Employee Benefits Guide
2018-2019
Welcome
Welcome to the Jamestown Public Schools Benefit Program
Jamestown Public Schools strives to provide a balanced, comprehensive benefits program for their employees. The Jamestown Public Schools Employee Benefits program offers you core benefits, such as Medical, Vision, and Life insurance as well as voluntary and supplemental benefits that help maximize your coverage options.
If you have questions please contact your Human Resources Department.
Changes for 2018-2019
- Added a $0 co-pay benefit on certain preventive medications (complete list available on the BCBS website under HSA Preventive Drug List)
- All members will receive new ID cards.
Enrollment Instructions
All full-time employees working at least 30 hours per week of continuous employment are eligible for coverage on the first or the 16th day of the month following date of hire. If you terminate employment or change to a part-time status, your coverage will terminate on the last day of the month that the change/termination occurs.
Please note: It is important that you enroll in a timely manner. If you do not enroll within your first 30 days of employment, you will not be eligible to enroll without a qualifying life event until the next open enrollment period.
Open enrollment will end on August 29, 2018 and benefits will begin September 1, 2018.
Life Event Changes
The following events allow you to change your benefits outside the open enrollment period:
- You get married, divorced, or legally separated
- You add a dependent child through birth, adoption, or change in custody
- Your spouse or dependent passes away
- Your dependent loses coverage or gains other coverage
- Your spouse loses or qualifies for coverage through his or her employer
If you have a change in status, you must notify Human Resources to complete the necessary change forms within 30 days of the change. You will need to present documentation, such as a birth, marriage or divorce decree.
BlueCross BlueShield of North Dakota
| Benefit | Details |
|---|---|
|
Annual Deductible
Single/EE+Dependent/Family
|
$250/$375/$500 |
|
Out-of-Pocket Maximum
Single/EE+Dependent/Family
|
$2,500/$3,750/$5,000 |
| Preventative Care | Covered 100% |
| Office Visits | $20 Primary/Specialist, then covered 90% |
| Emergency Room | $100 copay, then covered 90% |
| Urgent Care | $20 copay, then covered 90% |
| Inpatient Hospital | Covered 90% AD |
| Outpatient Hospital | Covered 90% AD |
| Chiropractic Visits | $20 copay, then covered 90% |
|
Mental Health
Outpatient
Inpatient
|
First 5 visits plan pays 100%, then covered 90% AD
Covered 90% AD
|
| Prescriptions - Retail Order (covers up to a 100 day supply) | |
|---|---|
|
Preventive care medication
(see BCBSND list)
Formulary
(applies to Out-of-Pocket Maximum)
Non-Formulary
|
$0 copay $15 copay, then covered 80% $15 copay, then covered 50% |
Please refer to District Human Resources for premium rates
This is a brief summary of your benefit. Please refer to plan summary for more details.
BCBSND Summary of Benefits
BCBSND: Jamestown Public Schools ClassicBlue 500
Summary of Benefits and coverage: What this Plan Covers and What You Pay for Covered Services
Coverage Period: 9/1/19-8/31/20
Coverage for: Individual, Parent and Child, Parent and Children, Two Person, Family | Plan Type: PPO
|
Important questions
|
answers
|
why this matters:
|
|---|---|---|
| What is the overall deductible? |
$500 individual / $750 parent and child / $750 parent and children / $1,000 two person / $1,000 family
Doesn't apply to preventive care or prescription drugs. Copays and coinsurance do not apply to the deductible.
|
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | Yes, Preventive care. |
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits. |
| Are there other deductibles for specific services? | Yes. $500 for infertility services. There are no other specific deductibles. | You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. |
| What is the out-of-pocket limit for this plan? | $2,500 individual / $3,750 parent and child / $3,750 parent and children / $5,000 two person / $5,000 family |
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |
| What is not included in the out-of-pocket limit? | Premiums, nonformulary drug sanction, infertility services, balance-billed charges and health care this plan doesn't cover. | Even though you pay these expenses, they don't count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Not Applicable. | This plan does not use a provider network. You can receive covered services from any provider. |
| Do you need a referral to see a specialist? | No | You can see the specialist you choose without a referral. |
|
common
medical event
|
services you May need | your cost | limitations, exceptions, & other important information |
|---|---|---|---|
|
If you visit a health care provider's office or clinic |
Primary care visit to treat an injury or illness
|
$20 copay/visit; 10% coinsurance | Deductible is waived. |
|
Specialist visit
|
$20 copay/visit; 10% coinsurance | Deductible is waived. | |
|
Preventive care/screening/ Immunization
|
No Charge | None | |
|
If you have a test |
Diagnostic test (x-ray, blood work) | 10% coinsurance | None |
| Imaging (CT/PET scans, MRIs) | 10% coinsurance | None | |
|
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at the BCBSND website |
Retail Pharmacy
Preventive Drug
Formulary Nonformulary |
0% coinsurance $15 copay/ prescription; 20% coinsurance $15 copay/ prescription; 50% sanction
|
Deductible is waived. One copay for a 1-100 day supply. |
|
Preferred Mail Order Pharmacy
Preventive Drug
Formulary
Nonformulary |
0% coinsurance
$15 copay/ prescription; 20% coinsurance $15 copay/ prescription; 50% sanction |
Deductible is waived. Mail order prescriptions must be received from the preferred mail order pharmacy. One copay for a 1-100 day supply. Mail order prescriptions must be received from the preferred mail order pharmacy. |
|
|
Preferred Specialty Pharmacy
Formulary
Nonformulary |
$15 copay/ prescription; 20% coinsurance $15 copay/ prescription; 50% sanction |
Specialty Drugs are subject to a dispensing limit of a 30-day supply. Specialty Drugs must be received from the preferred specialty pharmacy network. |
| common medical event | services you may need | your cost | limitations, exceptions, & other important information |
|---|---|---|---|
|
If you have outpatient surgery |
Facility fee (e.g., ambulatory surgery center) | 10% coinsurance | None |
| Physician/surgeon fees | 10% coinsurance | None | |
|
If you need immediate medical attention |
Emergency room care | $100 copay/visit; 10% coinsurance | Deductible is waived. |
| Emergency medical transportation | 20% coinsurance | None | |
| Urgent care | $20 copay/visit; 10% coinsurance | Deductible is waved. | |
|
If you have a hospital stay |
Facility fee (e.g., hospital room) | 10% coinsurance | Precertification may be required. |
| Physician/surgeon fees | 10% coinsurance | None | |
|
If you need mental health or behavioral health services |
Outpatient services | 0%/10% coinsurance | First five hours plan pays 100% |
| Inpatient services | 10% coinsurance | Precertification is required. | |
|
If you need substance abuse services |
Outpatient services | 0%/10% coinsurance | First five visits plan pays 100% |
| Inpatient services | 10% coinsurance | Precertification is required. | |
|
If you are pregnant |
Office visits | 10% coinsurance | Deductible is waived. |
| Childbirth/delivery professional services | 10% coinsurance | None | |
| Childbirth/delivery facility services | 10% coinsurance |
None |
|
|
If you need help recovering or have other special health needs |
Home health care | 20% coinsurance | Precertification is required. |
| Rehabilitation services | $15 copay/visit; 20% coinsurance | Deductible is waived. | |
| Habilitation services | $15 copay/visit; 20% coinsurance | Deductible is waived. Limited to 90 visits per benefit period. | |
| Skilled nursing care | 20% coinsurance | Precertification is required. | |
| Durable medical equipment | 20% coinsurance | Precertification may be required. | |
| Hospice services | 20% coinsurance | Precertification is required. | |
|
If your child needs dental or eye care |
Children's eye exam | Not covered | None |
| Children's glasses | Not covered | None | |
| Children's dental check-up | Not covered | None |
Excluded Services & Other Covered Services:
| services your plan generally does not cover (check your policy or plan document for more information and a list of any other excluded services.) | ||
|---|---|---|
|
|
|
| Other covered services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) | ||
|---|---|---|
|
|
|
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Contact BCBSND at their website or 1-844-363-8457 or the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or on their website. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, Visit HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Blue Cross Blue Shield of North Dakota at 1-844-363-8457 or www.BCBSND.com, The Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform.
Does this plan provide Minimum Essential Coverage? Yes.
If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.
Does this plan meet Minimum Value Standards? Yes.
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the price your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
(9 months of in-network pre-natal care and a hospital delivery)
- The plan's overall deductible $500
- Specialist copayment $20
- Hospital (facility) coinsurance 10%
- Other coinsurance 10%
Total Example Cost $12,800
Managing Joe's type 2 Diabetes
(a year of routine in-network care of a well-controlled condition)
- The plan's overall deductible $500
- Specialist copayment $20
- Hospital (facility) coinsurance 10%
- Other coinsurance 10%
Total Example Cost $7,400
Mia's Simple Fracture
(in-network emergency room visit and follow up care)
- The plan's overall deductible $500
- Specialist copayment $20
- Hospital (facility) coinsurance 10%
- Other coinsurance 10%
Total Example Cost $1,900
Note: these numbers assume the patient does not participate in the plan's wellness program. If you participate in the plan's wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: 1-844-363-8457.
*Note: This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?" row above.
The plan would be responsible for the other costs of these EXAMPLE covered services.
In accordance with federal regulations, Blue Cross Blue Shield of North Dakota is required to provide you the following disclosure:
Blue Cross Blue Shield of North Dakota complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross Blue Shield of North Dakota does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Blue Cross Blue Shield of North Dakota:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, please call Member Services at 1-800-342-4718 (toll-free) or through the North Dakota Relay at 1-800-366-6888 or 711.
If you believe that Blue Cross Blue Shield of North Dakota has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Civil Rights Coordinator
4510 13th Ave S
Fargo, ND 58121
701-297-1638 or North Dakota Relay at 800-366-6888 or 711
701-282-1804 (fax)
CivilRightsCoordinator@bcbsnd.com (email) (Communication by unencrypted email presents a risk.)
You can file a grievance in person or by mail, fax, or email within 180 days of the date of the alleged discrimination. Grievance forms are available at http://www.bcbsnd.com/report or by calling 800-342-4718. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
800-368-1019 or 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Vision Benefits
| benefit | description | copay | frequency |
|---|---|---|---|
| WellVision Exam |
|
$20 | Every 12 Months |
| Prescription Glasses | $20 | See frame and lenses | |
| Frame |
|
Included in Prescription Glasses | Every 12 Months |
| Lenses |
|
Included in Prescription Glasses | Every 12 Months |
| Lens Enhancements |
|
$55
$95-$105
$150-$175
|
Every 12 Months |
| Contacts (Instead of glasses) |
|
Up to $60 |
Every 12 Months |
| Benefit | Description |
|---|---|
| Extra Savings |
Glasses and Sunglasses
Reinal Screening
Laser Vision Correction
|
| coverage type | monthly cost |
|---|---|
| Employee | $12.51 |
| EE + spouse or one child | $20.00 |
| EE + Children | $20.41 |
| Family | $32.92 |
Premiums are based on a 9-month contribution schedule to cover a full 12-months of premiums
This is a brief summary of your benefit. Please refer to plan summary for more details.
Basic Life and AD&D
Jamestown Public Schools provides basic life coverage as well as Accidental Death and Dismemberment coverage for all active, full-time employees working at least 20 hours per week.
| Basic Life and AD&D Benefits | |
|---|---|
| Employee | $25,000 |
| Accidental Death (AD&D) | $25,000 |
| Accelerated Death Benefit | If you are terminally ill, advance payout of 50% not to exceed $750,000 |
| Age Reduction | 50% of original amount at age 70 |
| Conversion | If your employment ends, you can apply for an individual policy without evidence of insurability within 31 days. |
| Monthly Premium | Refer to District Human Resources |
Employees who work less than 20 hours per week and paid over a nine (9) month period of time are eligible to participate in the plan. Employees will receive pro-rated benefits based on the number of hours worked and the balance of cost will be responsibility of the employee.
Voluntary LTD Coverage
Jamestown Public Schools provides Voluntary LTD coverage for all active employees working at least 30 hours per week whose regular job assignment extends beyond the school year.
| Item | LTD |
|---|---|
| Minimum Benefit | Greater of $100 or 10% of gross disability payment |
| Benefits Begin | After 90-day elimination period/30 day accumulation feature |
| Pre-Existing Condition | 3 months prior/12 months insured |
|
Coverage Basis/Maximum Benefit
Non-Certified Staff
Teachers
Administration
|
66.67% Up to $3,000 per month
66.67% Up to $4,200 per month
66.67% Up to $6,000 per month
|
| Monthly Premium | Refer to District Human Resources |
Voluntary Life Insurance and AD&D
Voluntary Life Insurance is in addition to the basic life insurance. Voluntary Goup Life Insurance provides term life insurance at low rates. Current coverage includes financial protection in the event you, your spouse and/or one of your dependents die while covered under this benefit.
| Item | Voluntary Life benefits |
|---|---|
| Employee |
Increments of $10,000 up to maximum of $500,000
Guaranteed Issue - up to $150,000
|
| Spouse |
Increments of $5,000 up to 100% of employee's life or $500,000
Guaranteed Issue - up to $25,000
|
| Unmarried Dependent Children |
Live birth to 6 months old - $1,000;
6 months up to age 26 - $10,000
|
| Accelerated Death Benefit - Employee Only | Equal to 50% of your basic and supplemental life amounts up to $750,000 for voluntary benefits |
| Age Reduction | 65% of original amount at age 65 and 50% at age 70, and 30% at age 75 |
|
Portable (if elected prior to age 70) |
If your employment ends, you can apply for an individual policy without evidence of insurability within 31 days. Coverage terminates at age 70 |
Monthly rates per $1,000 purchased
| age | cost for employee or spouse |
|---|---|
| 15-24 | $0.063 |
| 25-29 | $0.072 |
| 30-34 | $0.09 |
| 35-39 | $0.117 |
| 40-44 | $0.207 |
| 45-49 | $0.351 |
| 50-54 | $0.576 |
| 55-59 | $0.90 |
| 60-64 | $1.40 |
| 65-69 | $2.52 |
| 70+ | $4.518 |
| Children | $0.20 per $1,000 |
This is a brief summary of your benefit. Please refer to plan summary for more details.
Aflac Options
Aflac Short-Term Disability
Cancer Care
(Policy Series A78000)
Cancer is a serious disease that, unfortunately, many people can relate to. Today, the chances of surviving cancer are better than ever, but the financial impact of cancer can be devastating. An Aflac Cancer Care insurance policy can help employees and their families better cope financially-and emotionally-if a positive diagnosis of cancer ever occurs.
Critical Care Protection
Critical Care Protection helps provide comfort to individuals who are concerned with the financial liability a serious health even can leave behind and offers multiple coverage options to accommodate almost any budget. Unlike other critical illness insurance policies on the market, Critical Care Protection helps cover expenses from initial diagnosis through treatment and provides options for more robust heart coverage.
Aflac Hospital Advantage
Accident Indemnity Advantage
(Policy Series A35000)
Accidents are not planned and can happen at any moment. But when it happens, medical bills can start adding up fast. Help your customers be prepared: Aflac Accident Indemnity Advantage insurance policies pays cash benefits to help provide peace of mind during the different stages of care and recovery. Benefits can be used to help pay for emergency treatment, broken bones, lacerations, concussions, broken teeth, and ambulance transportation, as well as for treatment-related transportation and lodging.
Also available: Life insurance, dental insurance, and Wage works unreimbursed medical and dependent daycare benefits.
For more information on how Aflac can help protect your financial interests contact
Judy Butler Phone 701-952-4909 Email: judith_butler@us.aflac.com
Employee Assistance Program (EAP)
An Employee Assistance Program (EAP) offers short-term confidential counseling on all aspects of life at no cost to you. Employees and household members can confidentially address and resolve personal and work-related challenges including:
- Relationship issues - Marriage counseling, family counseling, parent/child counseling, etc.
- Emotional health issues - stress, anxiety, depression, grief, elder parent challenges
- Drug and alcohol issues - assessments, evaluation and prevention education -this does not include treatment
- Workplace issues - Sexual harassment, dealing with difficult people, handling conflict, changes, job stress
- Crisis counseling - talk to a counselor 24/7
- Wellness Education classes - Drug & Alcohol Education, Stress Management, Parenting, Couples Education
- Legal issues - family law (divorce, wills, custody) and civil law (housing, harassment, motor vehicle) Receive free telephonic advice from a local lawyer and a 25% discount with the lawyer if additional assistance is required.
- Financial Issues - Budget counseling, debt management, retirement planning, student loan planning or repayment-through the Village Financial Resource Center
The Village Financial Resource Center
The number of sessions available to a covered individual's household is equal to the number of household members times (x) four (4). As an example, a household with five (5) members would have access to a maximum of 20 sessions (5 members x 4/member = sessions) per 12 month period. Any number of those sessions can be used by any member of the household up to the total number. There is a minimum of 8 sessions per household.
Confidential assistance is available 24 hours a day, 7 days a week
Important Notices
Federal regulations require Jamestown Public Schools to provide benefit eligible employees with the following notices:
Private Health Information
A portion o of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) addresses the protection of confidential health information. It applies to all health benefit plans. In short, the idea is to make sure that confidential health information that identifies (or could be used to identify) you is kept completely confidential and it will not be used or disclosed without your written authorization, except as described in the Plan's HIPAA Privacy Notice or as otherwise permitted by federal and state health information privacy laws. A copy of the Plan's Notice of Privacy Practices that describes the Plan's policies, practices and your rights with respect to your PHI under HIPAA is available from your medical plan provider. For more information regarding this Notice, please contact Human Resources or the medical plan directly.
Women's Health and Cancer Rights Act
Jamestown Public School's medical plan, as required by the Women's Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services.
This coverage will be provided in consultation with the attending physician and the patient, and will be subject to the same annual deductibles and coinsurance provisions that apply to the mastectomy. For more information, contact your medical plan provider.
Individual Coverage Mandate
Federal law requires that you have health care coverage or you may be subject to an income tax penalty. You can enroll in the Jamestown Public School health plan, or you may want to consider visiting the healthcare.gov website for more information on health plans available through the Healthcare Marketplace in your area.
Premium assistance under Medicaid and Children's Health Insurance Program (CHIP)
If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can 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, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or go to their website to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer's health plan is required to permit you and your dependents to enroll in the plan - as long as you and your dependents are eligible, but not already enrolled in the employer's plan. This is called a "special enrollment" opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance.
Contact Information
| Provider | phone number | e-mail address/website |
|---|---|---|
|
Medical
Blue Cross Blue Shield of ND
|
7-844-363-8457 | |
|
FSA
Wage Works
|
1-800-950-0105 | |
|
Life Insurance/Voluntary
LTD
Unum
|
1-800-421-0344
Claims 1-800-858-6843
Refer to HR for all other questions
|
|
|
Vision
VSP
|
1-800-877-7195 | |
|
Dental & Voluntary
Worksite Benefits
Aflac
|
Aflac HQ
1-800-922-3522
Claims Fax
1-877-442-3522
|
|
|
Aflac Local Representative
Judy Butler
Or
Local Admin - Cindy
|
Office: 701-952-4909
Cell: 701-320-4923
Fax: 701-952-4910
701-490-0121
Fax: 701-490-3208
|
or
|
We encourage you to read the entire enrollment guide before you enroll.
This benefit guide gives a brief description of what is in the official summary plan documents for these plans. The benefits that you receive are based upon the plan's official documents, not this guide or any other written or oral statement. If there is a conflict between this guide and the official plan document, the official plan documents will govern in all cases. Jamestown Public Schools reserves the right at any time to change or terminate these plans.