Human Resources, St. Norbert College, De Pere, WI 54115, (920) 403-3211
2016
ST. NORBERT COLLEGE
FACULTY NONCASH COMPENSATION
St. Norbert College (hereinafter referred to as Employer) is proud of the noncash compensation it
makes available to eligible employees.
Health Insurance
Administrator
United Medical Resources (www.umr.com)
Eligibility
.75 FTE with 1st of the month following employment as effective date.
Domestic Partner
Coverage
Same sex domestic partners are eligible for coverage (need declaration from residing county court)
Plan
Monthly Rates
Single
Employee + 1
Family
Spouse/Domestic
Partner Surcharge
PPO – Preferred Provider
HDHP (Health Savings Account - HSA Plan)
$105
$209
$311
$79
$160
$237
$75 per month
Plan Year
January 1st – December 31st
Lifetime Max
Unlimited
Deductible
In-Network
Out-of-Network
Embedded Deductible
$750 (Single); $1,500 (EE+1); $2,250 (Family)
$1,001 (Single); $2,002 (EE+1); $3,303 (Family)
Non-Embedded Deductible
$2,000 (Single); $4,000 (Family)
$4,000 (Single); $8,000 (Family)
Coinsurance
In-Network
Out-of-Network
80%
60%
90%
70%
Includes deductible and medical &Rx copays
$1,500 (Single); $3,000 (EE+1); $4,500 (Family)
$3,000 (Single); $6,000 (EE+1); $9,000 (Family)
Includes Deductible
$4,000 (Single); $8,000 (Family)
$8,000 (Single); $16,000 (Family)
N/A
$500 (Single); $750 (Family)
$20 Copay; then Deductible, 80% Coinsurance
$20 Copay; then Deductible, 60% Coinsurance
Deductible, 90% Coinsurance
Deductible, 70% Coinsurance
Out-of-Pocket Max
In-Network
Out-of-Network
H.S.A. Annual
Employer
Contribution
Office Visits/Instacare
In-Network
Out-of-Network
Routine/Preventive
In-Network
Out-of-Network
Inpatient Hospital
In-Network
Out-of-Network
Outpatient Hospital
In-Network
Out-of-Network
100%
100%
100%
Deductible, 70% Coinsurance
Deductible, 80% Coinsurance
Deductible, 60% Coinsurance
Deductible, 90% Coinsurance
Deductible, 70% Coinsurance
Deductible, 80% Coinsurance
Deductible, 60% Coinsurance
Deductible, 90% Coinsurance
Deductible, 70% Coinsurance
Urgent Care
In-Network
Out-of-Network
$50 Copay; then Deductible, 100% Coinsurance
$50 Copay; then Deductible, 100% Coinsurance
Deductible, 90% Coinsurance
Deductible, 70% Coinsurance
Emergency Room
In-Network
Out-of-Network
$100 Copay; then Deductible, 100% Coinsurance
Same as In-Network Benefit
Deductible, 90% Coinsurance
Same as In-Network Benefit
Ambulance Services
In-Network
Out-of-Network
Deductible, 100% Coinsurance
Same as In-Network Benefit
Deductible, 90% Coinsurance
Retail Prescriptions
Generic
Brand/Formulary
Non-Formulary
25% ($10 Minimum, $50 Maximum)
Rx copays will double for Maintenance Medications
if you continue to use retail after 2 consecutive fills.
Cost will increase to 50% ($20 min/$100 max)
Deductible, 90% Coinsurance
Deductible, 90% Coinsurance
Mail Order
Prescriptions
Generic
Brand
$30 Copay
$90 Copay
Generic Preventive HDHP Drugs are covered at 100%
(Mail Order Only).
Contraceptive
Coverage
No coverage, but members legal right to access coverage is accommodated through UMR
HSA Plan Notice
(In-Network)
No individual family member's deductible is considered satisfied until the full family deductible has been met.
However, no individual family member can exceed $6,650 in out-of-pocket expenses per year. The out-of-pocket
limit for all family members combined remains at $8,000.
PPO Network
- United Health Care Choice Plus Network (www.uhc.com/find_a_physician.htm)
Dental Insurance Plan
Administrator
Delta Dental (www.deltadentalwi.com)
Eligibility
.75 FTE with 1st of the month following employment as effective date.
Monthly Rates
- Single = $26.45
- 1 + 1 = $52.87
- Family = $101.69
Coverage
100% - Diagnostic and Preventive Services
80% - Basic Services
50% - Major Services such as Crowns, Inlays, Onlays, Bridges, Dentures, and Implants
Annual Max
$1,000 per person annual maximum ($1,000 lifetime maximum for orthodontic services)
Dentist List
Freedom to choose any dentist but can receive discounts if you choose one of Delta Dental’s Premier or PPO Dentists
Flexible Spending Account Plan
Description
Allow employees to set aside, or “bank,” pretax portions of their wages to be used to pay for a variety of medical and
dependent care expenses (i.e., deductible, co pays, Rx, Glasses, dental, childcare).
Eligibility
.75 FTE with 1st date of employment as effective date.
Medical
Maximum of $2,550 may be set aside for medical expenses. If participating in the HDHP plan, may contribute to
Limited Flexible Spending Account plan.
Dependent
Maximum of $5,000 may be set aside for dependent care expenses.
*Note
Enrollment in either plan is optional.
*Note
The plan year is January 1 through December 31 of each year and coincides with the plan year for health insurance.
*Note
$500 Rollover provision into next plan year with medical plan. Anything more than that not used by employee is
forfeited.
Short-Term Disability
Eligibility
.75 FTE with 1st of the month following employment as effective date.
Coverage
100% of employee’s basic monthly salary.
*Note
Employer provides this insurance at no cost to the Employee.
*Note
Provides income protection during a period of total disability (through the 90th day of disability) resulting from illness or
injury which renders Employee incapable of performing his or her normal occupation.
Long-Term Disability
Eligibility
.75 FTE with 1st of the month following employment as effective date.
Coverage
67% of employee’s basic monthly salary.
*Note
Employer provides this insurance at no cost to the Employee.
*Note
Provides income protection during a long term period of disability resulting from illness or injury which renders
Employee incapable of performing his or her normal occupation or later gainful occupation for which he or she
reasonably fits.
*Note
Disability insurance payments begin on the 91st day of a disability.
Faculty Parental Leave
Eligibility
This policy applies to all faculty members, regardless of gender, who are full-time, benefit eligible, tenured or tenure
track, and who, at the time of the birth or adoption, have completed one year of continuous full time service. Faculty
members can utilize this policy up to two times within any rolling four-year period. If both parents are members of the
St. Norbert College faculty, only one is eligible to receive the benefits under this policy. Faculty members who fail to
comply with the provisions of the policy are not entitled to its benefits.
Coverage
Options are made available where faculty member may choose to take off a full semester. Salary would be re-calculated
at 85% of the base salary. Other option available for birth or adoptions that cross semesters.
Term Life Insurance / Accidental Death and Dismemberment Insurance
Eligibility
.75 FTE with 1st of the month following employment as effective date.
Coverage
Two times the Employee’s annual salary at no cost to the Employee.
*Note
An accidental death and dismemberment rider is included with this policy.
*Note
Reduction rules apply beginning at age 65.
Optional Life Insurance
Eligibility
.75 FTE with 1st of the month following employment as effective date.
Coverage
Employee can purchase an additional 1 times their annual salary in coverage.
Monthly Rate
Variable rate depending on age group.
Optional Accidental Death and Dismemberment Insurance
Eligibility
.75 FTE with 1st of the month following employment as effective date.
Coverage
Available to Employees in multiples of $10,000 up to a maximum of $250,000, with the limitation that employees may
not select a principal sum that is larger than an amount equal to 10 times their annual salary.
Monthly Rate
Individual Coverage = $.50 for every $10,000 up to $250,000
Family Coverage = $.70 for every $10,000 up to $250,000
*Note
A family plan is available that allows for the coverage of spouses and dependents as well as employees.
Retirement Plan
Administrator
Teachers Insurance Annuity Association (TIAA) and College Retirement Equities Fund (CREF)
Eligibility
Employees may choose to participate in the TIAA-CREF plan immediately upon employment. Participation in the plan
is completely elective.
TIAA
A nonprofit legal reserve, life insurance, and annuity company founded in 1918 and incorporated in New York State.
CREF
A separate nonprofit corporation, companion to TIAA, established in 1952 to provide variable annuities based on
common stocks and other equity securities.
TIAA-CREF
Together they constitute a defined contribution retirement plan in which both the Employer and Employee participate.
Defined
Contributions
Contributions are based on regular earnings only, and both Employer and Employee contributions are sent to TIAACREF after each pay period. Contribution levels are as follows and can be made as pre-tax or post-tax:
Employee
St. Norbert College
2%
5%
3%
6%
4%
7%
5%
9%
*Note
Employer contribution will begin when the Employee begins participation in the plan.
*Note
The intended purpose of the funds is to provide retirement income and death benefits for participants and their families.
Group Supplemental Retirement Annuities
Deductions
May not exceed the limitations of sections 403 (b) and 415 of the Internal Revenue Code
*Note
Employer allows Employees to participate in supplemental retirement annuity programs designed for those who want to
set aside additional funds as pre or post tax.
*Note
This plan has a “hardship” or “loan” provision.
Group Long-term Care Insurance
Eligibility
.75 FTE with 1st of the month following employment as effective date.
*Note
Voluntary plan that provides guarantee issue to employees 65 and under. Benefit can also be used by spouses,
immediate family members, and some extended family member classes.
*Note
Insurance that helps pay a daily benefit for home care, assisted living facility, and nursing home facility expenses. Can
help protect personal assets such as retirement or pension plans. This plan is portable.
Tuition Waiver
Eligibility
Effective after one year of full-time employment (must be .75 FTE or greater).
*Note
Employer offers tuition waivers to full-time Employee, his or her spouse, and his or her dependent children in
accordance with current College policy.
Tuition Exchange
Eligibility
Effective after 3 years of full-time employment (must be .75 FTE or greater).
*Note
Employer offers tuition exchange to full-time Employee’s dependent children in accordance with current College
policy.
Educational Assistance for Master’s Programs
Eligibility
A Participant is eligible to receive benefits under the Plan if he/she has completed one year of full time service (.75 or
Greater FTE) prior to the first day of classes for the applicable academic term. In order for the Participant to receive
benefits under the Plan, the employee must be employed for the complete duration of the academic term.
*Note
In any Plan Year during which an employee is a Participant in the Plan, the College may (contingent on the
availability of financial resources) reimburse up to a maximum of $500 in tuition expenses in each academic term for
an educational course. The Participant must secure a grade of “B” or better or its equivalent in the educational course
to receive reimbursement. Expenses must be validated by receipts and a copy of the final grade must be presented. The
maximum annual reimbursement per Participant will be $2,000.
CatholicLink Tuition Discount
Eligibility
.75 FTE or greater full time employees
*Note
St. Norbert College, Notre Dame Academy, and the Green Bay Area Catholic Education have partnered together to
provide a discount program for dependents of employees working at those organizations with the goal of providing
exceptional faith-based educational experiences for students. Faculty and staff at any of these organizations will be
eligible to receive at least a 50 percent discount on tuition for each of their dependents to attend any of the three
organizations – regardless of which of the three employs them.
*Note
This program applies only to undergraduate programs at St. Norbert College, 9 – 12th grades at Notre Dame
Academy, and K-8th grades at Green Bay Area Catholic Schools.
Funeral Leave
Immediate
Up to 5 days for immediate family (parent, step-parent, spouse, child or step-child, brother/sister, parent-in-law,
brother/sister-in-law, children-in-law).
Extended
Up to 2 days for extended family (grandparent, aunt, uncle, cousin, niece/nephew, grandparent-in-law, grandchild) up
to 2 days.
Jury Duty and Military Leave
*Note
Employees shall receive the difference between their normal pay and remuneration for jury duty or military leave pay
if they earn less than their normal daily rate while performing these services.
*Note
A copy of any jury duty pay shall be forwarded to the College and the College shall pay the employee through the
normal payroll process.
*Note
St. Norbert College supports public policy and regulations to leaves for military service and complies with all state and
federal regulations regarding leave, pay and reinstatement rights.
Worker’s Compensation
*Note
Should you lose work time or incur medical expenses because of a work-related accident, you will be compensated by
this insurance program according to Wisconsin law.
Family & Medical Leave
Eligibility
After you have worked for the college for 12 months and meet certain other criteria.
*Note
Authorized absences may be for up to 12 weeks in a calendar year.
*Note
FMLA is an unpaid leave that does allow substitution of any paid time an employee has accrued.
Miscellaneous Additional Benefits
Direct Deposit
Use any bank or financial institution (mandatory).
Parking
Free in specified lots with proper automobile identification.
Sports Center
Free us of facilities with authorized ID.
Athletic Events
Free or reduced admission price for most events upon presentation of authorized ID.
Spouses/Dep
Children
Eligible for an authorized ID entitling them to free use of the Schuldes Sports Center and its facilities, free or reduced
admittance to most athletic events, and use of the Miriam B. and James J. Mulva Library.
For Further Information Contact:
Jesse Albers
Manager of HRIS, Compensation, & Benefits
(920) 403-3982
E-mail: jesse.albers@snc.edu
St. Norbert College
100 Grant Street
De Pere, WI 54115-2099
St. Norbert College is committed to the highest moral and ethical standards and to the spirit as well as the letter of law, in all its
employment policies and practices. It adheres to all policies of nondiscrimination on the basis of age, race, religion, creed, color,
handicap, marital status, sex, sexual orientation, national origin, ancestry, arrest record, veteran’s status, non job-related arrest
record or conviction as defined by current Federal and State statutes, as well as in its admissions practices, educational programs
and activities, as required by Title IX of the 1972 Education Amendments and code of Federal Regulations. The College insists
on a good faith effort on the part of all its employees in the area of equal employment.
EMPLOYEE RIGHTS AND RESPONSIBILITIES
UNDER THE FAMILY AND MEDICAL LEAVE ACT
Basic Leave Entitlement
Use of Leave
FMLA requires covered employers to provide up to 12 weeks of unpaid, jobprotected leave to eligible employees for the following reasons:
• For incapacity due to pregnancy, prenatal medical care or child birth;
• To care for the employee’s child after birth, or placement for adoption
or foster care;
• To care for the employee’s spouse, son or daughter, or parent, who has a
serious health condition; or
• For a serious health condition that makes the employee unable to
perform the employee’s job.
An employee does not need to use this leave entitlement in one block. Leave
can be taken intermittently or on a reduced leave schedule when medically
necessary. Employees must make reasonable efforts to schedule leave for
planned medical treatment so as not to unduly disrupt the employer’s
operations. Leave due to qualifying exigencies may also be taken on an
intermittent basis.
Military Family Leave Entitlements
Eligible employees with a spouse, son, daughter, or parent on active duty or
call to active duty status in the National Guard or Reserves in support of a
contingency operation may use their 12-week leave entitlement to address
certain qualifying exigencies. Qualifying exigencies may include attending
certain military events, arranging for alternative childcare, addressing certain
financial and legal arrangements, attending certain counseling sessions, and
attending post-deployment reintegration briefings.
FMLA also includes a special leave entitlement that permits eligible
employees to take up to 26 weeks of leave to care for a covered service
member during a single 12-month period. A covered service member is a
current member of the Armed Forces, including a member of the National
Guard or Reserves, who has a serious injury or illness incurred in the line of
duty on active duty that may render the service member medically unfit to
perform his or her duties for which the service member is undergoing medical
treatment, recuperation, or therapy; or is in outpatient status; or is on the
temporary disability retired list.
Substitution of Paid Leave for Unpaid Leave
Employees may choose or employers may require use of accrued paid leave
while taking FMLA leave. In order to use paid leave for FMLA leave,
employees must comply with the employer’s normal paid leave policies.
Employee Responsibilities
Employees must provide 30 days advance notice of the need to take FMLA
leave when the need is foreseeable. When 30 days notice is not possible, the
employee must provide notice as soon as practicable and generally must
comply with an employer’s normal call-in procedures.
Employees must provide sufficient information for the employer to determine
if the leave may qualify for FMLA protection and the anticipated timing and
duration of the leave. Sufficient information may include that the employee is
unable to perform job functions; the family member is unable to perform daily
activities, the need for hospitalization or continuing treatment by a health care
provider, or circumstances supporting the need for military family leave.
Employees also must inform the employer if the requested leave is for a reason
for which FMLA leave was previously taken or certified. Employees also may
be required to provide a certification and periodic recertification supporting the
need for leave.
Employer Responsibilities
Benefits and Protections
During FMLA leave, the employer must maintain the employee’s health
coverage under any “group health plan” on the same terms as if the employee
had continued to work. Upon return from FMLA leave, most employees must
be restored to their original or equivalent positions with equivalent pay,
benefits, and other employment terms.
Use of FMLA leave cannot result in the loss of any employment benefit that
accrued prior to the start of an employee’s leave.
Eligibility Requirements
Employees are eligible if they have worked for a covered employer for at least
one year, for 1,250 hours over the previous 12 months, and if at least 50
employees are employed by the employer within 75 miles.
Definition of Serious Health Condition
A serious health condition is an illness, injury, impairment, or physical or
mental condition that involves either an overnight stay in a medical care
facility, or continuing treatment by a health care provider for a condition that
either prevents the employee from performing the functions of the employee’s
job, or prevents the qualified family member from participating in school or
other daily activities.
Subject to certain conditions, the continuing treatment requirement may be met
by a period of incapacity of more than 3 consecutive calendar days combined
with at least two visits to a health care provider or one visit and a regimen of
continuing treatment, or incapacity due to pregnancy, or incapacity due to a
chronic condition. Other conditions may meet the definition of continuing
treatment.
Covered employers must inform employees requesting leave whether they are
eligible under FMLA. If they are, the notice must specify any additional
information required as well as the employees’ rights and responsibilities. If
they are not eligible, the employer must provide a reason for the ineligibility.
Covered employers must inform employees if leave will be designated as
FMLA-protected and the amount of leave counted against the employee’s
leave entitlement. If the employer determines that the leave is not FMLAprotected, the employer must notify the employee.
Unlawful Acts by Employers
FMLA makes it unlawful for any employer to:
• Interfere with, restrain, or deny the exercise of any right provided under
FMLA;
• Discharge or discriminate against any person for opposing any practice
made unlawful by FMLA or for involvement in any proceeding under or
relating to FMLA.
Enforcement
An employee may file a complaint with the U.S. Department of Labor or may
bring a private lawsuit against an employer.
FMLA does not affect any Federal or State law prohibiting discrimination, or
supersede any State or local law or collective bargaining agreement which
provides greater family or medical leave rights.
FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered
employers to post the text of this notice. Regulations 29 C.F.R.
§ 825.300(a) may require additional disclosures.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
For additional information:
1-866-4US-WAGE (1-866-487-9243) TTY: 1-877-889-5627
WWW.WAGEHOUR.DOL.GOV
WHD Publication 1420 Revised January 2009
U.S. Department of Labor | Employment Standards Administration | Wage and Hour Division
Authorization of Disclosure and Release of Information
St. Norbert College
I authorize St. Norbert College and/or AccuSource, Inc., to investigate all statements contained in my application for
employment and retrieve information relating to my past activities for purposes of such investigation from all
relevant individuals and organizations, including but not limited to personnel, educational institutions, government
agencies, companies, law enforcement agencies, and consumer reporting agencies, to supply any and all information
concerning my background and credit worthiness, and release the same from any liability resulting in providing such
information. The information received may include, but is not limited to, employment, academic, residential, motor
vehicle, consumer credit, and criminal records. I understand that I have the right to request additional information
about these inquiries and any subsequent reference reports. This additional information will be provided to me upon
written request to AccuSource, Inc. at 1240 E. Ontario Avenue, Suite 102-140, Corona, California 92881.
I hereby certify that all the statements and answers contained in my application for employment, on my resume and
other application materials, provided during all interviews, and on this form are true and complete to the best of my
knowledge, and I understand that any false statements and/or answers or omissions of information in those
statements or answers will be sufficient cause for cancellation of employment consideration or dismissal, if I have
been employed. I understand that by furnishing my birth date below, St. Norbert College and/or AccuSource, Inc.,
are using that information for the sole purpose of verifying identification as part of the criminal records check and
the birth date is not part of my application for employment. I release all parties for all liability for any damage that
may result from furnishing information, including this disclosure of my date of birth, and this authorization to St
Norbert College and/or AccuSource, Inc.
I hereby certify that I am not currently being charged with or being investigated for, any criminal matter, except as
detailed below, and have never been convicted of any offense, with the exception of minor traffic violations, except
as detailed below. I understand that a pending charge or prior conviction will not automatically bar me from
employment consideration. (Please provide details on each pending charge, investigation, and conviction, if any,
including: date, type of conviction or charge, state, county, and city of conviction or charge, penalty assessed, dates
of any future court actions, and any other relevant factors we should consider.)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I authorize that a photocopy or fax of this authorization be accepted with the same authority as the original; and
that this authorization be in effect throughout my candidacy for employment and, if employed by St. Norbert
College, this authorization remain in effect throughout my employment.
Print Name (First, Middle Initial, Last)
Signature
Street
SOCIAL SECURITY NUMBER
Date
City
State
Zip
BIRTHDATE (MONTH/DAY/YEAR)
/
DRIVER'S LICENSE NO.
STATE
/
EXPIRES