and in Idaho via video only.
Common Conditions Treated• Allergies • Bronchitis • Cold/Flu • Eye/Ear Infections• Headaches • Sinus Infections • Rash/Skin Irritation • Stomach Ache/Diarrhea • Upper Respiratory Infections • Urinary Tract Infections • Yeast Infections • And More …
�e Doctor is ALWAYS in – connect today - visit teladoc.com or call 800.835.2362.
06/2017
What is an HSA?
HSA What is it? A Health Savings Account is a personal bank account to help you save and pay for
covered health care services and qualified medical expenses. How do I get it? You have to sign up for a high deductible health plan that meets a deductible
amount set by the IRS. You also have to meet other IRS guidelines to be eligible to have it. You can learn about these at irs.gov.
Who owns it? You do. Who puts money in it? You. Your employer, family, and others can put money into it if they choose. How is money put in it? You can make deposits like you do with other personal bank accounts. Your
employer and family can also put money into the account. Your employer may allow you to deposit money straight from your paycheck, before the money is taxed.
Is there a limit on how much I can put in it?
Yes. The IRS sets a limit on how much you can put into it each year. You can usually find the limits in your health plan documents and at irs.gov. While there are annual limits, there is no limit to how much you can save over time.
If I don’t spend it all this year, can I use it next year?
Yes. Since you own the account, the money will stay in it until you choose to spend it. You can save and use it into retirement.
Can I cash it out at any point? Yes. But if you cash it out and do not use the money for qualified medical expenses, you will have to pay taxes on it. And you may also have to pay a 20% tax penalty.
Can I keep it if I leave my employer? What happens to the money?
Yes. You own the account.
When can I start spending it? You can start spending the HSA once you have signed up for a high-deductible health plan and have opened the account.
Do I have to pay taxes on it? No. You don’t have to pay federal or, in most instances, state income taxes on: - Deposits you or others make to an HSA - Money you spend from an HSA on qualified medical expenses - Interest earned from an HSA If you put money into an HSA using pre-tax payroll deposits through your employer You don’t have to pay Social Security taxes on it either.
If I don’t spend it, will it earn interest for me?
Yes, an HSA can earn interest. But the amount you can earn depends on the bank you use and how much you have in the account.
What can I pay for with it? You can pay for hundreds of qualified medical expenses, which are determined by the IRS. This can include services covered by a health plan. You can also use it to pay for dental, vision and many other health care services and supplies that are listed under Section 213(d) of the Internal Revenue Code.
Can I use it for things other than health care?
No, as long as you are under the age of 65. And if you use it for services that aren’t qualified medical expenses, you could pay a 20% penalty tax. If you are over the age of 65, you can use it for pretty much anything.
Can I have any other accounts with it?
Yes. You can have a limited-purpose Flexible Spending Account or limited-purpose HRA, which can only be used for eligible dental and vision services.
Can I use it to pay for Extension of Benefit plan premiums or other plan premiums?
Yes.
What’s the difference between a qualified medical expense and an eligible medical expense? A qualified medical expense is a health care service, treatment or item that the IRS says can be purchased without
having to pay taxes. An eligible medical expense is a health care service, treatment or item that the IRS says can be covered or reimbursed
(paid back) by a benefit plan.
Plan Description
Covered
Person
Total
Premium
Monthly
Amount Paid
by Employer
Monthly
Amount Paid
by Employee
Medical "Default" Employee only 787.00 777.00 10.00
1 Dependent 620.00 - 620.00
Family 950.00 - 950.00
Medical "Buy-up" Employee only 887.00 777.00 110.00
1 Dependent 767.00 - 767.00
Family 1,215.00 - 1,215.00
Dental PPO Employee only 44.00 44.00 -
1 Dependent 44.00 - 44.00
Family 88.00 - 88.00
-
Vision VSP Employee only 12.00 12.00 -
1 Dependent 8.50 - 8.50
Family 21.00 - 21.00
Please note the following
► Employees may choose any combination of medical, vision, and dental benefits
► Dependents may not have a benefit that the employee does not have.
Lay Plan
Priest &
Lay Plan
Priest &
Lay Plan
Lay Plan
Benefit Election Pricing
Health Benefits - Effective January 01, 2018
Employee copay for self
Employee cost for 1
Dependent
Employee cost for 2 or
more Dependents
Employer pays this for
employee only
No Employee copay for
"self" on Dental
Employee pays for
Dependents on Dental
No Employee copay for
"self" on Vision Plan
Employee pays for
Dependents on Vision
Employer pays this for
employee only
Employee copay for self
Employee cost for 1
Dependent
Employee cost for 2 or
more Dependents
ACCB Alaska Conference of Catholic Bishops – Insurance Division Employee Benefits ENROLLMENT / CHANGE FORM
This form can be used as an initial enrollment or to report a change in information. Please complete all information by printing clearly and firmly or by typing. If additional space is needed, please attach a statement with the appropriate information. Please check the applicable boxes below.
I. Location Name Term Date:
New Enrollment Re-Enroll Waiver Change Transfer from Location # _____ to # _____ Extended Benefits Terminate
II. EMPLOYEE INFORMATION LAY EMPLOYEE DIOCESAN PRIEST OTHER
LAST NAME FIRST MI SOC. SEC. NO.
STREET ADDRESS CITY STATE ZIP
DATE OF HIRE DATE FULL TIME OCCUPATION ANNUAL SALARY HOURS WORKED PER WEEK
EMPLOYEE EMAIL:
DATE OF BIRTH SEX MARITAL STATUS Home Phone (including area code)
( )
CELL PHONE (Including area code )
( )
III. DEPENDENT INFORMATION (Required if dependent coverage is to be added or changed) SEX DATE OF RELATIONSHIP Medical Dental Vision
FULL NAME (Including middle initial) SOC. SEC. NO. (M/F) BIRTH TO EMPLOYEE (X) (X) (X)
SPOUSE
DEPENDENT #1
DEPENDENT #2
DEPENDENT #3
IV. EMPLOYEE COVERAGE ELECTION LAY MEDICAL Default LAY MEDICAL “Buy-up” DENTAL VISION
PRIEST MEDICAL NONE, COMPLETE WAIVER SECTION
V. LIFE/AD&D & LTD INSURANCE COVERAGES – Eligible employees are automatically enrolled in the Basic Life and AD&D Plan, sponsored by ACCB.
Eligible employees are automatically enrolled in LTD after one year of employment. This is done by the Local administrator.
NAME OF PRIMARY BENEFICARY ADDRESS CITY STATE ZIP CODE
RELATIONSHIP DATE OF BIRTH
NAME OF CONTINGENT BENEFICARY ADDRESS CITY STATE ZIP CODE
RELATIONSHIP DATE OF BIRTH
NOTE: If you require additional space for additional Dependents or Contingent Beneficiaries, please attach separate sheets
PLEASE READ SECTIONS VI. & VII. CAREFULLY (if waiving coverage-please sign both!)
VI. RELEASE and APPLICATION SIGNATURE: I hereby certify that I am an eligible employee/beneficiary as defined in the Summary Plan Document, that the above information is complete and accurate, and all claims submitted will be for individuals who are eligible members of the health plan. I hereby authorize the Plan Sponsor to deduct, from my pay, my contributions to the cost of the benefits, which I indicated above and for which I am or may become eligible. The current benefits have been explained to me thoroughly. I understand that I am responsible for a greater portion of my health costs when in excess of the amounts payable under the plan. I also authorize any physician or other health care professional, hospital or other health care facility, counselor, therapist, or any other medical or medically related facility or professional to give the health plan, respective agents or representatives any and all information or records relating to health history, health examinations, services rendered, or treatment given including treatment for alcohol, substance abuse or mental or emotional disorders, A.I.D.S., or A.R.C. of me or any of my dependents applying for coverage or of any claim for benefits. I also authorize the health plan to disclose all such health or personal information related to myself or any covered dependent, to a health care provider, a health care service plan, a self-insurer, or any insurance company for the purpose of investigating or evaluating any claim for benefits. If my coverage is under a master policy held by my employer, an association, trust fund, union or similar entity, this authorization also permits disclosure of them for the purpose of administering my coverage, utilization review or financial audit. This authorization is effective immediately and shall remain in effect for use in connection with any claim for benefits for as long as any health coverage may be in effect. A photocopy of this authorization is as valid as the original.
I HAVE READ AND UNDERSTOOD SECTION VI – APPLICANT SIGNATURE X _______________________________________________________________ DATE ____________________
VII. WAIVER of COVERAGES The current benefits have been explained to me thoroughly. I DO NOT wish to enroll in the following coverage(s) ENROLLEE : MEDICAL DENTAL VISION DEPENDENT: MEDICAL DENTAL VISION Is the coverage being waived due to coverage by another health plan? YES NO I understand that by waiving the coverage above, I will not be entitled to any benefits provided by the plan.
THE INFORMATION PROVIDED ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I HAVE READ, UNDERSTOOD, AND AGREE TO SECTIONS VI AND THE TERMS OF THIS ENROLLMENT FORM.
WAIVER OF COVERAGE SIGNATURE X __________________________________________________________________________________________________________________ DATE ____________________________
TO BE COMPLETED BY LOCATION ADMINISTRATOR ONLY
EFFECTIVE DATE
VIII. REASON FOR THE CANCELLATION / CHANGE
EMPLOYEE COVERAGE:
Discharged Deceased: Date ____________ Last day worked: ____________ Retirement: Date________ Resignation: Date___________ Date of disability: ____________ Reduction of work hours New dependent (Spouse or Child) New name:_______________________________ Increase of work hours New address Other please specify: _______________________________________________________________
DEPENDENT COVERAGE: Death of covered employee Date of divorce / legal separation __________________ Eligible for Medicare No longer an eligible dependent Termination of dependent’s health coverage
LOCATION ADMINISTRATOR NAME
SIGNATURE DATE
File Location: Finance/AOA Health Ins/FY 2016/ Enrollment Package
