2021 Benefit Guide City of Lafayette_Final_202011251245526923

Eligible 1st day of employment Not Eligible ELIGIBLE DEPENDENTS FOR MEDICAL, DENTAL & VISION Many of the benefit plans also offer coverage for eligible dependents.. 7 KAISER HMO PLAN

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Plan Year 2021

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TABLE OF CONTENTS

Medical Coverage 5

Dental Coverage 9

Vision Coverage 12

Flexible Spending Accounts 14

Life and Accidental Death & Dismemberment 18

Long-Term and Short-Term Disability 19

Employee Assistance Program 21

Travel and ID Theft Assistance 22

Legal Assistance 23

Wealth Building 24

Rates 26

Contact Information 29

Terms and Definitions 32

Employees working in those positions classified as Regular Part-Time are considered Part-Time Employees Regular Part

‐Time Employees may access the health insurance plan at their own cost No classification of part-time employee is gible for dental, vision, life, LTD, STD, voluntary life, or AD&D benefits.

eli-Employee Status

Medical

Eligible 1st of month Following 30 days of service

Eligible 1st of month Following 30 days

Retirement Plan 401a (ICMA-RC) Eligible 1st day of employment Not Eligible

Deferred Compensation Plan (ICMA-RC) Eligible 1st of month following 30 days of

service

Eligible 1st day of employment

Fire and Police Pension Assoc (FPPA)

Sworn Fire and Police personnel only Eligible 1st day of employment

Not Eligible

ELIGIBLE DEPENDENTS FOR MEDICAL, DENTAL & VISION

Many of the benefit plans also offer coverage for eligible dependents Eligible dependents include:

• Your common law spouse;

• Your legal spouse, if not legally separated;

• Your child, through the end of the month in which they reach age 26 This includes:

– Your natural child;

– Your stepchild;

– An adopted child

• Your dependent unmarried child of any age who becomes totally disabled before reaching the age limit for

eligibility;

• Your child, for whom a Qualified Medical Child Support Order (QMCSO) has been issued

Note : It is your responsibility to notify Human Resources within 30 days of the qualifying event Failure to do so may

result in a loss of premiums paid for the dependent and/or financial responsibility for any claims incurred after the dependent became ineligible

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COVERAGE LEVELS

You must be enrolled in order to enroll your

dependents You may choose a different coverage

level for Medical, Dental and/or Vision The coverage

categories are:

• Employee only,

• Employee and spouse,

• Employee and child(ren),

• Family, or

• Waived coverage

WHEN IS MY COVERAGE EFFECTIVE?

If you enroll during the annual enrollment period,

the coverage you select will be effective January 1,

2021 provided you have met the eligibility

requirements

WHAT IF I CHOOSE NOT TO ENROLL NOW

OR MISS THE OPEN ENROLLMENT PERIOD?

If you choose not to enroll during open enrollment

or your eligibility period, you will be required to wait

until the next annual open enrollment unless you

have a qualifying change of status as described

• Marriage, death of spouse, divorce or legal separation

• Birth, adoption, placement for adoption or death of a dependent

• Termination or commencement of employment for you, spouse, or dependent

• Relocation or increase in hours of employment by you or your spouse

• Your dependent child satisfies or ceases to satisfy the requirements for coverage because of age

• A change in the place of residence or work for you, your spouse, or dependent

• You or your spouse experiences an open enrollment event

medical

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You may enroll in the HMO Plan 420P administered by Kaiser Permanente This plan requires members to see Kaiser

Physicians exclusively

Employees are required to enroll in the plan offered by the City; however, this requirement does not apply if the

employee is covered under another health insurance plan Proof of paid premiums for other coverage is required,

should the employee choose not to enroll in the City plan

HEALTH ENROLLMENT TIPS

To choose a coverage level and supplemental benefits that are best for you and your family, consider your choices and your prior and expected future medical needs:

• What were your expenses this year?

• Do you expect your medical expenses to increase next year in anticipation of surgery, chronic conditions, or

childbirth?

• How much are you willing to spend in premiums?

• How much can you afford to pay out-of-pocket for medical expenses?

Medical Coverage

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KAISER HMO PLAN 420P

Deductible

Individual Family

No Deductible

No Deductible

Out of Pocket Maximum

Individual Family

$2,000

$4,500

Preventive Care

Children’s Services Adult’s Services

$20 copay/visit

$35 copay/visit Plan pays 100%

$35 copay/visit

$150 copay/procedure

Maternity

Prenatal Care Delivery & Inpatient Well Baby Care

$0 copay/visit

$750 copay/admission

Hospital Facility Services

Inpatient Outpatient

$750 copay/admission

$150 copay/visit

Emergency Services

Emergency Room Urgent Care

Ambulance

$100 copay/visit, waived if admitted

$100 copay/visit at ER

$50 copay/visit at UC 20% coinsurance up to a max of $500/trip

Prescription Drugs - Level of Coverage and Restrictions on Prescriptions

Retail Generic Drugs Retail Preferred Brand Drugs Mail Order (90-day supply)

Specialty Drugs

$15 copay

$30 copay 2x retail copay 20% coinsurance to a max of $250/drug

Other Mental Health Care

Inpatient $750 copay/admission

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Alcohol & Substance Abuse

Inpatient Outpatient

$750 copay/admission

$20 copay/visit

Physical, Occupational & Speech Therapy

Inpatient Outpatient

$750 copay/admission

$20 copay/visit

calendar year

(for prescribed medically necessary part-time home health services; Not covered outside the

Service Area)

Not covered outside the Service Area

Skilled Nursing Facility Care

(for up to 100 days per calendar year for prescribed skilled nursing facility

services at approved skilled nursing facilities)

Plan pays 100%

Not covered outside the Service Area

Significant Additional Covered Services See Colorado Health Benefit Plan

Description Form

Check out these new and expanded services from Kaiser Permanente!

• Expanded primary and pediatric care hours to 7 a.m.—7 p.m., Monday through Friday, and 8 a.m.—noon on Saturdays

• Same day/next day prescription drug delivery

• Added more behavioral medicine specialists and expanded network of affiliated providers for increased access to

mental health and wellness services

• Contracted with DispatchHealth to provide in-home urgent care services in the Denver Metro Area

• 24/7 on-demand phone and video provider visits available to members

• Chat with a Doctor service hours extended to 6 a.m.—10 p.m., 7 days/week

• Partnered with Rally Health to develop Total Health Assessment tool that helps you reach health goals through

personalized summary and action plan

• The myStrength app is available at no cost to all members—provides personalized, interactive well-being activities

• The “Calm” app is now available to help members lower stress and reduce anxiety through meditation, mental

resilience, and sleep

dental

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Taking care of your teeth is an important part of your overall health The City of Lafayette offers you and your eligible dependents comprehensive dental coverage and services through Delta Dental of Colorado There are two PPO plans being offered with Delta Dental of Colorado:

• Base Plan PPO – This plan is replacing the EPO that was offered in the past You must utilize Delta Dental PPO

dentists This plan offers a lower annual benefit maximum with lower premiums There is no out-of-network coverage on this plan,

• Buy-Up Plan PPO – you must utilize Delta Dental PPO Premier dentists While “Premier” dentists are considered

in-network, you will get the best benefit by seeing a “PPO” provider This plan offers a higher annual benefit maximum and includes both in– and out-of-network coverage

Please refer to the Dental Benefits-At-A-Glance to review plan coverage

HOW YOU CAN SAVE MONEY BY CHOOSING NETWORK DENTISTS

Through Delta Dental, you are provided with a network of dentists Costs are generally lower when you use a network dentist; however, you may go to any dentist you choose, in or out-of-network (only on the Buy-Up plan) Network

dentists have agreed to special rates for Delta Dental participants If your PPO network dentist charges more for a covered service, you will not be billed for the balance However, if you see a Premier provider, they may balance bill you, although it will still be a better benefit than going entirely out-of-network

As an example: if the amount agreed upon through Delta Dental is $50 for a filling and your dentist normally charges

$60, you will not be responsible for the $10 difference if your dentist is in the Delta Dental PPO Network

If your dentist is not in the Delta Dental network, he/she can bill you for the difference, which you will then be obligated to pay Your Explanation of Benefits (EOB) will explain the amount that is covered and how much you are required to pay

DENTAL COVERAGE

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DELTA DENTAL OF COLORADO

Services

BASE PLAN Delta Dental PPO Only [In-Network Benefits Only]

BUY-UP PLAN Delta Dental PPO+Premier [In-Network]

BUY-UP PLAN Delta Dental PPO+Premier [Out-of-Network]

(Routine exam, X-Rays) 100%, no deductible 100%, no deductible 100%, no deductible Basic Services

(Fillings, Extractions) 50% after deductible 100% after deductible 80% after deductible Major Services

(Oral Surgery, Crowns, Root Canals) 50% after deductible 50% after deductible 50% after deductible Orthodontic Services

(Adult & Child) 50%, no deductible 50%, no deductible 50%, no deductible

Periodontal & Endodontic Services Covered

Under:

Basic Services Basic Services Basic Services

Dental insurance is often seen as unnecessary or a “luxury” item, when in reality, it’s just as important as your medical coverage People who see the dentist regularly have better dental outcomes

vision

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VSP VISION CARE

City of Lafayette offers you and your eligible dependents vision coverage through VSP Vision Care VSP includes a network of participating eye care providers Like the medical and dental benefits, you receive the maximum benefits under the plan and pay less out of your pocket when you seek care from a network provider You do have the option to seek care out-of-network, but you will pay more out of your pocket for those services

Frames

(once every 24 months)

Up to a $130 retail allowance and 20% off

the cost difference Reimburse up to $70

Contact Lenses

(in lieu of lenses/frames)

$130 allowance; 15% off fitting and

evaluation exam Reimburse up to $105 Medically necessary

Elective Up to a $130 allowance Reimburse up to $105

VISION COVERAGE

finances

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SAVE MONEY WITH A FSA

Flexible Spending Accounts are like personal bank accounts in which you set aside a predetermined amount of your weekly pay, before taxes, to cover certain expenses If you know you will have to pay certain medical and dental deductibles, co-pays, commuting expenses or child care expenses, why not use Flex Spending Accounts to pay for these expenses with before-tax dollars? Just remember to budget carefully!

bi-Employees are able to contribute up to $2,750* per year in their health care flex spending account There is a $5,000 annual limit for the dependent care flex spending account

In return for the tax savings, the IRS has set some strict rules around FSAs:

Rule 1 – Use it or lose it

Any money left in your FSA at the close of the plan year must be forfeited You may also forfeit money in your account when your participation in your FSA ends If your employment terminates, you may be eligible to choose to continue participation in your health care FSA under COBRA

Rule 2 – Separate plans

Your FSA can only be used for specific expenses as determined by the IRS If you have money left in your dependent care account, it cannot be used to pay for health care expenses Likewise, any money left in health care cannot be used for dependent care expenses

Rule 3 – Irrevocability

You cannot change the amount you contribute to the Health Care FSA and Dependent Care FSA until the next open enrollment, unless you experience a Qualified Life Event

THIS IS HOW YOU SAVE

The FSA Plan lets you turn part of your pay into tax-free dollars to pay for eligible health care or dependent care expenses you incur during the Plan Year Because FSA contributions and eligible spending withdrawals are not taxed, participating in the FSA decreases your taxable income while increasing your spending money for qualified expenses

*Pending IRS approval for 2021, subject to change

FLEXIBLE SPENDING ACCOUNTS

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In the example below, this employee is married, has one child, earns $1,000 per paycheck and claims three exemptions

on their W-4

To participate, you elect to have a portion of your pay deposited in a Health Care FSA and/or Dependent Care FSA As you incur eligible health care or dependent care expenses, you may submit claims for reimbursement from the appropriate FSA to pay yourself back with pre-tax dollars You may also use the debit card as described on the next page

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THE FSA DEBIT CARD

When you enroll in the Health Care Spending, Dependent Care or Transportation Account you will receive a debit card The card is a signature-based debit card that allows you to directly access flexible spending account funds There is no personal identification number (PIN) associated with the card so it cannot be used at ATM machines

Benefits to You:

• Improved cash flow

• Your spouse may also receive a card

• Convenience

• Payment is made at the point of service directly from

your Flexible Spending Account, no need to file a claim for services

• You incur no out-of-pocket expenses at the time of

service or payment for over-the-counter medicines and drugs

• The expense must be medically necessary and meet

the requirements for eligible expenses for the

Flexible Spending Account

• Food, personal use or cosmetic items are not eligible

expenses and cannot be purchased using the debit card

• Debit Cards may be used for dependent care expenses

if the provider accepts electronic payment from MasterCard

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HEALTH CARE FSA

What is a Health Care FSA?

You can use a Health Care FSA to reimburse yourself for eligible health care expenses that you incur for yourself and your dependents

• Claims deadline: Claims must be submitted by March 31st of the following year

• Grace period: Employees may incur health and dependent care expenses through March 15th of the next year, using the FSA grace period Any expenses incurred through that point will be applied to the previous year, as long

as claims are submitted by March 31st

UPDATES TO ELIGIBLE EXPENSES

Over-the-counter medications (no prescription needed) and menstrual products are now considered an eligible expense for which you can use FSA dollars to purchase

You may review the current listing of eligible and ineligible health care expenses by reviewing IRS Publications 502, Medical and Dental Expenses, available online at http://www.irs.gov/pub/irs-pdf/p502.pdf

Tip: Visit www.fsastore.com to view thousands of FSA-eligible over-the-counter products

DEPENDENT CARE FSA

What is a Dependent Care FSA?

You can use a Dependent Care FSA to pay for eligible dependent care expenses (such as daycare) for your dependents under age 13 or for an older disabled family member while you are working If you are married, your spouse must be working, looking for work, attending school full-time or be disabled

You may review the current listing of eligible and ineligible health care expenses by reviewing IRS Publications 503, Child and Dependent Care Expenses, available online at http://www.irs.gov/pub/irs-pdf/p503.pdf

TRANSPORTATION FSA

What is a Transportation FSA?

Individuals who sign up for this plan will set aside pretax dollars to pay for work related transportation expenses

• Participants will be issued a debit card (their medical spending or dependent care card serves triple duty)

• The debit card can be used to purchase RTD passes or punch cards online

• Participants can use their debit card in a parking garage or for other parking services for their work related parking expenses

• Participants can only use the available balance in their account

• An annual financial commitment is not required

• Participants are allowed to make changes to their payroll deductions quarterly

• Excess funds may be “rolled over” to the next plan year

If members choose not to use the debit card, they can submit reimbursement requests for transportation expenses via the WageWorks system The IRS does not require a receipt

You may review the current listing of Transportation expenses by reviewing IRS Publication 15-B, Fringe Benefits, available online at http://www.irs.gov/pub/irs-pdf/p15b.pdf