Updated August 2014

Office Hours: Monday-Friday 7:45-4:45 Edison Building: th St SW Contact our office at any time with questions: Phone: Fax:

 If forms are completed and returned within 30 days (of hire date) your insurance effective date will be your first day of employment  Health and Dental Application (Cost Shift and Birthday Rule apply for family health and/or dental coverage.)  Madison Nat’l Life Application Life Insurance/AD&D & LTD  Supplemental LTD (Start date determined by acceptance)  Cost share of premiums is determined by your employment contract  To decline coverage for any of the above, fill out Employee Information and sign waiver  Return completed forms to Insurance Services by dropping off at the Maintenance Service Building, Door 2 or send in inter-office mail

Madison National Life Life Insurance Cost = 11¢ per $1,000 of coverage Coverage amount is determined by your employment contract Coverage over $50,000 will be subject to income tax Example: $40,000 = 40 units x.11 = $4.40 per month premium (for your cost per month refer to your contract) There is a 30 day open enrollment period for new employees for Life & Long Term Disability. This is the one time you can sign up for basic life & LTD with no additional health questions. If you wish to apply for any coverage at a later date you will be required to complete an additional form and coverage is at the discretion of Madison National Life.

Basic Long Term Disability  Cost = 34 ¢ per $100 of your salary  Pays 66 2/3% of your salary, after a 90 calendar day elimination period (How long you have to be disabled before the plan will pay a benefit)  Example: $3000/mo. Salary ÷ $100 = 30 units x.34 = $10.20 per month premium (your monthly cost determined by your contract) Supplemental Disability  Employee pays 100% of cost  Cost = 21 ¢ per $100 plus the cost of basic LTD  Same as Long Term Disability, but pays 85% of your salary, after a 90 calendar day elimination period (How long you have to be disabled before the plan will pay you)  Example: $3000/mo. Salary ÷ $100 = 30 units x.21 = $6.30 per month premium (plus the portion of the Basic LTD you have to pay)  If you wish to apply for any coverage at a later date you will be required to complete an additional form and coverage is at the discretion of Madison National Life.

 In lieu of short term disability, the District offers Hospital Days ◦ Up to 20 days per calendar year (Refer to your employment contract for approved usage)  You may elect to sign up with Aflac for Short Term Disability and have your Aflac premiums payroll deducted  Doug Schwingler is the Aflac Agent  Aflac has an open enrollment period in November for coverage to change/begin the following year.

 Rochester Public Schools is self-insured and self administered, meaning the premiums paid are actually paying the claims.  There are two health plans available ◦ Copay Plan ◦ High Deductible Health Plan  There is no primary care facility. ◦ In network providers are encouraged for cost containment ◦ Mayo & OMC are in network providers ◦ PHCS is our out of state network ◦ When you choose a non participating provider, you pay any charges billed to you that exceed the allowed amount (Including ER visits)  Insurance benefits run by calendar year. ◦ Out of pocket expenses, deductibles, etc. ◦ Deductible amounts incurred in the last 3 months of the calendar year carry over into the new plan year (Does not apply if switching between plans) (Does not apply to investigational deductible)

 For employees who elect to participate in the high deductible health plan, the District will make an annual lump-sum contribution (shown on your January paycheck) to an HRA for the employee.  Single coverage -- $750  Family coverage -- $1500  Must be enrolled in the HDHP as of January 1 of each calendar year in order to receive contribution from the District.  Contributions for new hires are not prorated. 1st contribution will be Jan 1st of the following year.  If the employee separates employment or switches plans before the end of their first HRA contribution year, their remaining HRA balance will be forfeited.

 Fitness Club Membership Discount - $20 per month per person (two people age 18 and over if family coverage) covered by the RPS health plan who work out at least12 times per month.  $50 Prenatal Gift Card if enrolled in the Prenatal Support Program.  Flu Shots in September are FREE for all active and retired RPS employees who are still on the District’s health insurance plan. Family members are covered (age 10 years+) if employee has family coverage as primary through the RPS health plan.  EAP plan pays for one session per year with an EAP counselor. The Center for Effective Living,  Various activities throughout the school year to encourage work/life balance. See the wellness page or contact your site Wellness coordinator for more information.

 Individual deductible - $25 per calendar year  Family deductible - $75 per calendar year  Ortho coverage: $50 lifetime deductible –pays 50% of eligible expenses ◦ Over 18 - $ years waiting period ◦ Under 18 - $ year waiting period

80% coverage after deductible for basic services 2 cleanings per calendar year Fillings Extractions Fluoride (1 time per calendar year) Sealants (1 per tooth, per lifetime) 50% coverage after deductible for Major Services Root Canals Crowns Perio Implants (1time per 5 year period) Up to $1200 per calendar year maximum per person

Health & Dental Insurance Premiums Medical Teachers Copay Plan Employee Cost Per Month Copay Plan District Cost Per Month HDHP Employee Cost Per Month HDHP District Cost Per Month Employee$0$756.00$0$ Family$235.54$1,286.46$0$1, Medical All Other Staff Copay Plan Employee Cost Per Month Copay Plan District Cost Per Month HDHP Employee cost Per Month HDHP District Cost Per Month Employee$39.00$717.00$0$ Family$296.80$1,225.20$40.80$1, Dental Employee Cost Per MonthDistrict Cost Per Month Employee$0$34.00 Family$0$84.00 Cost Shift and/or Birthday Rule apply

 Dual Coverage is allowed. ◦ RPS will be YOUR primary insurance as your active employer ◦ Birthday rule is followed for coordination of benefits & cost shifting  Dependent’s primary insurance responsibility is determined using the birthday rule. Which ever parent’s birthday comes first in the calendar year, is primary on the children.  If you choose to decline spouse’s insurance coverage for either your spouse or your dependents against cost shifting rules, cost shift will apply  Example:  Parent 1 (RPS employee) DOB is July 1 st  Parent 2 (Employed elsewhere with employer contribution to insurance costs) DOB Feb 1 st  Parent 2 is primary for themselves and any applicable dependents. If you choose to take Rochester Public Schools as your primary insurance for spouse/dependents, cost shift would apply.

 All District employees are eligible to participate  You can have pre-tax dollars deducted from your paycheck to reimburse yourself for eligible health care and/or dependent daycare expenses incurred during the plan year  You can set aside up to $2496 for healthcare expenses and $4992 for dependent daycare expenses each year  If dollars are not spent they are lost  Submit claim form with receipts or Explanation of Benefits to Insurance Services and expenses will be reimbursed via ACH on the second and fourth Monday of the month (claim submission cut off is the Tuesday before)  Forms are on the District website (

Dependent Care Flexible Spending Reimbursement Expenses incurred to place your dependent into care while you are working: Dependent is defined as: A dependent child under age 13 Someone who is physically or mentally incapable of self-care who is dependent upon you for their care (spouse, elderly parent, etc.) Eligible dependent care provider is defined as: Other than dependents parents who is over the age of 18, not a dependent of the parents and provides either a Tax ID number or Social Security number.

Annual Open Enrollment  Usually two weeks near the end of October/ beginning of November for January 1 coverage.  You may enroll into the Flexible Spending Plan. Re-enrollment into the Plan is necessary each year.  If you are eligible and initially decline coverage, you may enroll in Health and/or Dental coverage.  If you are enrolled in Health and/or Dental coverage you may make changes to your initial selections.  If you are eligible and initially decline coverage, per your employment contract you will automatically be enrolled in the HDHP (single coverage) if you do not decline coverage during annual open enrollment.

Special Enrollment/Disenrollment Rights  No changes can be made to your health and/or dental coverage outside initial/open enrollment selections, unless you have a qualifying life event (QLE) occur.  Possible events are: ◦ Birth, adoption ◦ Marriage ◦ Divorce ◦ Loss/gain of eligibility for and/ or coverage ◦ Loss/change of employment *please see handout for more QLEs*

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 All premiums and flexible spending account contributions are deducted from your paycheck.  Premiums are paid one month in advance of coverage month.  There may be a extra premium(s) taken out of your first paycheck in order to cover the first month of coverage, which depends on the date your paperwork is completed and received in Insurance Services.