Benefits Orientation Presentation
Today’s Agenda
● All About ADP Totalsource
● What’s Going on in the
Benefits Marketplace
● Health Care Options
● Medical & Dental Plan
Information
● Vision Information
● Life/STD/LTD
● FSA
● Additional Benefit Options
● Enrollment Checklist
● MyTotalSource.com
 How to Login to MyTs.com
 Making Benefit Elections
● Important Items to Note
● Summary Plan Description
(SPD)
*Click on the link of the topic that you would like to go to above
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ADP TotalSource TotalBenefits
● Medical Insurance
● Aetna Life and Accidental Death &
Personal Loss Insurance
● Aetna Short and Long Term Disability
Coverage
● Vision Insurance
● Dental Insurance
● Health Care and Dependent Care Flexible
Spending Accounts (FSAs)
● JPMorgan Chase Health Savings Accounts
(HSAs)
● Health Advocate
● Commuter Benefits
● CIGNA Medical Benefits Abroad
● Universal Life Insurance
● Accidental Death & Dismemberment
Insurance
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Legal Services
Auto and Home Insurance
Pet Insurance
Disability Income Insurance
Critical Illness Plan
Level Term Life Insurance
Accident and Sickness Hospitalization
Plan
Cancer Plan
Employee Service Center (ESC)
My TotalSource
Life’s Solutions Employee Assistance
Program
ADP Personal Discounts Program
TotalSource University
Why Consider TotalBenefits?
● Think of your benefits package as a whole
Perks/Personal
Discounts
Individual Voluntary
Options
EAP
Voluntary
Benefits
Automatic, No-Cost
Benefits
Group Voluntary
Options
Commuter Benefits
Tax Savings
Accounts
Medical
Health Savings
Accounts
Flexible Spending
Accounts
Retirement
401(k)
Health Care
Life & Disability
Financial Protection
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Dental
Vision
Being With ADP Has Its Perks…
● Enhanced Benefit Package:
● Multiple Medical & Dental Plan Options, Vision coverage, Life, and Disability
Offerings, Flexible Spending Accounts – Health and Dependent Savings
Accounts
● Employee Perks include:
● Employee Service Center, Employee Assistance Program, Direct Deposit in
up to 3 checking accounts and 2 savings accounts, 24/7 Online Access to
Personal information/Changes, Optional Supplemental Insurance, Personal
discounts and much more!
Your Employer continues to make decisions regarding the organization,
day-to-day operations and your job responsibilities.
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Are You Ready to Enroll?
Enrollment Checklist
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Prior to enrolling make sure you
have the following information…
 Have you read your benefits package?
 If you are enrolling dependents, do you have their social security numbers
and dates of birth? (Dependent social security numbers are now a
mandatory requirement for enrolling dependents)
 If you are enrolling in an HMO or Dental HMO plan, have you selected a
primary care physician (PCP)?
 Have you read the acknowledgement section of your benefits package?
 If applicable, have you read the California Arbitration and/or the SRC Limited
Benefits Disclosures?
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MyTotalSource.com
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About MyTotalSource.com
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Log onto www.adptotalsource.com
Secure Access 24/7
View your paycheck
View your benefits
View & change direct deposit, tax withholdings & update your personal
profile
 Link to the personal discount programs
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First Time My TotalSource Users –
User Name
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Your User Name is constructed by using:
Your first initial
The first seven characters of your last name and
The last four digits of your social security number.
If your last name is shorter than three characters:
Add a one (1) after the last letter of your last name to make a minimum user
name of 8 characters.
● Examples:
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SSN
Name
Result
123445678
Joann Song
jsong5678
123554444
Bob Butterworth
bbutterw4444
123669989
Sue Lo
slo19989
233447896
Sam Smith Jr
ssmithjr7896
First Time My TotalSource Users Password
Your initial Password will be:
• The first character of your first name
• The six-digit file number (located in the paycheck detail section of
your earnings statement) and
• The first character of your last name
Example: If your name is Fred Smith and your paycheck file number
is 000056, your initial password will be: F000056S
To protect your privacy and My TotalSource's security, you will be prompted to
change your password after you log in the first time. Choose something that will be
easy for you to remember but hard for others to guess.
If you are unsuccessful in logging in, please call the Employee
Service Center at: 800-554-1802.
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Enrolling in Benefits via
MyTotalSource.com
Step 1. Click benefits link
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Step 2. Review & Elect Your Benefits
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Step 3. Elect FSA Plan Year Amount
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Step 4. Select your PCP or Dentist
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Step 5. Enter Dependent & Beneficiary Info
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Step 6. Determine Life Insurance
Distribution amounts
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Step 7. View your elections and Accept!
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Step 8. Print Confirmation Page &
Temporary Insurance Card
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Factors Currently Impacting Health
Care Costs In General
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H1N1: Impact on Health Care
Costs
● A study was conducted by the Centers for Disease Control to analyze the cost impact
of the H1N1 virus. They estimate that a patient with an undiagnosed infection or a
visitor in a hospital with no protection will result in 2,580 infected patients within 30
days. The cost of treating H1N1 will vary based on the different alert levels:
 Green alert (mandates personal protective equipment for health care workers in
direct contact with patients suspected of having H1N1) - this would result in an
additional $95 to prevent one additional infected patient and $23,600 to prevent
one death;
 Yellow alert (mandates enhanced personal protective equipment at all high-risk
areas) - this would result in an additional $3,221 to prevent one additional infected
patient and $828,000 to prevent one death;
 Orange alert (mandates N95 masks for all patient contact as well as all other
stated measures) - this would result in $7,153 to prevent one additional infected
patient and a staggering $2.5 million for one death averted.
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COBRA Participation has increased
with ARRA Subsidy
A study conducted from March 2009 to June 2009 of 200 large U.S. companies,
which covered 8 million employees. The study found that:
● COBRA enrollments doubled to 38% for eligible Americans. This figure is up from
19% for the previous period of September 2008 through February 2009.
● COBRA enrollments in the industrial manufacturing industry jumped 800% since the
subsidy became available. Original enrollment was just 7% and rose to 59% in the
four months following the subsidy.
A recent survey of more than 300 employers who attended Aon Consulting's
webinars on the COBRA subsidy, found that:
● Nearly 60% expected their overall health care costs to increase as a direct result of
the new federal COBRA subsidy.
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Health Care Options
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Health Care Options
● As we review the available Health options, we should keep in
mind that our needs and the needs of our families will be unique.
● Our Core F3Q and Buy Up 7AB plans are the same with no
increase in Deductibles, Co-pays, or Prescription drugs.
● Our current H.S.A. 7AI (hdhp) is no longer available. The
renewal plan is the 7AT. Difference: Prescription co-pays after
meeting the deductible.
● At most, the increase is 3% of the average $30k salary.
All elections are:
• Deducted on a pre-tax basis each pay period
• Part of Section 125 – Cafeteria Plans
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Benefit Effective Dates
ADPTS’ Plan Year is effective
from:
June 1st – May 31st
Deductible and Out-of-Pocket
Maximums are effective from:
January 1st – December 31st
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FLS/SST Plan Offerings
Type
Carrier
Medical
United Healthcare: High Deductible
Health Plan and two POS (Point of
Service) plans
Dental
Aetna: DMO (Dental Maintenance
Organization) and PPO (Preferred
Provider)
Vision
VSP
FSA
ADP Flex Direct
HSA
Chase
Life and Disability (Employer Paid)
Aetna
** Enrollment form
indicates monthly
premium amount.
** Premiums are deducted
per pay period.
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Medical Plan Information
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FLS/SST Plan Offerings
7AB
F3Q
Buy Up
Core
$75.00
$34.62
7AT
H.S.A.
Provider:
UHC
Member Service
Phone #
800.357.0978
Carrier Web address:
www.uhc.com
Employee
$57.90
Employee + Spouse
$166.25
$121.02
$128.73
$166.25
$121.02
$128.73
$234.09
$181.93
$175.19
Employee + Children
Employee + Family
Per Pay Period Deductions
Medical – United Health Care
Core – F3Q
Currently Enrolled:
Employee
Additional $10 mo
Employee Only - 25
Employee + Sp – 10
**Ideal for those who
have not been to the
hospital or plan to go.
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NOW:
$30
$34.62
$111.79
$121.02
$111.79
$121.02
$163.47
$181.93
Employee + Spouse
Additional $20 mo
Employee + Child – 6
Family - 9
WAS:
Employee + Children
Additional $20 mo
Employee + Family
Additional $30 mo
Core Plan F3Q
General Plan Info
In-Network
Deductible Individual/Family
2500/5000
Annual Out of Pocket
Max
5500/11000
Life Time Maximum
1,000,000
Co-Insurance
80%
Office Visits Copay
Amts
Per Visit
PCP
$25
Specialist
$50
RX Benefits
Tier 1
$10
Tier 2
$35
Tier 3
$60
Mail Order
Discounted 90 days supply
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Carrier/Product Info
Core Plan F3Q
General Plan Info
In-Network
Hospital Care
Inpatient
**Per occurrence Deductible of $500,
then covered at 80% after Deductible
Outpatient
**Per occurrence Deductible of $300,
then covered at 80% after Deductible
Emergency Care
Emergency Room
Covered at 80% after Deductible
Urgent Care Facility
$75 per visit
Ambulance
Covered at 80% after Deductible
Maternity Care
Pregnancy & Maternity
(Pre-Natal Care)
$25 copay for initial visit only
Preventive Care
Most items covered at $25/$50 Copay.
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Carrier/Product Info
Per Pay Period Deductions
Medical – United Health Care
Buy Up – 7AB
Currently Enrolled:
Employee Only - 19
Employee + Sp – 15
Employee + Child – 5
Family – 29
*Our plan with the most
coverage possible. If
you do not know what
to expect, but want to
be safe and covered
for any obstacle.
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Employee
Additional $20 mo
WAS:
NOW:
$66
$75.24
$147.79
$166.25
$147.79
$166.25
$199.47
$234.09
Employee + Spouse
Additional $40 mo
Employee + Children
Additional $40 mo
Employee + Family
Additional $75 mo
Buy Up 7AB
General Plan Info
In-Network
Deductible Individual/Family
1000/3000
Annual Out of Pocket Max
3500/7000
Life Time Maximum
5,000,000
Co-Insurance
80%
Office Visits Copay
Amts
Per Visit
PCP
$25
Specialist
$50
RX Benefits
Tier 1
$10
Tier 2
$35
Tier 3
$60
Mail Order
Discounted 90 days supply
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Carrier/Product Info
Buy Up 7AB
General Plan Info
In-Network
Hospital Care
Inpatient
Covered at 80% after Deductible
Outpatient
Covered at 80% after Deductible
Emergency Care
Emergency Room
$200 copay per visit
Urgent Care Facility
$75 per visit
Ambulance
Covered at 80% after Deductible
Maternity Care
Pregnancy & Maternity
(Pre-Natal Care)
$25 copay for initial visit only
Preventive Care
Most items covered at $25/$50 Copay.
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Carrier/Product Info
Per Pay Period Deductions
Medical – United Health Care
H.S.A. – 7AT
Currently Enrolled:
Employee Only - 3
Employee + Sp – 4
Employee
Additional $10 mo
Employee + Child – 0
Family – 3
**Good tax breaks for
H.S.A. Accounts
**Ideal plan for heavy
medical users that will
reach their deductibles
or for medical users
that do not go to the
doctor except for their
annual physical.
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WAS:
NOW:
$53.29
$57.90
$119.50
$128.73
$119.50
$128.73
$161.34
$175.19
Employee + Spouse
Additional $20 mo
Employee + Children
Additional $20 mo
Employee + Family
Additional $30 mo
H.S.A. HDHP 7AT
General Plan Info
In-Network
Deductible - Individual/Family
2,000 individual – 4,000 Combined
Annual Out of Pocket Max
4,000 / 8,000 - Includes Deductible
Change from 7AI (Additional 2k/4k for Prescription Co-pays)
Life Time Maximum
Unlimited or None
Co-Insurance
100%
Office Visits Copay Amounts
Per Visit
PCP
Covered at 100% after deductible
*Pay contracted rate per reason code for each visit
Specialist
Covered at 100% after deductible
*Pay contracted rate per reason code for each visit
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Carrier/Product Info
H.S.A. HDHP 7AT
General Plan Info
In-Network
Hospital Care
Inpatient
Covered at 100% after deductible
Outpatient
Covered at 100% after deductible
Emergency Care
Emergency Room
Covered at 100% after deductible
Urgent Care Facility
Covered at 100% after deductible
Ambulance
Covered at 100% after deductible
Maternity Care
Pregnancy & Maternity (Pre-Natal Care)
Covered at 100% after deductible
Preventive Care (Annual Physical)
Covered at 100%
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Carrier/Product Info
H.S.A. HDHP 7AT
General Plan Info
In-Network
RX Benefits
Tier 1
Covered at 100% after deductible + $10
Tier 2
Covered at 100% after deductible + $30
Tier 3
Covered at 100% after deductible + $50
Mail Order Discounted 90 day supply
Covered at 100% after deductible + $100
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Carrier/Product Info
Per Pay Period Deductions
Overview and Comparison
7AB
F3Q
7AT
Buy Up
Core
H.S.A.
$75.00
$34.62
$57.90
$166.25
$121.02
$128.73
$166.25
$121.02
$128.73
$234.09
$181.93
$175.19
Employee
Employee + Spouse
Employee + Children
Employee + Family
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Dental Provider Information
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Provider:
Aetna
Product:
PPO (In/Out of Network
Benefits)
Plan Description
PPOA
Member Service Phone #
800.357.0978
Carrier Web address:
www.aetna.com
Provider:
Aetna (Same)
Product:
DMO 54 (Must Select
Specific Dentist)
Plan Description
DMO
Member Service Phone #
800.357.0978
Carrier Web address:
www.aetna.com
Carrier/Product Info
Per Pay Period Deductions
Dental – Aetna
DMO Core
PPO Buy Up
Employee
$4.23
Change of $.15
$11.42
Change of $.74 mo.
Employee + Spouse
$12.60
$27.92
Change of $.30
Change of $1.49 mo.
$14.00
$30.28
Change of $.32
Change of $1.60 mo.
$23.77
$48.20
Change of $.49
Change of $2.43 mo.
Employee + Children
Employee + Family
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Dental Option - DMO
DMO / Managed Care Plan
Deductible - Individual/Family
No deductible or calendar year maximum
Copay
$5 Copay for office visits
Coverage
Preventative Services
Covered at 100%
Basic Services
Covered at 100%
Major Services
High level of coverage for most Major Dental
services
Orthodontic Services
Coverage for child & adult services
Dental Option - PPO
PPO Dental Preferred Provider Organization
Deductible - Individual/Family
50/150
Calendar Year Benefit Maximum
$1250 per member
Coverage
Preventative Services
Covered at 100%
Basic Services
Covered at 80%
Major Services
Covered at 50%
Orthodontic Services
Coverage for dependents up to age 19 with life
time maximum of $1,250 in network
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Carrier/Product Info
Vision Information
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Monthly Deductions
Vision –VSP
Employee
$2.63
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Employee + Spouse
$5.27
Employee + Children
$5.64
Employee + Family
$9.01
Vision Options
Benefit
Copay
Frequency
Well Vision Examination
$5
Once every 12 months
Single Vision, Lined Bifocal and Lined
Trifocal
$10
Once every 12 months
In-Network
Retail Allowance for Frames
$180
Contact Lenses (instead of glasses)
None
Once every 12 months with an allowance of
$150
Lasik
None
$150 allowance for both eyes,
5-15% discount
N/A
Services are reimbursed up to a maximum
amount depending on service.
Out-of Network
All Services
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Vision - VSP
● Save on exams, eyeglasses or contact lenses and Laser eye surgery.
● Benefits vary depending on whether services are provided in or out of
network
● No paper forms required, call your VSP participating provider to begin the
pre-approval process!
● Participating providers can be found at vsp.com
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Life/STD/LTD
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Life, Accidental Death & PL
● Employer Paid
● Basic Life insurance – $25,000
● Offered to all Full-Time eligible Employees
(working a minimum of 30 hours a week)
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Provided by Aetna
Long Term Disability (LTD)
● Employer Paid
● 60% up to $5,000/month
● Benefit begins after 180 days of disability
● *Offered to all Full-Time eligible Employees
(working a minimum of 30 hours a week)
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Provided by Aetna
Employee Assistance Program
(EAP)
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NEW! 24-hour toll free number dedicated to
ADP TotalSource worksite employees: 1-888-231-7015
All worksite employees and their dependents are eligible
Initial assessment by an EAP counselor
Referral to a provider best suited to deal with issue
Up to 3 face-to-face visits annually with licensed, certified counselor at no
cost to individual
Extensive Nationwide Network
Voluntary and Confidential Service
Assistance with Stress, Anxiety, Depression, Grief, ADD/ADHD, Eating
Disorders, Financial issues, Family Issues, Alcohol and Substance Abuse
Issues, Relationship Issues, Financial or Legal Counseling
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EAP Statistics
● EAP treated 2,688 members during the 2nd quarter of 2008
● Ages 18-44 were the highest utilizing age group for the quarter
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TotalSource University
● Classroom Training, in-person with an ADP
TotalSource Instructor
● Virtual Classroom Training, including My
TotalSource Training and Management
● Webinars (coming soon!)
● Online Seminars, delivered via streaming
video
● Online Training, available 24/7 at affordable
prices
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• 2,826 clients attended TSU
Classroom sessions
• TSU Classroom sessions
were offered in 48 major
metropolitan cities across
18 states
• Over 3,000 courses are
available through TSU
Online University
• Over 25,000 clients trained
onsite by HRBPs
• Top three training
requests:
• Preventing Harassment
in the Workplace
• Diversity in the
Workplace
• Customer Service
Employee Personal Discounts
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Program offers discounts from brand name retailers
Employees leverage ADP’s buying power to save money and time
Discounts also available for your business needs
Real Estate & Financial Services
Sign up for premium-level savings on luxury brands**
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** Available at a modest monthly fee
Flexible Spending Accounts
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What are Flexible Spending
Accounts (FSA)
● FSA’s are accounts that allow you to pay for certain medical and dependent
care expenses with pretax dollars.
● Employee contributions are deducted from each paycheck before Federal
Income and Social Security taxes are calculated.
● You will not pay taxes on eligible reimbursements.
•Please note: Use it or lose it – is an IRS requirement that if you
do not spend all the money you have in your FSA, that money
remaining in after July 31st of the following year will be forfeited
because it cannot be rolled over or refunded to you.
Refer to your Summary Plan Description
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What are Flexible Spending
Accounts (FSA)
● You can enroll initially when your worksite Employer begins the relationship
with ADP TotalSource or during FSA Open Enrollment every spring, for an
effective date of June 1st
● If participating in a HSA, you may only use FSA for dental and vision.
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Refer to your Summary Plan Description
Health Care FSA
● Allows you to pay for certain medically necessary expenses with pre-tax
dollars.
● *Contribute up to $3,500.00 for the plan year ($50.00 minimum).
● You may use the money even if not yet in the account.
● Direct Deposit Reimbursements
Health Care Reform Alert!
● Although the Reconciliation Bill delayed the imposition of a *$2,500 cap on all
health care FSA plans until 2013, the Reconciliation Bill did not alter a
provision included in H.R. 3590 that prohibits a participant in a health care
FSA or health savings account from being reimbursed for over the counter
medications, unless such medications are prescribed by a doctor. This
provision is effective beginning January 1, 2011.
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Health Care FSA
Examples of eligible expenses are:
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Copays
Deductibles
Eye glasses/contact lenses
Orthodontia
X-rays
Vaccinations/immunizations
Routine physicals
Infertility treatment
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Dependent Care FSA
● Allows you to pay for dependent care with pre-tax dollars.
● Contribute up to $5,000 for the plan year ($2500 if married and filing
separately) ($50 minimum)
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Dependent Care FSA
Examples of eligible expenses are:
• Care for dependent under the age of 13
• Regardless of age if they are physically/mentally
incapable of self care
Expenses for care while at work include:
• Care provided in your home (not by another
dependent)
• Qualified child care centers and after school
programs
• Certified ‘away from home’ facilities (provided not
more than 12 hours/day)
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Highly Compensated Employee
(HCE) Dependent Care FSA
For the 2010-2011 plan year a Highly Compensated Employee is defined
by the IRS as an individual that:
• Owns (or constructively owns) more than 5% of the stock,
capital or profits interest of a Client Company on any day during
the Plan Year, or
• Will be paid compensation by ADP TotalSource in excess of
$110,000 annually.
The definition of a HCE may change for future plan years.
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Highly Compensated Employee
(HCE) Dependent Care FSA
● Highly compensated Employees are only permitted to contribute up to $2000
per plan year to Dependent Care FSA.
● ADP TotalSource may at any time before or during the plan year impose
additional pre-tax contribution limits on a HCE if necessary to satisfy the nondiscrimination requirements applicable to the Dependent Care FSA.
● Open Enrollment and New Hire Enrollment materials disclose the new
requirement.
● Enrollment form and My TotalSource will recognize a HCE and limit their
Dependent Care FSA contribution accordingly.
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Tax Advantage of FSA’s
Without Medical Reimbursement Account
With the Medical Reimbursement Account
Annual Gross
(Taxable Income) ........................$30,000
Annual Gross
(Taxable Income) .....................$30,000
Less Federal Income ax/FICA.......-$6,040
Less Medical Reimbursement
Account…………….…………... -$1,000
Joe’s Annual Net Income….....….$23,960
Joe’s Taxable Income…............$29,000
Less Medical Expenses……….… -$1,000
Less Federal Income
Tax/FICA……………...……...-$5,813.50
Joe’s Spendable income…….......$22,960
Joe’s Spendable income…...$23,186.50
That’s $226.50 more dollars in Joe’s pocket for the year!
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Additional Value Added Benefit Options
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Principal 401(k) Plan
● Regardless of the economy’s performance, a 401(k) plan can help you retain
and recruit talented worksite employees.
How?
 The plan is no cost to you
 Easy plan administration
 Your own 401(k) Specialist
 Lifetime Funds - Choices made easy
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Ancillary (Voluntary) Benefits
● Colonial Insurance - Post Tax Benefits – Can make changes any time for no
reason!
 Universal Life
 Term Life
 Voluntary AD&D Individual
 Accident
 Hospital – Medical Bridge
 Individual disability income policy
 Cancer insurance
 US Legal services ($8.65 per pay)
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Ancillary (Voluntary) Benefits
● ADP TotalSource
 Auto/home insurance
 Group Universal Life
 Voluntary AD&D
 Legal services
 Pet insurance
 Individual universal and level term life
 Individual disability income policy
 Cancer insurance
 Employee Electronic Purchase Program (coming in 2010)
 ID TheftSmart (coming in 2010)
 Life-Prints (coming in 2010)
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HSA and HDHP
How Do I Qualify for a Health Savings Account?
To be eligible for HSA contributions, you must satisfy several
requirements on a monthly basis:
● Must have health coverage under a qualified High Deductible
Health Plan (HDHP)
● Cannot be covered under another health plan that is not a HDHP,
unless the health plan provides very limited coverage such as
dental or vision
● You must not be entitled to Medicare benefits or be eligible to be
claimed as a dependent on another person’s tax return
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Refer to page 20 in your Summary Plan Description
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Health Savings Account
How do I open my Health Savings Account?
● Complete the JP Morgan Chase application & send to the Employee
Service Center via mail or fax.
● It can take 30-45 days for the account to be set up.
● You can enroll online via the MyTotalSource.com website.
● Don’t Delay!
● After initial screening, the ESC will forward to Chase for the Identity
Verification Process. They will make 3 attempts to contact you.
● Provide necessary information as requested by JP Morgan Chase.
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HSA and HDHP – Additional
Information
There is an Investment Fund Option:
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Account holders with a minimum balance of $2,000 will have access to enroll in
the HSA Investment Account which allows for a number of mutual fund options.
●
Detailed information is available in the HSA Investment Service Description
booklet.
There are limitations for the use of FSA & HSA accounts:
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Participants can have both accounts during a plan year - provided that the FSA
is used to reimburse dental and vision expenses only.
●
If you enroll in both the FSA and HSA, the FSA will be “limited’ to these
expenses only.
●
Over-the-Counter drugs cannot be reimbursed under the FSA if you have an
HSA.
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HSA Enrollment Process
● Individual submits completed HDHP and HSA enrollment forms to ADPTS
(Note there is a separate HSA application to complete)
● ADPTS reviews the enrollment form for completeness and confirms the
applicant’s eligibility
● ADPTS verifies that all enrollment data matches the ADPTS database
● After the Employee’s enrollment return date has passed, ADPTS forwards
enrollment form to JPMC HSA Operations Center
● JPMC establishes the cardholder account
● JPMC stores image of application, including beneficiary information
● JPMC verifies applicant’s identity
● Card and welcome kit are sent to applicant by Chase’s fulfillment center after
the account opening date, along with the terms and conditions and a supply
of deposit slips
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Important Items to Note!
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What are pre-existing conditions?
● Only applicable with PPO Plans
● * Pre-existing conditions will be covered if you have had continuous health
coverage with no longer than a 63 day break
● May be required to provide the carrier with a HIPAA certificate to show proof
of prior coverage
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Pre-Certification & Step Therapy
● Pre-certification – encourages safe,
cost-effective use of prescription drugs
by requiring prior authorization by the
carrier before certain drugs will be
covered.
● Step-Therapy – some drugs are
covered only after one or more
prerequisites, clinically appropriate and
cost-effective alternative drugs, are tried
first – unless your doctor obtains a
medical exception.
● Prescription drugs that require Precertification or Step-Therapy can be
found on the carriers website
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Making Changes to your Benefits
● You can make changes to your Pre-Tax benefit elections during the
following times:
● Open Enrollment
 Employee would make changes during the Spring months for
an effective date of June 1st.
● Qualifying Event under Section 125 of IRS Code
 Employee must request QE change no later than 60 days from
the date of the QE. (Reference page 28 of the Summary Plan
Description)
 Examples of Qualifying Events:
• Change in Marital Status such as marriage, divorce, separation
• Addition in Dependents such as birth, adoption, court order
• Change in Employment such as hiring, termination,
beginning/ending of unpaid leave.
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Summary Plan Description
Booklet
This booklet summarizes the available benefit plan options.
● It will also include pertinent information about:
 Enrollment processes
 Flexible Spending Accounts (FSA)
 Health Savings Accounts (HSA)
 Consolidated Omnibus Budget Reconciliation Act (COBRA)
 Health Insurance Portability and Accountability Act (HIPAA)
 Qualifying Events
 Pre-Existing Conditions
 Other pertinent health care information
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Summary Plan Description
Booklet
● Plan options may include for both Medical and Dental:
 HMO (Health Maintenance Organization)
 OA (Open Access)
 POS (Point of Service)
 PPO (Preferred Provider Organization)
 HDHP (High Deductible Health Plan)
● Please note: Plan options may vary by market/Employee location
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We value your partnership.
Thank you for your time!
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