2015
Open Enrollment and
Benefits Guide
English
2015
Inscripción Abierta y
Guía de Beneficios
Español
Welcome!
This guide provides information about your benefits with
The Claremont Colleges… at the click of a mouse!
Use this guide as your go-to source when you are first
enrolling for your benefits, when changing your benefits
at Open Enrollment, or throughout the year as a benefits
resource.
Using This Guide…
The guide works like a website. Click underlined words to
jump to more information about that topic. You can also
use the “Last Viewed,“ “Back” and “Next” buttons to move
through the guide at your pace.
Click one of the links below to get started.
Your 2015
Open Enrollment Guide
Your Benefits Guide
2015 Open Enrollment Guide
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It’s Decision Time!
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Open Enrollment for your 2015 benefits is November 4 through
November 25, 2014 at 5:00 p.m. PST.
This is YOUR opportunity to review your current benefit elections and
make any necessary changes. Review this guide for information about:
■■ What’s new for 2015
■■ How to enroll
■■ A high-level overview of your benefits
■■ Your 2015 plan rates
■■ Important required federal notices.
You Must Take Action!
Open Enrollment is an active
enrollment for 2015. Active
enrollment means that you must
elect or decline benefits during
Open Enrollment. If you do not
actively enroll in the desired
benefit, you will not be covered
under the plan in 2015.
Questions? Who to Contact for benefits administration assistance.
Who to Contact
Forms
Notices
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Benefits Guide
For more information about any of The Claremont Colleges plans, click the “Benefits Guide” link on any
page to go to the more detailed Benefits Guide. This guide will be accessible on The Claremont Colleges
intranet all year.
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What’s New for 2015
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Find out what you need to know about the 2015 benefit changes before enrolling for or changing your benefits
this year. Keep in mind, you must elect or decline benefits during Open Enrollment. If you do not actively
enroll in the desired benefit, you will not be covered under the plan in 2015.
Changes to Your Medical Plans
The following plan changes will become effective January 1, 2015:
■■ Anthem Blue Cross HMO (CaliforniaCare)
–– Emergency room copay: The copay for emergency room visits will increase from $100 to $150 per visit.
–– Prescription drug copay: The copay for prescription medications will increase for brand-name and nonformulary medications, as follows:
• Generic prescriptions: $10 copay (no change from 2014)
• Brand-name prescriptions: $30 copay
• Brand-name non-formulary prescriptions: $50 copay
■■ All Medical Plans
–– Out-of-pocket maximum: Prescription drug copays and coinsurance will now apply toward the medical
plans’ out-of-pocket maximums.
Who to Contact
Forms
Notices
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Benefits Guide
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Changes to Your Dental Plans
The following plan changes will become effective January 1, 2015:
■■ MetLife PPO
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
–– X-ray frequency: For children age 19 or younger, the frequency for bitewing X-rays will decrease from twice
per year to once per year.
–– Fluoride application frequency: For children age 14 or younger, the frequency for fluoride application will
decrease from twice per year to once per year.
2015 Employee Premium Costs
As health care costs across the nation continue to rise, so do the costs here at The Claremont Colleges. Therefore,
your costs for coverage will increase again in 2015. The Claremont Colleges will take on the majority of this cost
increase, but we also needed to share some of this additional cost with you.
There are ways we can work together to help keep cost increases at a minimum, including using in-network
doctors, taking advantage of wellness resources, and using generic instead of brand-name drugs when filling
a prescription.
Who to Contact
Forms
Notices
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New Flexible Spending Account (FSA) Vendor
Effective January 1, 2015, PayFlex will replace BeneSyst as our Flexible Spending Account (FSA) administrator.
FSAs help you make your money go further by letting you set aside pre-tax dollars to pay for out-of-pocket
health care and dependent care expenses.
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Below is important information about submitting FSA claims for reimbursement in the coming months.
New FSA Administrator
PayFlex
PayFlex Contact Information
Phone: 888-678-8242
Website: www.PayFlexDirect.com
FILING CLAIMS:
Submit an online claim form at http://benesyst.net if filing the claim before
January 1, 2015.
For expenses incurred between now and
December 31, 2014
FILING CLAIMS:
Submit an online claim form at www.PayFlexDirect.com
Expenses incurred starting January 1, 2015 will
use your 2015 FSA
Submit a paper claim form to:
PayFlex Systems USA, Inc.
P.O. Box 4000
Richmond, KY 40476-4000
Fax: (888) 238-3539
Remember: You have until June 30, 2015 to submit claims to PayFlex for any
expenses eligible for reimbursement from your 2014 FSAs.
Who to Contact
Forms
Notices
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Benefits Guide
Health Fair 2015: Focused on Wellness
The Claremont Colleges wants to help you live the healthiest life you can—that’s why we’re focused on wellness
during this year’s Health Fair. The Health Fair takes place November 7, 2014, and you will be able to interact with
different plan representatives who will be able to connect you to important wellness services that you can use
through the different plans throughout 2015. And, be sure to take advantage of the FREE cholesterol and glucose
testing offered by Anthem.
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Health Care Reform in 2015
As you know, the Affordable Care Act (ACA, also known as “health care reform”) was passed in 2010. This law
extended medical coverage access to nearly everyone in the U.S. and eliminated restrictions on key benefits. The
ACA also includes the individual mandate, which requires nearly all Americans to have medical coverage or pay a
penalty (when they file their annual tax returns).
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Who to Contact
Forms
Notices
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Benefits Guide
If you are eligible for coverage through The Claremont Colleges, this is likely your best option to meet the
individual mandate. The plans offered through The Claremont Colleges is comprehensive and affordable
compared to other options that might be available to you.
However, if you are not eligible for coverage through The Claremont Colleges, visit www.GetInsured.com/Mercer,
a personalized service that can link you to a variety of quality medical plan options. You can also visit California’s
health insurance marketplace online at www.CoveredCA.com. The health insurance marketplace opens for
enrollment beginning November 15, 2014 for coverage effective in 2015.
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Faculty and staff of KGI and
CGU, click here.
Open Enrollment for your 2015 Claremont Colleges benefits is November 4 – November 25, 2014. Keep in
mind, if you do not actively enroll in your desired benefits during the Open Enrollment period, you will not be
covered under the plan in 2015.
To complete enrollment:
1. Review the changes for 2015 so you understand how these changes impact your 2015 benefits.
2.Review your current benefit choices. Ask yourself, does this coverage meet my expected needs? If not, what
should I change?
3.Log on to Ultipro using the link through your school’s website by November 25 to enroll for new plans or
make changes to your current coverage. See How to Enroll for more information.
Who to Contact
Forms
Notices
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Benefits Guide
Outside of the regular Open Enrollment period, you can only change your benefits if you experience a
qualified life event. Qualified life events include:
■■ Marriage, divorce or legal separation
■■ Birth or adoption
■■ A dependent that becomes ineligible for coverage
■■ Death of your dependent
■■ Loss/gain of coverage elsewhere for employee or spouse/domestic partner
■■ Change in work status for you or your spouse/domestic partner
Contact Benefits Administration for more information about what qualifies as a life event, including exceptions. See Who to Contact for
CUC Benefits Administration.
The Claremont Colleges’s Health and Welfare Plans are governed by Internal Revenue Code Section 125. Federal law prohibits any change in your
health plan elections during the plan year unless you or your dependent(s) experience a qualifying life event.
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How to Enroll
For Faculty and staff of CUC, RSABG, CMC, HMC, and Scripps
To enroll for new coverage or make changes to your current benefits
coverage, follow these steps to complete the online enrollment process:
What’s New for 2015
What to Do During
Open Enrollment
How to Enroll n
2015 Plan Rates
Your Benefits at a Glance
Faculty and staff of KGI and
CGU, see the next page.
1. Log on to Ultipro using the link through your school’s website.
2.Enter your login information.
–– If you need your login information, contact your Human Resources Representative.
3.Once logged on, click “Myself” and then “Open Enrollment.”
–– You can also view the “Quick Tour” video for instructions on how to make your elections.
4.Follow the instructions that appear on your screen to make changes, enroll or cancel your health
benefit elections. Please be sure to click Submit to complete your enrollment or change.
5.You may print a Confirmation Statement confirming your elections for your records.
If you do not have access to Ultipro, please contact your Human Resources Office or Benefits Administration for a
Benefit Election Worksheet to submit your elections. Changes you make to your current health benefit elections
during Open Enrollment will be effective January 1, 2015.
Who to Contact
Forms
Notices
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Benefits Guide
2015 Plan Year
Benefits elected during Open Enrollment will be effective January 1, 2015 through December 31, 2015.
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How to Enroll
FOR FACULTY AND STAFF OF CGU AND KGI:
To make changes or elections for the 2015 plan year, follow the instructions below:
What’s New for 2015
What to Do During
Open Enrollment
How to Enroll n
2015 Plan Rates
Your Benefits at a Glance
1. Log in to https://portal.adp.com.
2.Select User Login.
–– Input your User Name and Password.
(If you do not have a user name and password, select First Time Users Register Here to obtain your
user name and password. You will be asked to enter a registration code. Enter code cgu1-91711 (CGU) or
cgukgi-91711 (KGI).)
3.Select the Benefits Tab and click Review/Change Benefits.
–– All employees must update their college-provided life insurance beneficiary located in the Benefits Tab,
Review/Change Beneficiaries.
4.At the Welcome page, you will be guided through the Open Enrollment portal where you can change existing
coverage and/or elect coverage for you and your dependents.
5.Once you’ve completed your enrollment, you will be able to print a benefit summary of your 2015 elections
and coverage for your records.
6.2015 Open Enrollment elections must be made by 5:00 p.m. PST on November 25, 2014.
Who to Contact
Forms
Notices
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Benefits Guide
CONTACT INFORMATION:
■■ CGU:
–– Sarah Verrill at sarah.verrill@cgu.edu
■■ KGI:
–– Cheryl Merritt at cheryl_merritt@kgi.edu or 909-607-7853
–– Sarah Verrill at sarah.verrill@cgu.edu or 909-607-8828
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2015 Plan Rates
At No Cost to You…
The charts below list the monthly amounts that you will pay for your
benefit coverage beginning January 1, 2015.
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
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All benefit premium deductions for health, dental, vision, health savings
account (HSA) and flexible spending accounts (FSA) coverage are taken
on a pre-tax basis unless otherwise requested. Benefit deductions are
taken in the current month of coverage.
The Claremont Colleges pays
100% of the cost of coverage for:
■■ Core vision coverage
(employee-only)
■■ Basic Life Insurance
■■ Long-term disability*
■■ Employee Assistance Program
(EAP).
Monthly Employee Rates—Medical Plans
Kaiser HMO
Employee Only
Anthem Blue Cross HMO
(CaliforniaCare)
$43.39
Two Party
Family
Anthem Lumenos HSA
$53.14
$53.38
$182.23
$223.19
$224.42
$390.49
$477.82
$482.18
Monthly Employee Rates—Dental Plans**
Who to Contact
Forms
Notices
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MetLife DHMO
Employee Only
Two Party
Family
MetLife DPPO
$5.76
$56.72
$18.52
$126.80
$30.00
$190.52
More Rates
** RSABG employees pay 50% of the cost for Long-term disability insurance.
Benefits Guide
** R
ancho Santa Ana Botanic Garden (RSABG) is not participating in the employer subsidy for MetLife and therefore all dental premiums shown on the
above chart will be increased by $7.00 for RSABG employees.
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Monthly Employee Rates—Vision Plans
Anthem Core Plan
Employee Only
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Anthem Buy-Up Plan
$0.00
$4.48
Two Party
$1.36
$7.57
Family
$3.05
$12.53
Monthly Employee Rates—Supplemental Life Insurance
Rates for employees and spouses/domestic partners are based on the employee’s age.
Anthem Supplemental and Spouse/Domestic Partner Life Insurance
Age
Monthly Rate (per $1,000
of coverage)
Age
Monthly Rate (per $1,000
of coverage)
Under 30
$0.05 50-54
$0.40
30–34
$0.06 55-59
$0.62
35–39
$0.08 60-64
$0.97
40–44
$0.14 65-69
$1.74
45–49
$0.24 70 +
$3.11
Dependent Child(ren) Life Insurance: $0.50 per $5,000 of coverage, per family (regardless of the number of
children covered)
Who to Contact
Forms
Notices
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Benefits Guide
More Rates
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Monthly Employee Rates—Accidental Death & Dismemberment
(AD&D) Insurance Plan
Principal Sum1,2
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Who to Contact
Forms
Notices
Print and Search
Benefits Guide
Employee-Only
Coverage
Family Coverage
Principal Sum1,2
Employee-Only
Coverage
Family Coverage
$25,000
$0.50
$0.98
$275,000
$5.50
$10.73
$50,000
$1.00
$1.95
$300,000
$6.00
$11.70
$75,000
$1.50
$2.93
$325,000
$6.50
$12.68
$100,000
$2.00
$3.90
$350,000
$7.00
$13.65
$125,000
$2.50
$4.88
$375,000
$7.50
$14.63
$150,000
$3.00
$5.85
$400,000
$8.00
$15.60
$175,000
$3.50
$6.83
$425,000
$8.50
$16.58
$200,000
$4.00
$7.80
$450,000
$9.00
$17.55
$225,000
$4.50
$8.78
$475,000
$9.50
$18.53
$250,000
$5.00
$9.75
$500,000
$10.00
$19.50
1
Coverage amounts in excess of $250,000 may not exceed ten times annual base salary.
2
Principal sum amount cannot be increased after age 70.
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Your Benefits at a Glance
Benefits are an important part of your overall compensation.
Click the type of benefit you want to learn more about:
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Employer-Paid Benefit Coverage n
Benefits You Can Enroll n
in During Open Enrollment
Voluntary Benefits You Can Enroll n
in at Any Time
Wellness Resources n
Who to Contact
Forms
Notices
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Benefits Guide
■■ Employer-Paid Benefit Coverage
■■ Benefits You Can Enroll in During Open Enrollment
■■ Voluntary Benefits You Can Enroll in at Any Time
■■ Wellness Resources
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Employer-Paid Benefit Coverage
What’s New for 2015
What to Do During
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2015 Plan Rates
Your Benefits at a Glance
Employer-Paid Benefit Coverage n
Benefits You Can Enroll n
in During Open Enrollment
Voluntary Benefits You Can Enroll n
in at Any Time
Wellness Resources n
Who to Contact
Forms
Notices
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Benefits Guide
Benefit
Options
Who Pays
Vision Core Plan
■■ Employee coverage
The Claremont Colleges pays 100% of the cost of
coverage.
Basic Life Insurance
■■ Employee coverage
The Claremont Colleges pays 100% of the cost of
coverage.
Long-Term Disability
(If you are on the Rancho
Santa Ana Botanic
Garden’s staff, you must
elect this benefit if you
want coverage.)
■■ Group Long-Term Disability (LTD)
The Claremont Colleges pays 100% of the cost of
coverage.
For staff working at RSABG, The Claremont
Colleges pays 50% of the cost of coverage, and
you pay the remaining cost.
Group LTD coverage is available to faculty and
staff working 30 or more hours per week.
Employee Assistance
Program (EAP)
■■ Employee Assistance Program
The Claremont Colleges pays 100% of the cost of
coverage.
ARP
■■ Academic Retirement Plan
Employer contributions are subject to the
satisfication of eligibility requirements.
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Benefits You Can Enroll in During Open Enrollment
(November 4–November 25, 2014)
For more information, click the benefit name in the table below.
(Note: Benefits-eligible temporary employees are only eligible for medical and dental coverage.)
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Employer-Paid Benefit Coverage n
Benefits You Can Enroll n
in During Open Enrollment
Voluntary Benefits You Can Enroll n
in at Any Time
Wellness Resources n
Benefit
Options
Who Pays
Medical
■■ Kaiser Permanente HMO
You pay a portion of the cost of coverage.
Premiums are deducted from your paycheck on
a pre-tax basis. See 2015 Plan Rates for more
details.
■■ Anthem Blue Cross HMO
■■ Anthem Lumenos HSA
Health Savings Accounts
(HSAs)
■■ Mellon Health Savings Account
(You must be enrolled in the Anthem Lumenos
HSA or another high deductible health plan to
be eligible for dual coverage)
You can choose to contribute funds from your
paycheck to your HSA on a pre-tax basis. The
Claremont Colleges will also make a one-time
contribution to your account, depending on your
coverage level and eligibility status.
Dental
■■ MetLife DHMO
You pay a portion of the cost of coverage.
Premiums are deducted from your paycheck on
a pre-tax basis. See 2015 Plan Rates for more
details.
■■ MetLife DPPO
Vision
■■ Anthem Core Plan
■■ Anthem Buy-Up Plan
Who to Contact
Forms
Notices
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Premiums are deducted from your paycheck on a
pre-tax basis.
See 2015 Plan Rates for more details.
Flexible Spending
Accounts (FSAs)
■■ Health Care FSA
■■ Dependent Care FSA
■■ Limited Scope Health FSA
Benefits Guide
The Claremont Colleges pays the full cost of
employee-only coverage for the Anthem Core
Plan. You pay a portion of the cost of coverage for
Anthem Core Plan coverage for your dependents
and the Anthem Buy-Up Plan.
Contributions are deducted from your paycheck
on a pre-tax basis.
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Voluntary Coverage You Can Enroll in at Any Time
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Employer-Paid Benefit Coverage n
Benefits You Can Enroll n
in During Open Enrollment
Voluntary Benefits You Can Enroll n
in at Any Time
Wellness Resources n
Benefit
Options
Who Pays
Supplemental Life
Insurance
■■ Employee coverage
You pay the full cost of coverage. Premiums are
deducted from your paycheck on an after-tax
basis. See 2015 Plan Rates for more details.
■■ Spouse or domestic partner coverage
■■ Child(ren) coverage
Accidental Death &
Dismemberment (AD&D)
Insurance Plan
■■ Employee coverage
Retirement Plans
■■ Academic Retirement Plan
■■ Family coverage
■■ Tax Deferred Annuity Plan (TDA)
You pay the full cost of coverage. Premiums are
deducted from your paycheck on an after-tax
basis. See 2015 Plan Rates for more details.
Contributions are deducted from your paycheck
on a pre-tax basis.
Long Term Care Insurance
■■ Optional Long Term Care Insurance
You pay the full cost of coverage. Costs are
determined by your age and the plan you select
when you first enroll.
Long-Term Disability
(Rancho Santa Ana
Botanic Gardens staff)
■■ Group Long-Term Disability (LTD)
For staff working at RSABG, The Claremont
Colleges pays 50% of the cost of coverage, and
you pay the remaining cost.
Group LTD coverage is available to faculty and
staff working 30 or more hours per week.
See Forms and Notices for necessary documentation, including an Evidence of Insurability form.
Who to Contact
Forms
Notices
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Wellness Resources
If you enroll in a medical plan with The Claremont Colleges, you will also have access to wellness resources
through your plan provider, including programs that can help you:
■■ Quit smoking
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Employer-Paid Benefit Coverage n
Benefits You Can Enroll n
in During Open Enrollment
Voluntary Benefits You Can Enroll n
in at Any Time
Wellness Resources n
■■ Get more exercise
■■ Improve your diet with nutritional counseling
■■ Lose weight
In addition, disease management programs offer support, tools and information to help manage certain chronic
conditions like:
■■ Asthma
■■ Congestive heart failure
■■ Diabetes
■■ Hypertension (high blood pressure)
Go online to the Anthem or Kaiser Permanente websites to learn more about the programs they offer.
Who to Contact
Forms
Notices
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Benefits Guide
Ready for More Wellness?
For more detailed information about these and other wellness programs available, see the
Wellness Program section of the Benefits Guide.
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Who to Contact
CUC Benefits Administration
What’s New for 2015
What to Do During
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2015 Plan Rates
Your Benefits at a Glance
Who to Contact
CUC Benefits Administration n
Plan Providers n
Forms
Notices
Print and Search
Benefits Guide
If you have questions about your benefits or for additional information
on new enrollment, changes or cancellation of your benefits, contact
CUC Benefits Administration.
For KGI and CGU Contacts, see
the next page.
Contact
Phone
Email
Carol Saldivar,
Benefits Manager, Workers
Compensation & Disability
909-607-3195
carol_saldivar@cuc.claremont.edu
Monica Villanueva,
Benefits Representative
909-607-3684
monica_villanueva@cuc.claremont.edu
Anna Huerta,
Benefits Representative
909-607-9494
anna_huerta@cuc.claremont.edu
Claudia Garcia,
Benefits Representative
909-607-9493
claudia_garcia@cuc.claremont.edu
Tony Romero,
Retirement Analyst
909-621-8805
tony_romero@cuc.claremont.edu
Loo Hsing,
Senior Retirement Analyst
909-607-3780
loo_hsing@cuc.claremont.edu
Lissette Martinez,
Workers Compensation &
Disability
909-621-8847
lissette_martinez@cuc.claremont.edu
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CGU Benefits Administration
What’s New for 2015
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Who to Contact
KGI & CGU Benefits Administration n
Plan Providers n
Forms
Notices
Print and Search
Benefits Guide
Contact
Phone
Email
Sarah Verrill,
Payroll & Benefits Manager
909-607-8828
sarah.verrill@cgu.edu
KGI Benefits Administration
Contact
Phone
Email
Cheryl Merritt,
Director of Human Resources
909-607-7853
cheryl_merritt@kgi.edu
Sarah Verrill,
Payroll & Benefits Manager
909-607-8828
sarah.verrill@cgu.edu
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Plan Providers
You may also contact the providers directly with specific benefit coverage questions.
What’s New for 2015
What to Do During
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2015 Plan Rates
Your Benefits at a Glance
Who to Contact
CUC Benefits Administration n
Plan Providers n
Provider or Department
Phone
Website Address
Anthem Blue Cross HMO
(CaliforniaCare)
800-227-3771
www.anthem.com/ca
Anthem Lumenos HSA
866-207-9878
www.anthem.com/ca
Kaiser Permanente
800-464-4000
www.kp.org
Mellon HSA
877-472-4200
https://mybenefitwallet.com/
MetLife Dental
800-942-0854
www.metlife.com
Anthem Vision
866-723-0515
www.anthem.com
PayFlex FSA Administration
888-678-8242
www.PayFlexDirect.com
United Behavioral Health—
Employee Assistance Program
800-234-5465
www.liveandworkwell.com/default.asp?
ProgramPIN=claremontcolleges
Anthem Blue Cross Life
Insurance
800-552-2137
www.anthem.com/ca
Zurich Voluntary AD&D
866-841-4771
www.zurichna.com
ING TriTerm Life
800-955-7736
N/A
Genworth—Long-Term Care
(Policies issued on or after
1/1/2012)
800-416-3624
http://genworth.com/groupltc
Username: Claremont
Password: groupltc
John Hancock—Long-Term Care 800-482-0022
(Policies issued before 1/1/2012)
http://longtermcare.jhancock.com
Username: claremont
Password: mybenefit
Forms
Notices
Print and Search
Benefits Guide
Continued
2015 Open Enrollment Guide
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Plan Providers (Continued)
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Provider or Department
Phone
Website Address
Fidelity
800-343-0860
www.mysavingsatwork.com
TIAA-CREF
800-842-2776
www.tiaa-cref.org
Vanguard
800-662-2003
https://personal.vanguard.com/us/home
Medicare
800-MEDICARE (800-633-4227)
www.medicare.gov
■■ Los Angeles County (Center for Health
Care Rights)
213-383-4519
www.chcsbc.org
■■ Orange County (Council on Aging)
714-560-0424
www.coaoc.org
■■ San Bernardino County (HICAP of San
Bernardino County)
909-256-8369
www.hicapsbc.org
California Casualty (Auto and Home
Insurance)
877-411-1427
www.calcas.com
Assist America (In conjunction with
Business Travel Accident policy through
AC Newman)
609-921-0868 x 221
www.assistamerica.com
Health Insurance Counseling & Advocacy
Program
This guide provides general benefit plan and enrollment information only. For specific details, conditions and exclusions, please refer to the official
summary plan descriptions (SPDs). If there is a discrepancy between this guide and an official SPD or Collective Bargaining Agreement, the official
document will govern.
Who to Contact
CUC Benefits Administration n
Plan Providers n
Forms
Notices
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Benefits Guide
2015 Open Enrollment Guide
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Forms
Use the links below to open the corresponding form:
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Who to Contact
Forms
Notices
Print and Search
Benefits Guide
Form
What It Means for You
■■ Anthem Evidence of Insurability (EOI) Form
To confirm you are generally in good health when electing or
increasing life insurance with Anthem
■■ Domestic Partner Affidavit
To verify unmarried domestic partner relationship
■■ PayFlex FSA and LPFSA Claim Form
To file a claim for reimbursement from your FSA
■■ Long-Term Disability (EOI) Form
To confirm you are generally in good health when electing
long-term disability coverage (for RSABG only)
■■ Beneficiary Change Form
To change and verify your elected beneficiaries for Life and
AD&D insurance
■■ Benefits Election Form
To elect benefits during the year if you experience a qualified
life event
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Notices
Federal laws require that The Claremont Colleges provides you with certain notices that inform you about your
rights regarding eligibility, enrollment and coverage of health care plans. The following sections explain these
rules; please read them carefully. Click the notice in the table below for more information; these notices are also
available in the benefits guide.
What’s New for 2015
What to Do During
Open Enrollment
2015 Plan Rates
Your Benefits at a Glance
Who to Contact
Forms
Notices
Print and Search
Benefits Guide
Notice
What it Means for You
■■ Life Event Changes Information Sheet
Describes qualified life events that allow you to make changes to
your benefits outside the Open Enrollment period
■■ Special Enrollment Rights
Describes when you can enroll for coverage when you have
previously declined coverage
■■ Women’s Health and Cancer Rights Act of 1998
Provides information regarding a woman’s rights after a
mastectomy
■■ Newborns’ and Mothers’ Health Protection Act
Describes protections for mothers and their newborn children
relating to the length of their hospital stays following childbirth
■■ Consolidated Omnibus Budget Reconciliation Act (COBRA)
Provides details about how COBRA can provide ongoing health
benefits after coverage ends under certain conditions
■■ Medicaid and the Children’s Health Insurance Program
(CHIP) Notice
A list of states that have premium assistance programs to help
you pay for medical coverage if you are unable to afford health
care coverage premiums
■■ Health Insurance Portability and Accountability Act (HIPAA)
Describes your rights to health privacy
■■ Your Prescription Drug Coverage and Medicare
Explains that prescription drug coverage through The Claremont
Colleges is as good as, or better than, Medicare prescription drug
coverage
■■ Summary Annual Reports
Annual reports of The Claremont Colleges benefits
■■ Summary of Benefits and Coverage
Summarizes important information about your health coverage
options in a standard format to help you compare each option
––Kaiser Permanente HMO
––Anthem Blue Cross HMO
––Anthem Lumenos HSA
––Anthem Blue Card Lumenos HSA (for out-of-area participants)
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Your Benefits Guide
Your benefits are an important part of your overall compensation. The
Claremont Colleges is pleased to offer a comprehensive array of benefits
to protect your health, your family and your way of life, including:
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
■■ Health care coverage, including medical, dental and vision benefits
■■ Financial protection for you and your family, including disability, life
and accident insurance coverage
■■ Retirement savings opportunities
■■ Work-life resources through the Employee Assistance Program
■■ Other voluntary benefits include Flexible Spending Accounts (FSAs),
Health Savings Accounts (HSAs) and other financial benefits.
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Check It Out!
This interactive guide will not
only help you find information
easily, but it’s environmentally
friendly.
The guide works like a website.
Click underlined words to jump
to more information about that
topic. You can also use the “Last
Viewed,“ “Back” and “Next”
buttons to move through the
guide at your pace.
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Your Benefits
The following benefit programs are available to you. Click the benefit plan below for more information.
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
■■ Medical Benefits
–– Kaiser Permanente HMO
–– Anthem Blue Cross HMO
–– Anthem Lumenos HSA
• Mellon Health Savings Account
■■ Dental Benefits
–– MetLife DHMO
–– MetLife DPPO
■■ Vision Benefits
–– Anthem Core Plan
–– Anthem Buy-Up Plan
■■ Employee Assistance Program
■■ FSAs
–– Health Care FSA
–– Limited Scope Health FSA
–– Dependent Care FSA
■■ Long-Term Disability
–– Basic Coverage
■■ Supplemental Life Insurance Benefit
■■ Accidental Death & Dismemberment Insurance
(AD&D)
■■ Long-Term Care
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Your Medical Benefits
The Claremont Colleges offers three medical plans for you to choose from. Click the plan name for more detail:
■■ Anthem Blue Cross (CaliforniaCare) HMO
■■ Kaiser Permanente HMO
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
■■ Anthem Lumenos HSA
Anthem Blue Cross (CaliforniaCare) HMO and Kaiser Permanente HMO Plans
The HMO plans offer affordable health care for you and your family through a network of health care providers.
When you enroll in an HMO plan, you (and each enrolled family member) will be asked to select a primary care
physician (PCP) from the network. The PCP you choose will help you manage all aspects of your health care. You
have the right to designate any primary care provider who participates in the plan’s network and who is available
to accept you or your family members.
Plan Features:
1. You must select and use a primary care physician (PCP) from the HMO network to coordinate your care.
2.HMOs do not have deductibles or coinsurance. Instead, you pay a copay when you visit your PCP or a specialist
whom you have been referred to by your PCP.
3.If you use doctors, hospitals, labs, pharmacies or other health care facilities outside the HMO, you are
responsible for paying the full cost (except in an emergency).
4.There are no claim forms to file.
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
More
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Anthem Blue Cross (CaliforniaCare) HMO and Kaiser Permanente HMO Plans
(Continued)
Here’s what you need to know about the difference in receiving care from the plans:
Anthem Blue Cross (CaliforniaCare) HMO
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
You must receive all of your non-emergency care from doctors and hospitals in the Anthem Blue Cross
(CaliforniaCare) HMO network, and the care must be under your PCP’s direction or the plan will not pay benefits.
Women may go directly to a gynecologist in their PCP’s medical group or practice association without a referral
from their PCP. Care received from an out-of-network provider will not be covered (except for emergency care).
How to Find an In-Network Anthem Provider
1. Go to anthem.com/ca.
2.Under “Useful Tools” on the right, select “Find a Doctor.”
3.Under “Search by selecting a plan/network,” go to “Select a state.” You can enter the name of your state or
select it from the drop-down list.
4.Under “Select a plan/network,” you can enter the name of your plan/network under the “Medical (Employer
Sponsored)” heading, or select it from the drop-down list then choose “Select and Continue.”
–– The HMO plan name is “Blue Cross HMO (CA Care)-large group.”
5. Using the drop-down boxes, select what type of doctor and the location you’re looking for, then select
“Search”.
6. For more info about a provider (like skills and training), just select that name in the directory.
You can also download Anthem’s mobile app to search for an in-network provider. Download the Anthem Blue
Cross app for Android or Apple smartphone.
More
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Anthem Blue Cross (CaliforniaCare) HMO and Kaiser Permanente HMO Plans
(Continued)
Kaiser Permanente HMO
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
You have the option of going to any Kaiser Permanente facility to receive your care. Care received from a
non-Kaiser facility will not be covered (except for emergency care).
How to Find a Kaiser Permanente Provider
1. Go to www.kp.org/newmember
2.Click on “Find a Doctor”
3.Select “California-Southern”
4.Enter the name of your physician and your location
Once you have selected a Primary Care Physician you can use Kaiser Permanente’s My Doctor portal at
www.kp.org/mydoctor to email your doctor and access health care tools.
30-mile Requirement
If you are enrolled in the Anthem Blue Cross HMO (CaliforniaCare) plan, you must elect a primary care
physician or medical group within 30 miles of where you live or work in order to receive care.
If you attempt to elect a doctor who is outside of these limits then the plan may prevent you from electing
that doctor, even if he or she is accepting new patients, or the medical group may disenroll you from their
medical group facility. To find out whether your primary care physician meets this requirement, contact
Anthem customer service.
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Anthem Lumenos HSA
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
With the Anthem Lumenos HSA Plan, you have the flexibility to choose
any doctor or facility and receive benefits. However, if you go to Anthem
Lumenos HSA network doctors and facilities, you will pay less because
Anthem Lumenos HSA network providers have agreed to charge lower,
negotiated rates.
Plan Features:
1. Flexibility to go to in-network and out-of-network providers
2.Lower out-of-pocket expenses when you see in-network providers
Need More Detail?
Click here to review A Guide to
the Anthem Lumenos HSA Plan.
This guide has more detail about
how the Anthem Lumenos HSA
plan works, and how to make
the most of the tax-advantaged
Health Savings Account (HSA).
3.100% coverage for preventive care with in-network providers
4.Coinsurance for most services once you meet the plan’s deductible
5.Out-of-pocket maximum(s) to help protect you from the expense of a possible catastrophic illness or injury
6.A tax-advantaged Health Savings Account (HSA) for those individuals who are not enrolled in Medicare Parts
A and/or B. Go to Health Savings Account (HSA) for more information about this unique savings account.
A note about Reasonable and Customary charges
When you use in-network providers, the coinsurance percentage is lower due to negotiated rates. If you use outof-network providers, the coinsurance percentage is higher and is based on Reasonable and Customary charges.
You must also pay any amount over the R&C limit.
More
Think About Participating in the Limited Scope Health Care FSA/Health Savings Account
If you enroll in the Anthem Lumenos HSA Plan and open a Health Savings Account (HSA), a Limited Scope
Health FSA is available to you. The Limited Scope Health FSA allows you to pay for eligible dental and
vision expenses (i.e., deductibles, copays, coinsurance). You can also use the Limited Scope Health FSA to
pay for medical expenses and prescription drugs AFTER you’ve met your plan’s deductible. Click here for
more details about how a Limited Scope Health FSA works together with an HSA.
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Anthem Lumenos HSA (continued)
How to Find an In-Network Anthem Provider
1. Go to anthem.com/ca.
2. Under “Useful Tools” on the right, select “Find a Doctor.”
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
3. Under “Search by selecting a plan/network,” go to “Select a state.” You can enter the name of your state or
select it from the drop-down list.
4. Under “Select a plan/network,” you can enter the name of your plan/network under the “Medical (Employer
Sponsored)” heading, or select it from the drop-down list then choose “Select and Continue.”
–– The Anthem Lumenos HSA plan name is “Blue Cross PPO (Prudent Buyer)-large group.”
5. Using the drop-down boxes, select what type of doctor and the location you’re looking for, then select
“Search”.
6. For more info about a provider (like skills and training), just select that name in the directory.
You can also download Anthem’s mobile app to search for an in-network provider. Download the Anthem Blue
Cross app for Android or Apple smartphone.
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How the Anthem Lumenos HSA Works
How does an HSA Plan work? It’s like a house.
ROOF
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
OUT-OF-POCKET MAXIMUM
2nd FLOOR
COINSURANCE
1st FLOOR
ANNUAL DEDUCTIBLE
FOUNDATION
PREVENTIVE CARE—FREE
1. Roof: Your annual out-of-pocket maximum for innetwork usage caps your expenses, like the roof of
a house. Once you reach the annual out-of-pocket
maximum for in-network usage, the plan pays 100%
of your costs for the rest of the year. Please note: your
out-of-pocket expenses could exceed your maximums
when using out-of-network providers and facilities.
2. Second Floor: Comprehensive coverage with
coinsurance paid by you and the medical plan. Once
you meet the deductible, the plan pays a percentage
of the cost and you pay the rest. You can pay for your
portion with the tax-free money you contribute to
your HSA.
3. First Floor: Your contribution to your deductible. The
first floor of this house represents the first expenses
you will pay for your health care. You can use the
tax-free money that you contribute to your HSA to
cover this amount.
4. Foundation: Preventive care is the plan’s foundation,
covered at 100% by the medical plan. This is the
point from which you grow your most valuable health
knowledge and healthy habits. Most appropriate
preventive care received in-network is free to you and
your family.
Don’t Forget to Open Your HSA!
If you enroll in the Anthem Lumenos HSA and you are not enrolled in Medicare Parts A and/or B, you have the option to enroll
in a Health Savings Account (HSA) with Mellon Financial. An HSA is a special account that lets you pay eligible expenses—like
deductibles, coinsurance and prescription drugs—with tax-free dollars. An HSA can be offered only with a medical plan that
meets the IRS high deductible health plan requirements—like the Anthem Lumenos HSA.
Go to the Health Savings Account (HSA) section to learn more about the HSA and how it works.
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Health Savings Account (HSA)
If you choose to enroll in the Anthem Lumenos HSA plan, you have the option to enroll in a Health Savings
Account (HSA) as long as you are not enrolled in Medicare Parts A and/or B. An HSA is a personal savings
account created from pre-tax employee contributions to be used for qualified medical expenses. Federal
regulations limit HSAs for plans with a high deductible, like the Anthem Lumenos HSA plan. Keep in mind that if
you enroll in an HSA and an FSA, you will only be eligible for the Limited Scope FSA, due to IRS regulations.
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
An HSA can also be used as an investment tool. Your account balance can roll over from year to year. And, the
HSA is completely portable—you can take it with you if you change jobs or retire. You can then use this tax-free
money to pay for eligible medical expenses for you or your dependents (excluding domestic partners).
You can make pre-tax contributions into an interest-bearing account managed by Mellon Bank. When you enroll
in an HSA, you will receive a welcome kit from Mellon Bank with more information about using your HSA. Once
you open your HSA, you will receive a debit card linked to your HSA account. You can use this debit card to pay
for any eligible expenses, and the money will be taken directly from your account. You will also have the option to
request a checkbook associated with the account and can use checks to pay for eligible expenses.
For information about the fees and rate schedule for your HSA account, please visit Mellon Bank online at
www.mybenefitwallet.com, or call 877-472-4200.
HSA Basics
Funding
You can contribute to your HSA directly from your salary on a pre-tax basis if you select Mellon as your
HSA provider. You can also contribute to another financial institution’s HSA using post-tax dollars up to
the IRS limit:
■■ The maximum annual contribution is $3,350 per individual*
■■ The maximum annual contribution is $6,650 per family*
■■ If you are 55 years of age or older, there is a catch-up contribution option in the amount of $1,000
* These amounts include any employer contributions. Only non-highly compensated participants (employees who had an annual
compensation of less than $115,000 in 2014) who are not enrolled in Medicare A and/or B are eligible for the employer contribution.
Qualified Expenses
The money that you put into the HSA can be used to pay for qualified medical expenses, including the
Lumenos HSA’s deductible or coinsurance, and other out-of-pocket health care expenses like dentist
visits and eye exams. Additionally, the money that you roll over can be used for future eligible expenses,
including long-term care. There may be restrictions on who the plan will cover, for more details see
A Guide to the Anthem Lumenos HSA Plan.
FSA Participation
If you are also enrolled in a Health Care FSA, eligible expenses under the FSA will be reimbursed on a
limited-scope basis. Limited-scope FSA reimbursements are for non-medical related expenses that you
choose not to use your HSA to reimburse, such as dental or vision copays or coinsurance payments. Refer
to Limited Scope Reimbursements for more information.
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Medical Benefits at a Glance
The chart below provides an overview of the most commonly used benefits. For more detail about any of the
plans’ provisions, click the plan name in the table heading.
Benefit
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Kaiser HMO
Anthem Blue Cross
(CaliforniaCare) HMO
Kaiser Permanente
Network
Anthem Blue Cross
Providers
Anthem Lumenos HSA
In-Network
Out-of-Network
Employer HSA Contribution—for employees who earned less than $115,000 in 2014 (when opened through Mellon Bank)
Employee Only
N/A
N/A
$450
Family
N/A
N/A
$900
Employee HSA
contribution maximum
(not including the
employer contribution)
N/A
N/A
$2,900 (employee only)/$5,750 (family)
Employee HSA catch-up
contribution (ages 55 and
over)
N/A
N/A
$1,000
Employee Only
None
None
$1,500
Family
None
None
$3,000 (includes insured employee & one or more
members of the employee’s family)
Calendar-year deductible
Out-of-pocket maximum (per calendar year) Some benefits do not apply toward the out-of-pocket maximum
Employee Only
$1,500
$1,500
$3,000
$6,000
Family
$3,000
$3,000 (two party)/
$4,500 (family)
$6,000
$12,000
Lifetime Maximum
Unlimited
Unlimited
$200 copay per
admission
$300 copay per
admission
Unlimited
Inpatient Services
Inpatient Hospital
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Continued
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Medical Benefits at a Glance (Continued)
Benefit
Pre-Admission Testing
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Kaiser HMO
Anthem Blue Cross
(CaliforniaCare) HMO
Kaiser Permanente
Network
Anthem Blue Cross
Providers
Anthem Lumenos HSA
In-Network
Out-of-Network
Plan pays 100%
Plan pays 100%
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Plan pays 100%
Drugs, Medicine, Casts,
Dressings, Special Duty
Nursing (when prescribed
and medically necessary)
Plan pays 100%
Plan pays 80% after
deductible
Plan pays 60% after
deductible
X-ray, Laboratory
Plan pays 100%
Plan pays 100%
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Physical Therapy
Plan pays 100%
Plan pays 100%
Plan pays 80% after
deductible (maximum
24 visits combined with
occupational therapy)
Plan pays 60% after
deductible (maximum
24 visits combined with
occupational therapy)
Cost of Administering
Blood Transfusions
Plan pays 100%
Plan pays 100%
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Whole Blood Plasma
No charge if replaced
Plan pays 100%
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Hospice Care
Plan pays 100%
Plan pays 100%
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Skilled Nursing Facility
Plan pays 100% (limit
100 days per calendar
year)
Plan pays 100% (limit
100 days per calendar
year)
Plan pays 80% after
deductible (limit 100
days per calendar year)
Plan pays 60% after
deductible (limit 100 days
per calendar year)
You pay a $20 copay
(PCP), or
You pay a $25 copay
(PCP), or
Plan pays 80% after
deductible
Plan pays 60% after
deductible
You pay a $30 copay
(specialist)
You pay a $40 copay
(specialist)
Outpatient Services
Office Visits
Continued
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Medical Benefits at a Glance (Continued)
Benefit
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Kaiser HMO
Anthem Blue Cross
(CaliforniaCare) HMO
Kaiser Permanente
Network
Anthem Blue Cross
Providers
Anthem Lumenos HSA
In-Network
Out-of-Network
X-rays, Laboratory Tests
Plan pays 100%
Plan pays 100%
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Routine Exams
Plan pays 100%
Plan pays 100%
Plan pays 100%
Plan pays 60% after
deductible
Routine Immunization
Plan pays 100%
Plan pays 100%
Plan pays 100%
Plan pays 60% after
deductible
Preventive Care
Plan pays 100%
Plan pays 100%
Plan pays 100%
Plan pays 60% after
deductible
Outpatient Surgery (at a
Plan facility)
You pay a $30 copay
You pay a $100 copay
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Short-Term Rehabilitation
(physical, occupational,
or speech therapy)
You pay a $20 copay per
visit; benefits are limited
to medically necessary
therapy authorized by a
Plan physician.
Plan pays 80% after
You pay a $25 copay
deductible (maximum
per visit ($40 for
24 visits)
specialist); limited to
a 60-day period of
care after an illness or
injury; additional visits
available when approved
by your medical group
Plan pays 60% after
deductible; benefit
limited to $25/visit
(maximum 24 visits)
Chiropractic Care
Not covered
$25 per visit, short
term (referral from PCP
required)
Plan pays 80% after
deductible
Plan pays 60% after
deductible; benefit
limited to $25/visit
Acupuncture
Not covered
You pay a $25 copay per
visit ($40 for specialist)
Plan pays 80% after
deductible (limited to
$30/visit, 12 visits per
calendar year)
Plan pays 60% after
deductible (limited to
$30/visit, 12 visits per
calendar year)
Cardiac/Pulmonary
Rehabilitation
You pay a $15 copay per
visit
You pay a $40 copay
per visit
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Continued
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Medical Benefits at a Glance (Continued)
Benefit
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Kaiser Permanente
Network
Anthem Blue Cross
Providers
Anthem Lumenos HSA
In-Network
Out-of-Network
You pay a $25 copay per Plan pays 80% after
visit (limited to 100 visits deductible (limited to
per calendar year)
100 visits)
Plan pays 60% after
deductible (limited to
100 visits)
Emergency Room
Services and Supplies
You pay a $100 copay;
waived if admitted
You pay a $150 copay;
waived if admitted
Plan pays 80% after
deductible
Plan pays 80% after
deductible
Ambulance
You pay a $50 copay
per trip
Plan pays 100%
Plan pays 80% after
deductible
Plan pays 80% after
deductible
Office Visits (for mother)
Plan pays 100%
You pay a $25 copay
per visit
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Hospital (for mother)
You pay a $200 copay
per admission
You pay a $300 copay
per admission
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Office Visits (for baby)
Plan pays 100% for well
baby visits, up to age
23 months
You pay a $20 copay
per visit
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Anthem Blue Cross
(CaliforniaCare) HMO
Plan pays 100% (limited
to 100 2-hour visits per
calendar year)
Home Health Care
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Kaiser HMO
Emergency Services
Maternity Care
Outpatient Family Planning
Elective Interrupted
Pregnancy
You pay a $20 copay
You pay a $150 copay
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Tubal Ligation
You pay a $20 copay
You pay a $150 copay
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Vasectomy
You pay a $20 copay
You pay a $100 copay
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Counseling &
Consultation
You pay a $20 copay
You pay a $25 copay
($40 for specialist)
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Continued
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Medical Benefits at a Glance (Continued)
Benefit
Kaiser HMO
Anthem Blue Cross
(CaliforniaCare) HMO
Kaiser Permanente
Network
Anthem Blue Cross
Providers
Anthem Lumenos HSA
In-Network
Out-of-Network
Medical Equipment
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Plan pays 80%; in
accordance with
DME formulary and
prescribed by a Kaiser
physician
Plan pays 100%
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Inpatient Care
You pay $200 per
admission
You pay $300 per
admission
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Outpatient Care
You pay a $20 copay per You pay a $25 copay per
visit ($40 for specialist)
visit/individual therapy
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Durable Medical
Equipment
Mental Health
You pay a $10 copay per
visit/group therapy
Substance Abuse
Inpatient Care
You pay a $200 copay
per admission
You pay a $300 copay
per admission
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Outpatient Care
You pay a $20 copay
per visit for individual
therapy
You pay a $25 copay per
visit ($40 for specialist)
Plan pays 80% after
deductible
Plan pays 60% after
deductible
You pay a $5 copay per
visit for group therapy
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Continued
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Medical Benefits at a Glance (Continued)
Benefit
Kaiser HMO
Anthem Blue Cross
(CaliforniaCare) HMO
Kaiser Permanente
Network
Anthem Blue Cross
Providers
Anthem Lumenos HSA
In-Network
Out-of-Network
Prescription Drugs—Preventive
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Preventive
N/A
N/A
Plan pays 100%
Prescription Drugs—Retail (up to a 30-day supply)
Generic
You pay a $10 copay
You pay a $10 copay
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Brand Formulary
You pay a $25 copay
You pay a $30 copay
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Brand Non-formulary
You pay a $25 copay
You pay a $50 copay
Plan pays 80% after
deductible
Plan pays 60% after
deductible
Prescription Drugs—Mail-order (up to a 100-day supply)
Generic
You pay a $20 copay
You pay a $10 copay
Plan pays 80% after
deductible
Brand Formulary
You pay a $50 copay
You pay a $60 copay
Plan pays 80% after
deductible
Brand Non-formulary
You pay a $50 copay
You pay a $100 copay
Plan pays 80% after
deductible
Plan pays 100%
Plan pays 100%
Plan pays 100%
Not covered
Vision Care
Preventive Eye Exams
Plan pays 60% after
deductible
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Your Dental Benefits
Dental coverage is key to your overall health. Eligible
employees are offered a choice of two dental plans:
■■ MetLife DHMO
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
■■ MetLife DPPO
Next
Quick Guide to Dental Services:
Preventive services include: semi-annual
check-ups (including X-rays), cleanings
and fluoride treatments (for children)
Basic services include: diagnostic X-rays,
fillings and extractions
Major services include: bridges, crowns
and dentures
Use In-Network Providers
To search for providers who participate in your dental plan’s network, follow the steps below:
1. Go to www.metlife.com.
2. Click “Find a Dentist” located on the right side of the home page.
3. Select Dental PPO or Managed Dental Plan (Dental DMO), depending on your choice of plan.
4. Enter the ZIP code of the city in which you want to find a dentist. Click “Go.”
■■ For the PPO plan, you will be directed to a list of dentists within a 30 mile radius of the ZIP code you
entered. You can modify your search by using the “Modify Your Search” options at the top of the
“Find a Dentist” page.
■■ For DMO coverage, you will be directed to the Find a Dentist Advanced Search page where you will
input the plan name using the drop down menu. Select Met3757. You can also modify the mile radius
option in the Location box to narrow down or broaden your search. Click “Search.”
Alternatively, you can call 800-942-0854.
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MetLife DHMO
The MetLife DHMO plan works much like a medical HMO plan. When you enroll in a DHMO plan, you (and each
enrolled family member) will be asked to select a Primary Care Dentist (PCD) from the network.
Plan Features:
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
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Guide
1. You must select and use a primary care dentist (PCD) from the MetLife network to coordinate your care,
including referrals to specialists within the network.
2.There are no deductibles or annual dental maximum.
3.Preventive and basic services are covered at 100% with the exception of prophylaxis cleaning, sealants and
space maintainers.
4.General services such as fillings and simple extractions are subject to copays.
5.Major dental services, such as crowns, inlays and dentures, require a copay.
6.If you use a dentist outside the DHMO network, you are responsible for paying the full cost (except in
an emergency).
To view the Metlife DMO co-payment schedule, click here.
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MetLife DPPO
With the MetLife DPPO Plan, you have the flexibility to choose any dentist and receive some benefits. However,
if you go to a MetLife network dentist, you will pay less because MetLife dentists have agreed to charge lower,
negotiated rates.
Plan Features:
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
1. You can choose any dentist, but will pay less if you choose a MetLife dentist.
2.You pay the first $50 in eligible expenses per person ($150 maximum per family) each year, then the plan pays
benefits (out-of-network deductibles are $75 per person or $225 per family).
3.Preventive services are covered at 100% and aren’t subject to
the deductible (covered 90% for out-of-network services).
4.Basic services are covered at 80%, and major services are
covered at 50%, after you’ve met the deductible.
5.The MetLife DPPO Plan covers up to $2,000 of eligible dental
expenses per covered family member each calendar year.
Diagnostic and preventive benefits are not counted toward
the annual maximum.
6.The MetLife DPPO Plan has a lifetime maximum of $2,000 per
covered family member for orthodontia services.
Coverage levels are different when using an out-of-network
provider. See Dental Benefits at a Glance for more details.
How the Dental DPPO Works
See any PPO
network provider
See a provider outside
the PPO network
Pay a deductible and
any applicable
coinsurance, and you
will pay less because
rates are negotiated
Flexibility of choosing
any dentist, but you will
pay a higher deductible;
the rates are not
negotiated, so you
may be charged more
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Dental Benefits at a Glance
The chart below provides an overview of the most commonly used dental benefits. For more details about any of
the plans’ provisions, click the plan name in the table heading.
Benefit
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
MetLife DHMO
In-Network
MetLife DPPO
In-Network
Out-of-Network
Calendar-Year Deductible*
None
Individual: $50/Family: $150
Individual: $75/Family: $225
Calendar-Year Maximum
Benefit*
Unlimited
Plan pays up to $2,000 per
person/year
Plan pays up to $2,000 per
person/year
Routine Examination: Cleaning
(once every 6 months), Fluoride
Treatment (including bitewing
X-rays)
You pay $0
Plan pays 100%; deductible
does not apply
Plan pays 90%; deductible does
not apply
Office Visits
You pay $0
Plan pays 80% after deductible
Plan pays 80% after deductible
Fillings: Amalgam Composite/
Resin
You pay $0 to a $240 copay
(depending on number of
surfaces)
Plan pays 80% after deductible
Plan pays 80% after deductible
Simple Extractions
You pay a $5 copay
Plan pays 80% after deductible
Plan pays 80% after deductible
Copays as listed in the
schedule of covered services
and copays
Plan pays 50% after deductible
Plan pays 50% after deductible
Preventive/Diagnostic*
General Services (Restorative)
Major Services
Caps, Crowns, Dentures
Orthodontia
Adults
You pay a $1,695 copay
Dependent Children (to age 19)
You pay a $1,695 copay
Evaluation and Consultation
You pay a $100 copay
Treatment Plan and Records
You pay a $200 copay
Retention
$250 copay
Plan pays 50% up to $2,000 lifetime maximum benefit;
deductible does not apply
*Deductible and calendar-year Maximum are not applicable to preventive or diagnostic services.
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Vision Benefits
Eligible employees are automatically enrolled in the core vision coverage through Anthem at no cost. This plan
includes coverage for eye exams and eyeglasses or contact lenses. You receive a higher level of coverage when
you use network providers. Anthem uses a network of nationwide providers, including national retailers like
Target and LensCrafters.
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Increased coverage is available for purchase through the Buy-Up Plan.
Vision Benefits at a Glance
The chart below provides an overview of the most commonly used vision benefits. For more details about any of
the plans’ provisions, click the plan name in the table heading.
Benefit
Core Plan
In-Network
Buy-Up Plan
In-Network
Out-of-Network
Eye Exam (Once every 12 months)
Plan pays 100% after a $10 copay Plan pays 100% after a $10 copay
Plan pays up to $79
Frames (Once every 12 months)
You receive a 35% discount
Plan pays up to a $130 allowance; you Plan pays up to $100
receive a 20% discount on amounts
over allowance
Lenses (Once every 12 months)
Single Vision
Lined Bifocal
Lined Trifocal
You pay $50
You pay $70
You pay $105
Plan pays 100% after a $15 copay
Plan pays up to $36
Plan pays up to $60
Plan pays up to $79
Contact Lenses (Once every 12 months)
You receive a 15% discount
Plan pays up to a $130 allowance; you Plan pays up to $115
receive a 15% discount on doctor’s
professional fees. Materials are paid
at usual & customary rates
Find the right Anthem doctor for you at www.anthem.com.
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Employee Assistance Program (EAP)
Confidential advice and counseling are available at no cost to you through the Employee Assistance Program
(EAP). When you contact the EAP you can speak confidentially to a counselor or other professional who can help
with issues, such as:
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
■■ Parenting issues
■■ Self-improvement
■■ Loss or grieving issues
■■ Mental health issues
■■ Relationship problems
■■ Financial concerns
■■ Substance abuse issues
■■ Legal-referral assistance
Employees and their legal spouse, domestic partner and eligible dependents receive up to five (5) counseling
sessions with a licensed/certified therapist by phone or in person per family member, per issue, each
calendar year.
Access to the EAP is available 24/7 year-round. All records, including medical information, referrals and
evaluations, are kept strictly confidential in accordance with federal and state laws.
More information is available in the EAP Brochure.
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Did You Know? The EAP is 100% paid by The Claremont Colleges!
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Flexible Spending Accounts (FSAs)
FSAs help you make your money go further by letting you set aside before-tax dollars to pay for certain
out-of-pocket eligible expenses and dependent care costs. Here’s how they work:
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
■■ You make contributions from your pay on a pre-tax basis. Contributions and eligible reimbursed expenses
aren’t subject to federal income tax, Social Security tax, and, in most cases, state income tax.
■■ The tax savings help offset the cost of eligible health care and dependent care expenses.
■■ You are not taxed on reimbursements from your FSAs.
The Claremont Colleges offers three types of FSAs:
■■ Health Care FSA—To pay for eligible medical, dental, and vision expenses
■■ Limited Scope Health Care FSA—To pay for eligible dental and vision expenses if you participate in an HSA or
are enrolled in Medicare Parts A and/or B
■■ Dependent Care FSA—To pay for eligible child and elder care expenses
Making FSA Contributions
The annual amount you contribute to your FSA is deducted from your paychecks in equal installments, on a pre-tax
basis, from January through December 31, 2015, and credited to your FSA account(s).
Incurring Claims
You can incur claims for eligible expenses from January 1, 2015 through March 15, 2016. You will have until
June 30, 2016 to submit claims for reimbursement.
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Health Care FSA
You can use the funds in your Health Care FSA to pay for eligible expenses like deductibles, copays and coinsurance
for you and your eligible dependents. You can contribute up to $2,550 per plan year, before tax. You don’t have to
have medical, dental or vision coverage through The Claremont Colleges to enroll in the Health Care FSA.
Eligible/Ineligible expenses
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Here are a few common examples of expenses you can reimburse from your Health Care FSA:
■■ Ambulance services
■■ Contact lenses
■■ Insulin
■■ Artificial teeth/limbs
■■ Crutches
■■ Laser eye surgery
■■ Copays
■■ Deductibles and coinsurance
■■ Long-term care expenses
■■ Chiropractic care
■■ Hearing aids
■■ Stop-smoking programs
Below are some examples of ineligible expenses:
■■ Cosmetic surgery (if not medically necessary)
■■ Health insurance premiums
■■ Teeth bleaching
■■ Over-the-counter medications
For a full list of eligible and ineligible expenses, go to www.PayFlexDirect.com.
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Limited Scope Health Care FSA
If you participate in an HSA or if you are enrolled in Medicare Parts A and/or B, you can participate in a Health
Care FSA called a Limited Scope Health Care FSA. You can contribute up to $2,550 for eligible expenses.
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
This FSA offers limited-scope reimbursements for eligible non-medical expenses, such as dental and vision
plan deductibles, copays and coinsurance. Additionally, once you’ve met your medical plan’s deductible, you
can use the Limited Scope Health Care FSA to cover medical expenses and prescription drug costs.
Keep in mind that you cannot use a Limited Scope Health Care FSA for any of the expenses that are not
eligible for reimbursement from a regular Health Care FSA.
The Limited Scope Health Care FSA is a great option if you want to save the money in your HSA for future
health care expenses (because HSA funds roll over each year). To learn more about how a Limited Scope
Health Care FSA works with an HSA, check out this brochure.
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
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Dependent Care FSA
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
The Dependent Care FSA may be used to pay for expenses that allow you (or your spouse, if married) to work. A
dependent child is one under the age of 13 or any disabled tax dependent who is living with you. In any calendar
year, you can contribute, before tax, up to $5,000 ($2,500 if married and filing separately). The limit applies to all
contributions made by you and your spouse to any dependent care spending accounts through The Claremont
Colleges and any other employer combined.
Eligible/Ineligible expenses
Here are some examples of eligible expenses you can reimburse
from your Dependent Care FSA:
■■ At-home child and elder day care
■■ Before- or after-school care
■■ Care at certain child and elder day care centers
■■ Charges from certain child and elder day care providers
■■ Pre-school and nursery schools
■■ Summer day camp
Below are some examples of ineligible expenses:
■■ Tuition
■■ Child or elder day care provided by someone living in your
home
■■ Overnight camp
Eligible Dependents
An eligible dependent is a person
who shares the same primary place of
residence with you for more than six
months each year and is:
■■ Your child under age 13 whom you can
claim as a dependent on your federal
income tax return;
■■ Your spouse who is mentally or
physically disabled; or
■■ Your dependent who is mentally or
physically disabled and whom you
can claim on your federal income tax
return.
In most cases, your domestic partner and
children of your domestic partner are
not considered eligible dependents for
purposes of your Dependent Care FSA.
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Health Care FSA and Limited Scope Health Care FSA Reimbursements
If you enroll in the Health Care FSA or the Limited Scope Health Care FSA, you will receive a debit card you can
use for eligible health care expenses. Even if you use the debit card, be sure to save all receipts in the event the
administrator needs to verify eligibility.
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
If you don’t use your debit card to pay for expenses, you may submit a claim for any eligible expenses. Both
reimbursement options require that you submit your receipts for eligible expenses to the FSA administrator.
Reimbursements are generally paid through direct deposit or check by a third party administrator. You do not
pay federal income, state income or Social Security taxes on FSA expenses.
Dependent Care FSA Reimbursements
To be reimbursed, you must save your receipts and submit a claim for any eligible expenses. Reimbursements
are generally paid through direct deposit or check by a third party administrator. You do not pay federal income,
state income or Social Security taxes on FSA expenses. You can only be reimbursed from contributions you have
made to your account.
Don’t Forget: If You Don’t “Use It” You Will “Lose It”!
When estimating your annual expenses, consider only those that you are reasonably certain you will incur.
Any amount left in your FSA after March 15, 2016 is forfeited. This is called the “Use it or Lose it” rule.
Your account will be left open for claims until June 30 of the following calendar year. All FSA claims must be
submitted within 90 days of termination or unpaid leave of absence.
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
More
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Life Insurance
Keep In Mind…
All benefits eligible employees receive Basic Life Insurance. You
also have the option to purchase additional coverage for yourself
and your eligible dependents.
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Next
Basic Life Insurance
Basic Life Insurance is fully paid by The Claremont Colleges.
Coverage is automatic—you don’t have to enroll in it. However, you
do need to select a beneficiary. The beneficiary or beneficiaries
receive your benefit amount in the event of your death.
The amount of the benefit is equal to one times your basic
annual earnings (rounded to the next $1,000). The minimum
coverage amount is $20,000, and the maximum coverage
amount is $50,000.
Supplemental Life Insurance
Beginning on the first of the year
following your 65th birthday, your life
insurance coverage amount decreases.
Your premiums will be based on the
reduced coverage amount. Anthem Blue
Cross pays a percentage of your benefit
amount as follows:
■■ Age 65 to 70 = 65%
■■ Age 70 to 75 = 50%
■■ Age 75+ = 30%.
Conversion Privilege
Conversion options are available should
you leave The Claremont Colleges.
You may choose to purchase additional insurance coverage for
yourself through Anthem Blue Cross on a post-tax basis. This
coverage would be in addition to the basic benefit provided by The Claremont Colleges. You can also purchase
supplemental coverage for your eligible dependents, subject to Evidence of Insurability (see following page).
Coverage for supplemental life insurance is available in the following amounts:
Eligible Member
Coverage Amount
Employee
1–4 times your basic annual earnings (rounded to the nearest $1,000), to a maximum of
$1,000,000 (combined with Basic Life)
Spouse
$10,000 increments, to a maximum of $250,000 or 50% of your combined Basic and
Supplemental Life Insurance coverage
Child(ren) (birth—6 months)
$100
Child(ren) (6 months and older)
$5,000
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Evidence of Insurability (EOI)
When you purchase Supplemental Life Insurance for yourself, your spouse or your dependents, you may need to
provide Evidence of Insurability (EOI).
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
If you purchase Supplemental Employee Life Insurance, Spouse Life Insurance, or Child Life Insurance when you
are first eligible (within 30 days of your hire date), you do not need to provide Evidence of Insurability (EOI)
unless you purchase coverage above a certain amount:
■■ For yourself: Amounts above two times your annual earnings or $355,000
■■ For your spouse: Amounts above $20,000
After this 30-day period, you will be required to provide EOI if you choose to enroll in or increase your coverage
amount at any time throughout the year.
An EOI form is available on the Forms and Notices page.
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Long-Term Disability Coverage
You are automatically enrolled for Long-Term Disability Insurance on your first day of employment if you work
30 hours or more per week.
Your Benefits
After you have been disabled for 180 days, you may apply for long-term disability coverage which could pay
66⅔% of your covered monthly salary, up to a maximum benefit of $15,000 per month.
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Did You Know?
The long-term disability premium is 100% paid for by The Claremont Colleges. If you are an RSABG
employee, you pay 50% of the cost of LTD coverage, and coverage is voluntary for these employees.
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Accidental Death & Dismemberment (AD&D) Insurance Plan
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
The Claremont Colleges also offers employees voluntary
coverage to protect you and your family in the event of an
accident-related death or dismemberment. You can choose
individual or family coverage (according to IRS regulations). You
pay the full cost for this coverage.
Conversion Privilege
Conversion options are available should
you leave The Claremont Colleges.
Coverage for Accidental Death & Dismemberment (AD&D)
Insurance is available in the following amounts:
Type of Coverage
Coverage Amount
Employee
$25,000 increments, up to $500,000, but not exceeding 10x your annual salary* if the selection
is over $250,000
Spouse
Insured employee’s coverage amount (principal sum)
Children
$50,000
* If you attempt to elect coverage that is more than 10x your annual salary, your coverage amount will automatically be lowered to 10x your annual salary.
At age 70, for you and your insured dependents, the principal sum will be reduced based on your previous
principal sum according to the following schedule:
Age at Date of Loss
Loss Percent of Principal Sum
70–74
65%
75–79
45%
80–84
30%
85 & Over
15%
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Long-Term Care Insurance
The Claremont Colleges sponsors a Group Long Term Care Insurance
Plan for active employees and their eligible family members. Genworth is
the administrator of the Group Long Term Care Insurance Plan.
Your Benefits
Your Medical Benefits n
Your Dental Benefits n
Your Vision Benefits n
Employee Assistance Program n
Flexible Spending Accounts n
Life Insurance Benefit n
Evidence of Insurability n
Long-Term Disability n
Accidental Death & Dismemberment n
(AD&D) Insurance
Long-Term Care n
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Long-term care insurance provides enrollees with access to personal
assistance from care coordinators who are knowledgeable in the field of
long term care. In addition to conventional nursing home coverage, the
policy covers services received in your own home; other types of care
facilities may be covered.
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More Information
Go to www.genworth.com/
groupltc for more information
about the long-term care
coverage available through
Genworth.
You will have guaranteed acceptance into the plan regardless of your current health status if you are a
newly-hired eligible employee or newly-eligible employee age 18–69, and you apply within 60 days of first
becoming eligible for this benefit.
Your age and the plan you select when you first enroll determine your monthly premium rate for the coverage.
The younger you are when you become insured, the lower your cost will be. Active faculty and staff and their
spouses or qualified domestic partners pay premiums through direct billing or automatic bank withdrawal.
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Who’s Eligible for Benefits
The Claremont Colleges offers benefits to full-time, part-time and temporary employees who meet eligibility
requirements. You can also enroll your spouse or domestic partner and your eligible child(ren) for coverage.
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Employee Type
Effective Date
All Benefits-Eligible Employees
First day of the month after Date of Hire; or 30 days after date of hire.1, 2
Date of Hire when Date of Hire is the first
1
Close of eligibility for new faculty with a July 1 Date of
day of the month. Enrollments received
Hire is 60 days after Date of Hire. Be effective date for
in Benefits Administration prior to initial
other than Basic Group Life Insurance may be August 1.
eligibility date become effective on the
2
initial eligibility date, not sooner.
Applications received in Benefits Administration prior
Interim Employees
(Except Temporary Employees)
Temporary Employees
Student Employees
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
First of the month following 30 days after
the 12 month measurement period in
which the temporary employee works at
least 30 hours per week as defined by the
Affordable Health Care Act. Temporary
employees hired before January 1, 2015,
and have been granted benefits will be
grandfathered.
Close of Eligibility
to the Close of Eligibility Date become effective on
the Initial Effective Date. Applications received after
Close of Eligibility Date cannot be accepted. Affected
employees are required to reapply at a subsequent
open enrollment period.
First of the month following 60 days after
the 12 month measurement period in which
the student works at least 30 hours per
week as defined by the Affordable Health
Care Act.
For more detailed eligibility information, see the Statement of Benefit Eligibility for Centrally Administered
Employee Benefits Programs.
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If You Are NOT Eligible for Health Benefits
Health care reform’s individual mandate requires you to have medical coverage in 2015. If you are not eligible for
health benefits through The Claremont Colleges there are several resources you can use to find comprehensive
coverage. You can’t be denied coverage through these public insurance marketplaces, and you may be eligible
for tax credits that lower the cost of health insurance.
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
GetInsured
Contact GetInsured
Through GetInsured you can compare health insurance plans and find
Call 877-917-7957 or visit
one that best meets your needs and budget. You can find out if you are
www.GetInsured.com/Mercer
eligible for tax credits that will lower your coverage costs, and you can
for personalized service.
enroll in a plan that specifically meets your unique medical needs. Every
plan includes great benefits like preventive doctor visits, prescriptions,
birth control and emergency care. With GetInsured, a licensed agent can help you navigate your insurance
options, determine if you are eligible for tax credits, and help you get enrolled so that your coverage can begin
by January 1, 2015.
CoveredCA
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
The state of California provides a public insurance marketplace for California residents needing health care
coverage. Visit www.CoveredCA.com to explore a variety of comprehensive insurance plans that you can enroll
in for coverage starting January 1, 2015.
Open Enrollment Through the Public Marketplaces
Open Enrollment through the public marketplaces begins November 15, 2014. The deadline to enroll in
coverage beginning January 1, 2015 is December 15, 2014.
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Eligible Dependents
When you enroll, you can enroll your eligible dependents in the same coverage you are selecting for yourself,
including medical, dental and vision coverage, as well as supplemental life and accident insurance.
Your eligible dependents include:
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
■■ Your spouse
■■ Your domestic partner
■■ Your children (including the children of your domestic partner)
who are:
–– 26 years old or less
–– Any age who are mentally or physically disabled and meet certain
requirements.
To Enroll Your Dependents
for Coverage…
You will need:
■■ the dependent(s) name(s),
■■ relationship to employee,
■■ marriage/birth certification or
other form of documentation
proving life event,
■■ dependent Social Security
number, and
■■ date of birth.
Domestic Partner Coverage
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
The IRS does not recognize domestic partners as legal dependents for purposes of tax reporting. For this
reason, The Claremont Colleges must report the value (employer subsidy) of medical benefits. Employee
contributions for domestic partner benefits are made after tax. For California-registered domestic partners
or married domestic partners, deductions are made on a pre-tax basis for state withholding. The employer
contributions of health and/or dental benefits must be included in the employee’s taxable income for federal
and state withholding for any state other than California for registered and married domestic partners.
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Enrolling for Benefits
To enroll for benefits when you are first eligible or when you have a
qualified life event during the year, contact Benefits Administration. See
Who to Contact for CUC Benefits Administration.
Your Benefits
Who’s Eligible
Enrolling for Benefits
When to Enroll n
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Enrolling During Open
Enrollment?
See How to Enroll in the 2015
Open Enrollment Guide for
enrollment instructions.
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When to Enroll
When You Are First Eligible
Your Benefits
Who’s Eligible
Enrolling for Benefits
When to Enroll n
2015 Plan Rates
Wellness Resources
Retirement Plan
When you are first eligible for benefits coverage, you have 30 days from your eligibility date to enroll in health
benefits. If you don’t enroll during the first 30 days after your eligibility date, you will only be enrolled in coverage
that’s automatically provided to you (Core vision, Employee Assistance Program, basic life, long-term disability
and the Academic Retirement Plan).
When a Qualified Life Event Occurs
After your initial eligibility enrollment period, you may change your benefits during Open Enrollment or when you
experience a qualified life event. Qualified life events include:
■■ Marriage, divorce, or legal separation
■■ Birth or adoption
■■ A dependent that becomes ineligible for coverage
■■ Death of your spouse or one of your children
■■ Change in work status of your spouse/domestic partner
■■ Employee enrolling in Medicare Part B
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
If you experience a qualified life event, you may change your coverage within 30 days of the event. Necessary
documentation will be required. Contact Benefits Administration for more information about what qualifies as a
life event, including exceptions. See Who to Contact for CUC Benefits Administration.
When Coverage Begins
Benefits elected when you are first eligible will be effective on the 1st of the month following hire or, if you
are hired on the 1st of the month, benefits will be effective immediately.
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2015 Plan Rates
The charts below list the amounts that you will pay per month for your
benefit coverage beginning January 1, 2015.
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
All benefit premium deductions for health, dental, vision, health savings
account (HSA) and flexible spending accounts (FSA) coverage are taken
on a pre-tax basis unless otherwise requested. Benefit deductions are
taken in the current month of coverage.
Monthly Employee Rates—Medical Plans
Kaiser HMO
Anthem Blue Cross HMO
(CaliforniaCare)
At No Cost to You...
The Claremont Colleges pays
100% of the cost of coverage for:
■■ Core vision coverage
(employee only)
■■ Basic Life Insurance
■■ Long-term disability*
■■ Employee Assistance Program
(EAP).
Anthem Lumenos HSA
Employee Only
$43.39
$53.14
$53.38
Two Party
$182.23
$223.19
$224.42
$390.49
$477.82
$482.18
Family
Monthly Employee Rates—Dental Plans**
MetLife DHMO
Employee Only
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Two Party
Family
MetLife DPPO
$5.76
$56.72
$18.52
$126.80
$30.00
$190.52
More Rates
** RSABG employees pay 50% of the cost for Long-term disability insurance.
** R
ancho Santa Ana Botanic Garden (RSABG) is not participating in the employer subsidy for MetLife and therefore all dental premiums shown on the
above chart will be increased by $7.00 for RSABG employees.
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Monthly Employee Rates—Vision Plans
Anthem Core Plan
Employee Only
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Anthem Buy-Up Plan
$0.00
$4.48
Two Party
$1.36
$7.57
Family
$3.05
$12.53
Monthly Employee Rates—Supplemental Life Insurance
Rates for employees and spouses/domestic partners are based on the employee’s age.
Anthem Supplemental and Spouse/Domestic Partner Life Insurance
Age
Monthly Rate (per $1,000
of coverage)
Age
Monthly Rate (per $1,000
of coverage)
Under 30
$0.05 50-54
$0.40
30–34
$0.06 55-59
$0.62
35–39
$0.08 60-64
$0.97
40–44
$0.14 65-69
$1.74
45–49
$0.24 70 +
$3.11
Dependent Child(ren) Life Insurance: $0.50 per $5,000 of coverage, per family (regardless of the number of
children covered)
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
More Rates
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Employee Rates—Accidental Death & Dismemberment (AD&D)
Insurance Plan
Principal Sum1,2
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Employee-Only
Coverage
Family Coverage
Principal Sum1,2
Employee-Only
Coverage
Family Coverage
$25,000
$0.50
$0.98
$275,000
$5.50
$10.73
$50,000
$1.00
$1.95
$300,000
$6.00
$11.70
$75,000
$1.50
$2.93
$325,000
$6.50
$12.68
$100,000
$2.00
$3.90
$350,000
$7.00
$13.65
$125,000
$2.50
$4.88
$375,000
$7.50
$14.63
$150,000
$3.00
$5.85
$400,000
$8.00
$15.60
$175,000
$3.50
$6.83
$425,000
$8.50
$16.58
$200,000
$4.00
$7.80
$450,000
$9.00
$17.55
$225,000
$4.50
$8.78
$475,000
$9.50
$18.53
$250,000
$5.00
$9.75
$500,000
$10.00
$19.50
1
Coverage amounts in excess of $250,000 may not exceed ten times annual base salary.
2
Principal sum amount cannot be increased after age 70.
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Wellness Resources
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
The Claremont Colleges recognizes that wellness is an important component of helping you create and maintain
a healthy lifestyle. The wellness programs offered by Anthem Blue Cross HMO (CaliforniaCare)/Anthem Lumenos
and Kaiser Permanente provide tools and information that can help you make important healthy lifestyle choices.
These programs enhance your core benefits by offering savings on alternative health and wellness products
and services.
All employees are eligible to participate in the wellness programs offered by their respective health plans.
Whether you are looking for help to quit smoking, creating an exercise plan, or need some nutritional guidance,
these programs offer you the tools to help you get there. See Wellness Offerings from Your Plan Provider for a
list of the tools and programs available from our medical plan carriers.
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
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Wellness Offerings from Your Plan Provider
Your plan providers offer a number of health and wellness services that are covered for free under your medical plan:
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Anthem Blue Cross HMO and Lumenos HSA Plan
Kaiser Permanente HMO
■■ Free preventive care (in-network only for Lumenos HSA
members)
■■ Free immunizations like the annual flu shot and pneumonia
vaccine
■■ 24/7 Nurseline provides an on-call nurse that you can call at
any time, day or night
■■ Future Moms is a no-cost resource to expecting mothers who
want to access advice nurses and specialists, wellness info,
and health screenings
■■ Condition Care provides on-hand advice nurses and other
resources to members affected by chronic and long-term
health problems including asthma, diabetes, and heart failure.
■■ Free preventive care
■■ Free immunizations like the annual flu shot and pneumonia
vaccine
■■ Healthy Lifestyle Programs cover:
–– Health Assessment
–– Maternity and pregnancy
–– Pain management
–– Weight loss
–– Nutrition
–– Smoking cessation
–– Depression and stress management
–– Insomnia
–– Diabetes management
–– Chronic condition management
■■ LiveHealth Online (LHO) gives you quick and easy 24/7
access to doctors, including private video chats. LHO
consultations are covered by your regular copay.
■■ MyHealth Record is a feature of Anthem’s website that stores
your medical and immunization records all in one place.
■■ 360°Health offers an online library of health-related
information and tools to help members with anything from
managing a condition to organizing health records
■■ Discounts on eye care and eye care vendors for services like
Premier LASIK
■■ Discounts on health programs and fitness clubs, such as
Weight Watchers and Gold’s Gym
■■ Wellness Coaching encourages members to focus on health
and wellness improvement initiatives
■■ ChooseHealthy is a website that offers discounts on fitness
and health club membership rates and other health-improving
resources such as health and fitness books, videos and
personalized exercise and nutrition plans
■■ Discounts on alternative care services for acupuncture or
massage therapy,
Start Today!
Start Today!
To access these helpful tools from Anthem visit
www.anthem.com/ca to get started.
To access these helpful tools from Kaiser, visit
www.kp.org or call Member Services at
800-464-4000.
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Retirement Plan
Academic Retirement Plan (ARP)
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Academic Retirement Plan n
The Academic Retirement Plan (ARP) is the primary retirement plan for The Claremont Colleges. All faculty and
staff (excluding students) are eligible to participate in the ARP through voluntary elective deferrals upon date of
hire. Eligibility for employer contributions is dependent upon job classification, satisfying a service requirement,
and attainment of age 21. Check with your Human Resources Office for information on your institution’s ARP
eligibility requirements for employer contributions. Different retirement plan options apply for employees of
Rancho Santa Ana Botanic Garden.
How to Enroll
Eligible employees can enroll online through www.tiaa-cref.org/theclaremontcolleges or by completing and
returning a paper enrollment form to the CUC Benefits Office. If an enrollment form is not completed within
30 days of your eligibility date for employer contributions, contributions made on the employee’s behalf will
be made by default to the appropriate Vanguard Target Retirement Fund for his/her age as described in the
enrollment materials provided by the Human Resources Office.
Contributions
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
Employer contributions are made as a percentage of eligible compensation. Employee voluntary elective
deferrals can be made on a pre-tax or Roth after-tax basis. Employer and employee contributions are remitted to
your TIAA-CREF account after every pay period.
Vesting
Contributions are vested 100% immediately upon participation in the ARP.
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Distributions
You are able to take a distribution from the Academic Retirement Plan if you meet one of the following criteria:
■■ Termination of employment for employer or employee contributions
■■ Reaching age 59½ for employee elective deferrals
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
■■ Meeting minimum loan requirements and/or qualifying under Internal Revenue Service (IRS) Safe Harbor
Hardship Withdrawal Guidelines for employee elective deferrals
■■ Death of the employee
For more information on the Academic Retirement Plan, click here.
Academic Retirement Plan n
Who to Contact
Forms
Notices
Print and Search
Open Enrollment
Guide
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Who to Contact
CUC Benefits Administration
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Benefits Administration Offices n
Plan Providers n
Forms
Notices
Print and Search
Open Enrollment
Guide
For KGI and CGU Contacts, see
the next page.
If you have questions about your benefits or for additional information
on new enrollment, changes or cancellation of your benefits, contact
CUC Benefits Administration.
Contact
Phone
Email
Carol Saldivar,
Benefits Manager, Workers
Compensation & Disability
909-607-3195
carol_saldivar@cuc.claremont.edu
Monica Villanueva,
Benefits Representative
909-607-3684
monica_villanueva@cuc.claremont.edu
Anna Huerta,
Benefits Representative
909-607-9494
anna_huerta@cuc.claremont.edu
Claudia Garcia,
Benefits Representative
909-607-9493
claudia_garcia@cuc.claremont.edu
Tony Romero,
Retirement Analyst
909-621-8805
tony_romero@cuc.claremont.edu
Loo Hsing,
Senior Retirement Analyst
909-607-3780
loo_hsing@cuc.claremont.edu
Lissette Martinez,
Workers Compensation &
Disability
909-621-8847
lissette_martinez@cuc.claremont.edu
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CGU Benefits Administration
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Benefits Administration Offices n
Plan Providers n
Forms
Notices
Print and Search
Open Enrollment
Guide
Contact
Phone
Email
Sarah Verrill,
Payroll & Benefits Manager
909-607-8828
sarah.verrill@cgu.edu
KGI Benefits Administration
Contact
Phone
Email
Cheryl Merritt,
Director of Human Resources
909-607-7853
cheryl_merritt@kgi.edu
Sarah Verrill,
Payroll & Benefits Manager
909-607-8828
sarah.verrill@cgu.edu
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Plan Providers
You may also contact the providers directly with specific benefit coverage questions.
Your Benefits
Who’s Eligible
Enrolling for Benefits
2015 Plan Rates
Wellness Resources
Retirement Plan
Who to Contact
Benefits Administration Offices n
Provider or Department
Phone
Website Address
Anthem Blue Cross HMO
(CaliforniaCare)
800-227-3771
www.anthem.com/ca
Anthem Lumenos HSA
866-207-9878
www.anthem.com/ca
Kaiser Permanente
800-464-4000
www.kp.org
Mellon HSA
877-472-4200
https://mybenefitwallet.com/
MetLife Dental
800-942-0854
www.metlife.com
Anthem Vision
866-723-0515
www.anthem.com
PayFlex FSA Administration
888-678-8242
www.PayFlexDirect.com
United Behavioral Health—
Employee Assistance Program
800-234-5465
www.liveandworkwell.com/default.asp?
ProgramPIN=claremontcolleges
Anthem Blue Cross Life
Insurance
800-552-2137
www.anthem.com/ca
Zurich Voluntary AD&D
866-841-4771
www.zurichna.com
ING TriTerm Life
800-955-7736
N/A
Genworth—Long-Term Care
(Policies issued on or after
1/1/2012)
800-416-3624
http://genworth.com/groupltc
Username: Claremont
Password: groupltc
John Hancock—Long-Term Care 800-482-0022
(Policies issued before 1/1/2012)
http://longtermcare.jhancock.com
Username: claremont
Password: mybenefit
Plan Providers n
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Plan Providers (Continued)
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Provider or Department
Phone
Web Site Address
Fidelity
800-343-0860
www.mysavingsatwork.com
TIAA-CREF
800-842-2776
www.tiaa-cref.org
Vanguard
800-662-2003
https://personal.vanguard.com/us/home
Medicare
800-MEDICARE (800-633-4227)
www.medicare.gov
■■ Los Angeles County (Center for Health
Care Rights)
213-383-4519
www.chcsbc.org
■■ Orange County (Council on Aging)
714-560-0424
www.coaoc.org
■■ San Bernardino County (HICAP of San
Bernardino County)
909-256-8369
www.hicapsbc.org
California Casualty (Auto and Home
Insurance)
877-411-1427
www.calcas.com
Assist America (In conjunction with
Business Travel Accident policy through
AC Newman)
609-921-0868 x 221
www.assistamerica.com
Health Insurance Counseling & Advocacy
Program
This guide provides general benefit plan and enrollment information only. For specific details, conditions and exclusions, please refer to the official
summary plan descriptions (SPDs). If there is a discrepancy between this guide and an official SPD or Collective Bargaining Agreement, the official
document will govern.
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Forms
Use the links below to open the corresponding form:
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Form
What it Means for You
■■ Anthem Evidence of Insurability (EOI) Form
To confirm you are generally in good health when electing or
increasing life insurance with Anthem
■■ Domestic Partner Affidavit
To verify unmarried domestic partner relationship
■■ PayFlex FSA Claim Form
To file a claim for reimbursement from your FSA
■■ Long-Term Disability (EOI) Form
To confirm you are generally in good health when electing
long-term disability coverage (for RSABG only)
■■ Beneficiary Change Form
To change and verify your elected beneficiaries for Life and
AD&D insurance
■■ Benefits Election Form
To elect benefits during the year if you experience a qualified
life event
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Notices
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Federal laws require that The Claremont Colleges provides you with certain notices that inform you about your
rights regarding eligibility, enrollment and coverage of health care plans. The following sections explain these
rules; please read them carefully. Click the notice in the table below for more information; these notices are also
available in the benefits guide.
Notice
What it Means for You
■■ The Affordable Care Act (ACA)
Describes the Patient Protection and Affordable Care Act
(often referred to as the “Affordable Care Act” or “health care
reform law”)
■■ Life Event Changes Information Sheet
Describes qualified life events that allow you to make changes to
your benefits outside the Open Enrollment period
■■ Special Enrollment Rights
Describes when you can enroll for coverage when you have
previously declined coverage
■■ Women’s Health and Cancer Rights Act of 1998
Provides information regarding a woman’s rights after a
mastectomy
■■ Newborns’ and Mothers’ Health Protection Act
Describes protections for mothers and their newborn children
relating to the length of their hospital stays following childbirth
■■ Consolidated Omnibus Budget Reconciliation Act (COBRA)
Provides details about how COBRA can provide ongoing health
benefits after coverage ends under certain conditions
■■ Medicaid and the Children’s Health Insurance Program
(CHIP) Notice
A list of states that have premium assistance programs to help
you pay for medical coverage if you are unable to afford health
care coverage premiums
■■ Health Insurance Portability and Accountability Act (HIPAA)
Describes your rights to health privacy
■■ Your Prescription Drug Coverage and Medicare
Explains that prescription drug coverage through The Claremont
Colleges is as good as, or better than, Medicare prescription drug
coverage
■■ Summary Annual Reports
Annual reports of The Claremont Colleges benefits
■■ Summary of Benefits and Coverage
Summarizes important information about your health coverage
options in a standard format to help you compare each option
––Kaiser Permanente HMO
––Anthem Blue Cross HMO
––Anthem Lumenos HSA
––Anthem Blue Card Lumenos HSA (for out-of-area participants)
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Special Enrollment Rights
Special enrollment events allow you and your eligible dependents to enroll for health coverage outside the Open
Enrollment period under certain circumstances if you lose eligibility for other coverage, become eligible for state
premium assistance under Medicaid or the State Children’s Health Insurance Program (S-CHIP), or acquire newly
eligible dependents. This is required under the Health Insurance Portability and Accountability Act (HIPAA).
Your Benefits
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If you decline enrollment in The Claremont Colleges medical plan coverage for you or your dependents (including
your spouse/domestic partner) because of other health insurance coverage, you or your dependents may be able
to enroll in a Claremont Colleges medical plan without waiting for the next Open Enrollment period if you:
1. Lose other coverage. You must request enrollment within 30 days after the loss of other coverage.
2.Gain a new dependent as a result of marriage, birth, adoption or placement for adoption. You must request
enrollment within 30 days after the marriage, birth, adoption or placement for adoption.
3.Lose Medicaid or Children’s Health Insurance Program (S-CHIP) coverage because you are no longer eligible.
You must request enrollment within 60 days after the loss of such coverage.
In addition, you may enroll in a Claremont Colleges medical plan if you become eligible for a state premium assistance
program under Medicaid or S-CHIP. You must request enrollment within 60 days after you gain such coverage.
Women’s Health and Cancer Rights Act of 1998
The act requires that all group health plans providing medical and surgical benefits with respect to a mastectomy
must provide coverage for all of the following:
■■ Reconstruction of the breast on which a mastectomy has been performed
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■■ Surgery and reconstruction of the other breast to produce a symmetrical appearance
■■ Prostheses
■■ Treatment of physical complications of all stages of mastectomy, including lymphedemas
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, which apply for the mastectomy. For deductibles and
coinsurance information applicable to the plan in which you enroll, please refer to the plan descriptions.
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Newborns’ and Mothers’ Health Protection Act
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Group health plans and health insurance issuers 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 vaginal delivery, or less than 96 hours following a cesarean section. 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). In any case, plans and
issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for
prescribing a length of stay not in excess of 48 hours (or 96 hours).
Consolidated Omnibus Budget Reconciliation Act (COBRA)
If you are an employee with medical, dental or vision coverage through The Claremont Colleges, you have the
right to choose continuation coverage if you lose your group health coverage due to reduction in your hours
of employment or the termination of your employment for reasons other than gross misconduct. Your eligible
dependents may also have the right to elect and pay for continuation of coverage for a temporary period in
certain circumstances where coverage under the plan would otherwise end, such as divorce, or dependent
children who no longer meet eligibility requirements.
Important Note: This brief summary of the right you and your dependents have to continue insurance is
not intended as the official notice of your rights required by federal and state law. We’ve included this brief
summary to inform you that you have these rights. You will receive a separate, detailed explanation of your
right to continue health insurance coverage when applicable. Specific information is also available from Benefits
Administration at 909-621-8151.
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You can also call 800-MEDICARE (800-633-4227). TTY users should call 877-486-2048. If you have limited
income and resources, extra help paying for Medicare prescription drug coverage is available. For information
about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 800-772-1213
(TTY 800-325-0778).
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Medicaid and the Children’s Health Insurance Program (CHIP) Offer
Free or Low-Cost Health Coverage to Children And Families
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If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your
employer, your state may have a premium assistance program 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, 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 877-KIDS NOW or www.insurekidsnow.gov 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. If you have questions about enrolling in your employer plan, you can contact the
Department of Labor electronically at www.askebsa.dol.gov or by calling toll-free 866-444-EBSA (3272).
You may be eligible for assistance paying your employer health plan premiums—contact the State of
California for further information on eligibility:
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Website: http://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx
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Health Insurance Portability and Accountability Act (HIPAA)
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The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the circumstances under which
coverage may be excluded for medical conditions present before you enroll. Under the law, a preexisting
condition exclusion generally may not be imposed for more than 12 months (18 months for a late enrollee). The
12-month (or 18-month) exclusion period must be reduced by prior health coverage as long as there was no break
in coverage equal to or exceeding 63 days. In other words, you will be given credit, based on your prior coverage,
toward satisfying any applicable preexisting condition exclusion imposed by the plan.
Your Prescription Drug Coverage and Medicare
The key purpose of this notice is to advise you that the prescription drug coverage you have under the Claremont
University Consortium Health and Welfare Plan is expected to pay out, on average, at least as much as the
standard Medicare prescription drug coverage will pay in 2015. (This is known as “creditable coverage.”) Please
read this notice carefully and keep it where you can find it.