BENEFITS GUIDE November, 1, 2021 - October 31, 2022 - Ave Maria University
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BENEFITS GUIDE November, 1, 2021 - October 31, 2022
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Table of Contents
Introduction 1 Introduction to Benefits
Contacts 2 Who to Contact with Questions
Medical 3 Benefits & Costs
Dental 15 Benefits & Costs
Vision 18 Benefits & Costs
Health Savings Account 20 Understanding HSAs
Flexible Spending Accounts 23 Understanding FSAs
HSA vs. FSA 24 Comparison of Accounts
Life Insurance 25 Benefits & Costs
Disability 28 Benefits & Costs
Accident 30 Benefits & Costs
Critical Illness 31 Benefits & Costs
Group Indemnity Medical 33 Benefits & Costs
Eligibility & Enrollment 34 Who’s Eligible, How & When to Enroll
ADP Workforce Now 35 Step-by-Step Instructions
Introduction
Ave Maria University is pleased to offer our employees an exceptional benefits
program. Through Ave Maria University, you are eligible to elect Medical, Dental,
Vision, HSA, FSA, Voluntary Life, and/or Allstate Benefits.
Ave Maria University provides employees with Life and AD&D, Short Term Disability,
Long Term Disability, Adoption Assistance, and Teladoc benefits. These benefits are
designed to help protect you and your family while you’re employed with Ave Maria
University.
It is very important to think about the needs of your family when making decisions
about your benefits. We encourage you to read the following materials about the
benefits, your contributions, and the coverages carefully; please share this
information with your dependents.
Notice to all Plan Enrollees
The organization that sponsors or arranges your health plan has certified
that it qualifies for an injunction with respect to the Federal requirement
to cover contraceptive services without cost sharing. During this period,
coverage under your health plan will not include coverage of contraceptive
medications, devices, appliances, or other Health Care Services when
provided for contraception.
The information in this Enrollment Guide is presented for illustrative purposes and is based on
information provided by Brown & Brown of Southwest Florida. The text contained in this Guide was
taken from various summary plan descriptions and benefit information. While every effort was
taken to accurately report your benefits, discrepancies or errors are always possible. In case of
discrepancy between the Guide and the actual plan documents the actual plan documents will
prevail. All information is confidential, pursuant to the Health Insurance Portability and
Accountability Act of 1996. If you have any questions about your Guide, contact the HR Department.
1
CONTACTS
Ave Maria University HR
Jerilyn Schwarz Optum Rx
Director of Human Resources 1-800-791-7658
(239) 304-7074 optumrx.com
Jerilyn.Schwarz@avemaria.edu
Ave Maria University HR
MetLife Dental
Debbie Lennox
1-800-275-4638
(239) 280-2563
metlife.com/mybenefits
Debbie.Lennox@avemaria.edu
Brown & Brown of Southwest Florida
Eva Tutela VSP Vision
Benefits Consultant 1-800-877-7195
(239) 298-5094 vsp.com
etutela@bbswfla.com
Brown & Brown of Southwest Florida
Tim Cocchi First Florida Integrity Bank HSA
Senior Account Executive (239) 354-5250
(239) 213-2036 FirstFloridaIntegrityBank.com
tcocchi@bbswfla.com
UMR Medical WageWorks FSA
1-800-826-9781 1-800-950-0105
umr.com takecarewageworks.com
Mutual of Omaha Life & Disability
1-800-775-8805 Life
Teladoc 1-800-877-5176 Disability
1-800-835-2362 1-800-316-2796 EAP
teladoc.com 1-800-856-9947 Travel Assist
(312) 935-3658 Travel Assist
mutualofomaha.com
Click this video link or scan this QR Code Allstate Benefits
with your phone’s camera to launch the 1-800-348-4489
2021 Benefits Presentation:
https://youtu.be/ilB99XLQBcc allstateatwork.com/mybenefits
2
MEDICAL
Locate a Participating Provider:
• Go to umr.com
• Click on Find a Provider
• Select UnitedHealthcare Choice Plus Network
• Click on the View Providers button
Costs Per Pay Effective November 1, 2021
Individual1 Family2
Coverage Buy-Up Core
HDHP HDHP
Employee $83.74 $41.87 $28.71 N/A
Employee + Spouse $184.22 $108.86 N/A $77.74
Employee + Child/ren $165.08 $82.54 N/A $56.23
Employee + Spouse + Child/ren $259.57 $149.52 N/A $106.46
1
The HDHP has an Individual Deductible if you cover only yourself.
2
The HDHP has a Family Deductible if you cover one or more dependents. If you cover a spouse and/or
child/ren on the HDHP, the Family Deductible must be met before the plan begins to pay. The Family
Deductible can be satisfied by one family member or a combination of family members. Once the Maximum
is satisfied, all family members are covered at 100% - whether satisfied by one family member or a
combination of family members.
3
MEDICAL
Sample ID Card:
New members will receive a set of 2 ID cards. You may request
additional ID cards by logging into umr.com as a registered member.
You can also access a digital ID from your mobile phone; simply use
your mobile web browser to go to umr.com.
If you are currently enrolled, and you are not making any changes, you
will not receive a new ID card.
4
MEDICAL
Individual1 Family2
Buy-Up Core
HDHP HDHP
You Pay You Pay You Pay You Pay
Services
In-Network3 In-Network3 In-Network3 In-Network3
Calendar Year Deductible
- Individual $500 $1,000 $1,400 $2,800
- Family $1,500 $3,000 N/A $2,800
Coinsurance 20% 20% 20% 20%
Calendar Year Maximum
- Individual $2,500 $3,500 $5,000 $5,000
- Family $5,000 $7,000 N/A $5,000
The Calendar Year Maximum includes your Calendar Year Deductible, Coinsurance and all Copays. It is
the most you’re expected to pay for In-Network covered services between January 1 and December 31.
Preventive Care Covered at 100% Covered at 100% Covered at 100% Covered at 100%
Teladoc Consultations Covered at 100% Covered at 100% $49 per Consult $49 per Consult
Office Visits
- Primary Care $20 Copay $25 Copay Deductible + 20% Deductible + 20%
- Specialists $40 Copay $45 Copay
Urgent Care Facility $45 Copay $50 Copay Deductible + 20% Deductible + 20%
Emergency Room
- Facility $200 Copay $300 Copay Deductible + 20% Deductible + 20%
- Physician Deductible + 20% $100 Copay
Independent Lab Services Covered at 100% Covered at 100% Deductible + 20% Deductible + 20%
Independent Diagnostic
Testing Facility
$50 Copay $50 Copay Deductible + 20% Deductible + 20%
- X-ray
$150 Copay $200 Copay
- Advanced Imaging Services
1
The HDHP has an Individual Deductible if you cover only yourself.
2
The HDHP has a Family Deductible if you cover one or more dependents. If you cover a spouse and/or
child/ren on the HDHP, the Family Deductible must be met before the plan begins to pay. The Family
Deductible can be satisfied by one family member or a combination of family members. Once the Maximum
is satisfied, all family members are covered at 100% - whether satisfied by one family member or a
combination of family members.
3
Non-Network benefits are subject to a separate and higher Deductible, Coinsurance, and Maximum - plus
balance-billing.
5MEDICAL
Individual1 Family2
Buy-Up Core
HDHP HDHP
You Pay You Pay You Pay You Pay
Services
In-Network3 In-Network3 In-Network3 In-Network3
Ambulatory Surgical Center
- Facility $100 Copay $150 Copay Deductible + 20% Deductible + 20%
- Physician Deductible + 20% $45 Copay
Outpatient Hospital Facility
- Facility $200 Copay Deductible + 20% Deductible + 20% Deductible + 20%
- Physician Deductible + 20% $100 Copay
Inpatient Hospital Facility
- Facility $600 Copay Deductible + 20% Deductible + 20% Deductible + 20%
- Physician Deductible + 20% $100 Copay
Prescription Drugs
Deductible, then: Deductible, then:
Retail 30 days
$10 Copay $10 Copay $10 Copay $10 Copay
- Generic
$50 Copay $50 Copay $50 Copay $50 Copay
- Preferred
$80 Copay $80 Copay $80 Copay $80 Copay
- Non-Preferred
Prescription Drugs
Deductible, then: Deductible, then:
Mail Order 90 days
$25 Copay $25 Copay $25 Copay $25 Copay
- Generic
$125 Copay $125 Copay $125 Copay $125 Copay
- Preferred
$200 Copay $200 Copay $200 Copay $200 Copay
- Non-Preferred
1
The HDHP has an Individual Deductible if you cover only yourself.
2
The HDHP has a Family Deductible if you cover one or more dependents. If you cover a spouse and/or
child/ren on the HDHP, the Family Deductible must be met before the plan begins to pay. The Family
Deductible can be satisfied by one family member or a combination of family members. Once the Maximum
is satisfied, all family members are covered at 100% - whether satisfied by one family member or a
combination of family members.
3
Non-Network benefits are subject to a separate and higher Deductible, Coinsurance, and Maximum - plus
balance-billing.
6WHEN CAN I USE TELADOC?
So many reasons • When you need care now
• If your doctor is unavailable
to use Teladoc®! • If you’re considering the ER or
urgent care center for a non-
emergency issue
• On vacation, on a business trip,
Teladoc gives you 24/7/365 access to a doctor or away from home
• For short-term prescription
through the convenience of phone or video consults. refills
It's an affordable option for quality medical care.
GET THE CARE YOU NEED
Teladoc doctors can treat many
medical conditions, including:
• Cold & flu symptoms
• Allergies
• Bronchitis
Talk to a doctor anytime, Receive quality Prompt treatment, • Skin problems
anywhere you happen to care via phone or average call back in • Respiratory infection
be online video 16 min • Sinus problems
• And more!
SHARE WITH YOUR PCP
With your consent, Teladoc is
happy to provide information
A network of doctors Secure, personal and No limit on about your Teladoc consult to
that can treat children portable electronic consults, so your primary care physician.
of any age health record (EHR) take your time
Talk to a doctor anytime for Free
Teladoc.com 1-800-Teladoc
Facebook.com/Teladoc Teladoc.com/mobile
© 2015 Teladoc, Inc. All rights reserved. Teladoc and the Teladoc logo are trademarks of Teladoc, Inc. and may not be used without written permission. Teladoc does not replace the primary care
7
physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA
controlled substances, non therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse 10E-103A
of services. Teladoc phone consultations are available 24 hours, 7 days a week while video consultations are available during the hours of 7am to 9pm, 7 days a week. 0914MEDICAL
1. Stay In-Network! Prior to every service, verify the provider that is treating you is In-Network. Your
Medical network is UnitedHealthcare Choice Plus. It is your responsibility to verify your providers
participate in your network – even when your physician refers you to a specialist or lab. Ask the
provider if they “participate” in your network; do not ask if they “accept” your insurance. You can
search for participating providers online at umr.com.
2. Coverage Outside of Florida! Your coverage works outside of Florida. As long as the out-of-state
provider participates in their state’s UnitedHealthcare Choice Plus network, your In-Network benefits
apply. Search for National Providers at umr.com.
3. Urgent Care vs Emergency Room (ER)! Emergency Room Visits are more expensive and take more
time than an Urgent Care Center. Save the ER visits for a true medical emergency. Plan ahead and
verify the hours of operation of the participating Urgent Care Center near your home or office.
4. Pricing Tool! Use the myHealthcare Cost Estimator (myHCE) online tool to get cost estimates for
treatments and procedures based on your health plan. Know before you owe.
5. Preventive Care! Wellness services are covered at 100% In-Network. Mammograms are covered at
100% whether routine or diagnostic, In-Network or Out-of-Network. A routine colonoscopy is covered
at 100% for individuals age 50 and older once every 10 years, In-Network or Out-of-Network.
6. Preferred Lab! LabCorp and Quest Diagnostics are the preferred labs for UMR. Make sure you’re going
to a LabCorp or Quest drawing station, or ask your provider to send your lab work to LabCorp or Quest
to avoid unnecessary costs.
7. Disease Management! Once you are identified as having a chronic condition, you are automatically
enrolled into the Disease Management Program. You will receive an introduction letter and a follow-up
telephone call from a registered nurse. For more information on the Disease Management Program, call
1-866-575-2540.
8. Prior Authorization! UMR requires prior authorization on Advanced Imaging Services (AIS): MRI,
CAT, PET. Your physician is responsible for obtaining the authorization. If the AIS is denied, the
radiology group will provide an alternate method of treatment. If your physician feels strongly that you
need the AIS, have your physician call and request a “peer-to-peer review”. The number your
physician should call is 1-866-494-4502.
8MEDICAL
9. Monthly EOBs! Don’t pay a provider bill without first matching it to your UMR Explanation of Benefits
(EOB). You can view your EOBs online at umr.com.
10. Customer Service! If you have a claim or benefit question, contact UMR at 1-800-826-9781. If you
are not satisfied with the results after speaking with UMR, please contact Brown & Brown of
Southwest Florida.
11. Fill Generic! When prescribed a new medication, ask your provider for samples. If the new
medication works, ask for the Generic. When a prescription is filled with a Brand name medications
when a Generic is available, you will pay the Brand copay, plus the difference in cost between the
Brand and Generic. If you haven’t met your deductible, you will pay the Brand cost and receive credit
for the Generic cost toward the deductible. If you cannot take Generic, have your physician write
“Medically Necessary” on your Brand prescription to avoid unnecessary costs.
12. Prescription Savings! Publix provides several medications for free, including antibiotics,
Amlodipine, Lisinopril and Metformin. Publix also offers a 90-day supply of select medications for
$7.50. Many Generic medications are available for $4 at Walmart and Winn Dixie. Walgreens has a
prescription savings club where members can get a 90-day supply of many Generics for $10.
Prescription savings are also available with your AAA membership. For brand names drugs you may
find manufacturer assistance at needymeds.org, blinkhealth.com, and goodrx.com. Visit fsastore.com
or hsastore.com to learn which over the counter items are eligible for purchase with your FSA or HSA
funds; learn which products require a prescription for purchase with FSA or HSA funds.
13. Pharmacy Programs! UMR has programs in place to help control costs. When filling a prescription
with UMR for the first time, refer to the Prescription Drug List (PDL) to see if your medication requires
prior authorization, has a quantity limitation, requires you try an alternate medication first (step-
therapy), or is a specialty pharmacy medicine that is only covered when filled through Optum’s
Specialty Pharmacy. You can view the PDL online at umr.com. If you have questions regarding your Rx
coverage, you can call Optum, the Pharmacy Benefit Manager for UMR, 24/7 at 1-877-559-2955.
9Check. Choose. Go. SM
When you need care, call your primary care physician or family doctor first.
Your physician has easy access to your records, knows the bigger picture of your health and may even offer same-day appointments
to meet your needs. When seeing your physician is not possible, however, it’s important to know your quick care options to find the
place that’s right for you and help avoid financial surprises.
Quick Care Options Needs or Symptoms Average Cost*
• Choosing where to get • Health and wellness help
24/7 Nurse Line
Call the number on your health
medical care
• Finding a doctor
• Answers to questions
about medicines 0
$
plan ID card for expert advice. or hospital
Virtual Visits • Cold • Pinkeye
Anywhere, anytime online
doctor visits.
• Flu
• Fever
• Sinus problems $
50
Convenience
Care Clinic
• Skin rash
• Flu shot
• Minor injuries
• Earache
$
65
Treatment that’s nearby.
• Low back pain • Infections
Urgent Care Center • Respiratory (skin, eye, ear/nose/throat,
genital-urinary)
190
$
(cough, pneumonia, asthma)
Quicker after-hours care. • Minor injuries
• Stomach
(burns, stitches, sprains,
(pain, vomiting, diarrhea)
small fractures)
Emergency Room (ER) • Chest pain • Major burns
For serious immediate needs. • Shortness of breath
• Severe asthma attack
• Severe injuries
• Kidney stones
$
1,700
Freestanding ERs Ask before you enter:
Many people have been surprised by their bill after visiting a freestanding emergency room (FSER). • Is this an urgent care center
FSERs, sometimes referred to as urgency centers, typically bill at ER rates (or higher) and can be or an ER?
$1,500 more than an Urgent Care Center. Neither located in nor attached to a hospital, FSERs are
able to treat similar conditions as an ER but do not have an ER’s ability to admit patients. • Is this facility a
network provider?
10myHealthcare Cost
Estimator (myHCE)
Your window to cost
transparency and quality care
myHealthcare Cost Estimator (myHCE) is an online tool that gives you easy
access to the information you need to make informed health care decisions.
It shows cost estimates for hundreds of treatments and procedures based INSTRUCTIONS ON
on the contracted rates your health plan has negotiated with providers ACCESSING TOOL …
and medical facilities. The estimate also accounts for your deductible, You can begin using myHCE
out-of-pocket maximum, co-pay/co-insurance, paid or remaining amounts. right away by visiting
umr.com and logging into
At UMR, we focus not only on cost, but also quality of care. When selecting your member site. Just look
your doctor in the tool, you are able to view both Premium Care Physicians for the shopping cart icon on
and other in-network medical providers. Our quality and cost efficiency your personal home page.
measurements make sure that you get the best service at a reasonable price.
Health
cost estimator
These cost and quality efficient providers can be identified in the tool with
a stamp and are part of your designated network. Premium Care
Physicians are doctors in your network who offer their services at a lower
co-pay/co-insurance than other in-network doctors. They have also been
screened for quality service.
myHCE can help you through every step of your treatment. It allows you to
find treatment options and learn about recommended care. You can even
create and save a care path to track the appointments, tests and follow-up
care related to your health needs.
11Utilization management updates - July 1, 2019
Step therapy — Select
Most medical conditions have many medication options. Although
their clinical effectiveness may be the same, the cost can be very
different. The Step Therapy program gives you the treatment you
need, usually at a lower cost.
Here’s how it works:
With this program, you must try a Step 1 medication first, before a
Step 2 medication may be covered. When you bring a prescription
to your pharmacy, our system will check the medication for step
therapy requirements. If your old pharmacy claims show you have
tried a Step 1 medication in the recent past, the Step 2 medication
may be filled. If not, the pharmacist will contact your doctor to
explain next steps.
We encourage you to talk about your treatment and medication
options with your doctor. If you have questions about the Step
Therapy program, call the phone number on your member ID card.
Select Formularies
12Discover the convenience of
OptumRx® Mail Service Member SelectSM
Mail Service Member Select is a home delivery program that makes it easy for you to
receive your ongoing medications by mail. This program will save you time and help
you better manage the medication you take regularly. Not only is home delivery safe
and reliable, it also offers the following advantages:
Cost savings: You may pay less for your medication with a three-month
supply through OptumRx.
Convenience: Get free standard shipping on medications delivered
to your mailbox.
24/7 access and reminders: Speak to a pharmacist who can answer your
questions any time, any day. Even set up text and email reminders to help
you remember to take or refill your medications.*
Choose your fill preference
You can choose to fill your maintenance medication through either OptumRx or a retail
pharmacy. If you choose a retail pharmacy, you must disenroll from the Mail Service
Member Select program.
The program allows you two retail pharmacy fills of your maintenance medication
before you must choose. If you do not take action after the second retail fill, you may
pay more for your medication until you make a decision.
13Making the choice
To choose home delivery, use any of the following options.
By online registration:
Visit optumrx.com, register and follow the simple step-by-step
instructions. You can manage your medication online, including
filling new prescriptions and transferring other prescriptions to
home delivery. You can also set up text message reminders to help
manage your medication schedule. Be sure to have your health plan
ID card and medication bottles on hand.
By phone:
Just call the member phone number on the back of your plan ID
card to talk with a customer service representative right now. It’s
helpful to have your plan ID card and medication bottle available.
The representative can also contact your doctor directly if you need
a new prescription.
By mail:
Ask your doctor for a new prescription for up to a three-month
supply, plus refills for up to one year. Then go to optumrx.com
and download the new prescription order form. Mail it to the address
provided on the bottom of the form.
By fax / ePrescribe:
Ask your doctor to call 1-800-791-7658 for instructions on how to
fax your prescription directly to OptumRx. Or your doctor can send
an electronic prescription to OptumRx.
To disenroll from Mail Service Member Select, contact OptumRx by calling the
member phone number on the back of your ID card or visit optumrx.com to
manage your home delivery options under My Account.
*OptumRx provides this service at no cost. Standard message and data rates charged by your carrier may apply.
optumrx.com
OptumRx specializes in the delivery, clinical management and affordability of prescription medications and consumer health
products. We are an OptumTM company — a leading provider of integrated health services. Learn more at optum.com.
All OptumTM trademarks and logos are owned by Optum, Inc. All other brand or product names are trademarks
or registered marks of their respective owners.
© 2015 Optum, Inc. All rights reserved. ORX7321-MSMS_150608 49995-082015
14DENTAL
Locate a Participating Provider:
• Go to metlife.com
• Click on Dentist under I want to find a MetLife...
• Enter the Zip, City or State you want to search
• Select PDP Plus as your Network
• Click the Submit button
Costs Per Pay Effective November 1, 2021
Coverage High Plan Low Plan
Employee $11.23 $3.91
Employee + Spouse $33.84 $10.80
Employee + Child/ren $34.98 $9.57
Employee + Spouse + Child/ren $60.17 $16.59
15DENTAL
High Plan Low Plan
Services Services
You Pay1 You Pay1
$50 per person $50 per person
Calendar Year Deductible Calendar Year Deductible
$150 per family $150 per family
Preventive Preventive
Exams, X-rays, Cleanings, Covered at 100% Exams, X-rays, Cleanings, Covered at 100%
Fluoride, Space Maintainers Fluoride, Space Maintainers
Basic
Basic
Sealants, Fillings, Root
Sealants, Fillings, Oral
Canal, Periodontics, Oral Deductible, then 20% Deductible, then 20%
Surgery (Simple),
Surgery, General
Periodontal Maintenance
Anesthesia
Major
Root Canal, Periodontics,
Major
Crowns/Inlays/Onlays,
Crowns/Inlays/Onlays,
Deductible, then 50% Oral Surgery (Complex), Deductible, then 50%
Bridges, Dentures and
General Anesthsia,
Implants
Bridges, Dentures and
Implants
Orthodontia 50% up to $1,000 Orthodontia
Not Covered
Children up to age 19 Lifetime Maximum Children up to age 19
Plan Pays Plan Pays
90th Percentile of
Out-of-Network Out-of-Network
Usual Customary and Fee Schedule
Reimbursement Reimbursement
Reasonable
Calendar Year Calendar Year
Maximum $5,000 per person Maximum $1,000 per person
Preventive, Basic & Major Preventive, Basic & Major
Predetermination of Benefits: Before treatment begins for inlays, onlays, single crowns,
prosthetics, periodontics and oral surgery, your provider should file a dental treatment plan
with MetLife. MetLife will provide a written response indicating benefits that may be
payable for the proposed treatment. Ask your Dental Provider to submit a predetermination of
benefits.
1
Out-of-Network services are subject to balance-billing.
Please see your complete MetLife benefit summary for coverage guidelines, located on ADP.
16Dental Insurance
Dental information available
through the MetLife Mobile App
Viewing your dental plan just got easier with the MetLife Mobile App.1
You can:
• Find a dentist
• Get estimates for most procedures
• View your plan summary
• View your claims
• Track your brushing and flossing
• View your ID card
It’s easy! Search “MetLife” at iTunes App Store or Google
Play to download the MetLife US Mobile App, or scan the
QR codes. Search our network of thousands of dentists
and specialists to find a provider near you.
Or log-in to MyBenefits to access your plan information.1
It’s available 24 hours a day, seven days a week.
1. To use the MetLife mobile app, employees can choose to register at metlife.com/mybenefits from a
computer or directly through the app. Certain features of MetLife US Mobile App are not available for
some MetLife Dental Plans.
Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain
exclusions, exceptions, waiting periods, reductions, limitations and terms for keeping them in force.
Please contact MetLife or your plan administrator for complete details.
Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166
L0118502349[exp0119][All States][DC,GU,MP,PR,VI] © 2018 METLIFE, INC.
17VISION
Locate a Participating Provider:
• Go to vsp.com
• Click on Find a Doctor
• Search by Location, Office or Doctor
Costs Per Pay Effective November 1, 2021
Coverage Low Plan High Plan
Employee $1.45 $6.06
Employee + One $2.90 $10.27
Employee + Child/ren $2.90 $10.42
Employee + Spouse + Child/ren $4.32 $16.45
18VISION
Services Basic Premier
$10 Copay $10 Copay
Eye Exam every 12 months every 12 months
Materials $25 Copay $25 Copay
Materials Copay then Materials Copay then
$130 allowance with $180 allowance with
Frames 20% off the remaining 20% off the
balance remaining balance
every 24 months every 12 months
Lenses: Single, Bifocal, Materials Copay Materials Copay
Trifocal, Lenticular every 12 months every 12 months
Progressives 20-25% Discount $0
Scratch Resistant Coating,
Anti-Reflective Coating, 20-25% Discount $0
Tints, and Photochromics
$130 allowance $180 allowance
Contacts in lieu of glasses every 12 months every 12 months
Contact Lens Fitting & 15% discount 15% discount
Evaluation Capped at $60 Capped at $60
Extra $20 toward featured frame brands
Mail-in rebate savings for contacts
20% off additional Rx glasses and non-Rx sunglasses
15-20% off LASIK
ID Cards are Not Issued - locate a participating VSP provider, and when you make your
appointment, tell them you’re a member of VSP
1
See the detailed VSP benefit summary on ADP for out of network reimbursement.
19HEALTH SAVINGS ACCOUNT
Employees who participate in the HDHP may be eligible to set aside money in a Health Savings
Account (HSA). The money you contribute to an HSA is exempt from taxes; you save on FICA and
Federal taxes when contributing through payroll, and you spend the money tax-free when you
spend it on qualified expenses.
Qualified expenses include unreimbursed medical, dental and vision expenses incurred by you and
your eligible dependents - even if you don’t cover your dependents. An HSA is similar to a Flexible
Spending Account (FSA); however, the HSA is a personal bank account, not a plan, so there’s no
“use-it or lose-it” rule. The money in your HSA remains in your HSA until you’re ready to spend it;
there’s no time limit. If you change jobs or retire, you take the HSA with you.
HSA funds can also be spent on Medicare, Cobra and Long Term Care insurance premiums.
The HSA is not an automatic feature of enrolling in the HDHP; it is a separate application that you
must make with First Florida Integrity Bank.
If you would like to have funds deducted from your paycheck, on a pre-tax basis, and directly
deposited into your HSA, you must provide payroll with your HSA account and routing numbers.
Similar to other direct deposits you may have set-up through payroll, you can increase, decrease,
start or stop your HSA contributions throughout the year.
Who is eligible to open and fund a HSA?
Anyone who is:
• covered by a qualified high deductible health plan (HDHP), and
• not covered under another medical plan that is not a qualified HDHP - including Medicare,
Medicaid, TriCare, VA and/or a general purpose Health Care Flexible Spending Account (FSA)
What happens if I am currently participating in an FSA; when can I open the HSA?
• If you are only participating in the Dependent Care FSA, you can open the HSA as of your
effective date in the qualified HDHP
• If you are participating in the Health Care FSA, you cannot open the HSA until the FSA plan
year ends and your FSA balance is $0
• The Ave Maria University FSA plan year ends 10/31/2021; however, there is a 2.5 month
extension during which you can spend the remaining funds (through 1/15/2022). If you have
funds in your FSA on 11/1/2021, you cannot open the HSA until 2/1/2022 - the first of the
month following the extension
20HEALTH SAVINGS ACCOUNT
How much can I contribute to a HSA?
The IRS sets a contribution limit every calendar year. For 2021, the contribution limits are:
• $3,600 for Individual Coverage - just you on the plan (2022 limit will be $3,650)
• $7,200 for Family Coverage - you and any number of dependents (2022 limit will be $7,300)
• If you’re age 55 or older, you can contribute up to $1,000 more than the limits listed here
What if I establish a HSA mid-year?
Your HSA contributions are generally determined on a monthly basis. If you establish an HSA
mid-year, you’re allowed to make the full year’s contribution, provided you are eligible on
December 1 of that year and you remain eligible to make HSA contributions throughout the next
calendar year.
How do I make contributions to my HSA?
You can contribute to your HSA through payroll deductions.
Where can I find a list of qualified expenses?
Refer to the list found at irs.gov - search Publication 502.
When can I start using the funds in my HSA?
You can use the funds in your HSA once they are available. If you incur expenses under the
qualified HDHP prior to having enough funds in your HSA, you can reimburse yourself months or
years later, once you do have the funds available - so long as you were enrolled in the qualified
HDHP at the time of service and the HSA was established at the time of service.
Can I use my HSA to pay for non-qualified expenses?
Money withdrawn from a HSA for non-qualified expenses is taxable and subject to a 20%
penalty. Although the 20% penalty goes away at age 65, the non-qualified expenses are always
subject to income tax.
21HEALTH SAVINGS ACCOUNT
What happens to my HSA if I leave my employer?
The HSA is yours to keep. If you continue to meet the eligibility criteria for funding the account, you
can continue making contributions to your HSA. If you are no longer eligible to fund the account,
you’re still eligible to spend the money (tax-free) on qualified expenses.
Can I use the money in my HSA to pay for my dependents’ health care expenses?
You can use the money in your HSA to pay for the health care expenses belonging to your eligible
spouse and/or dependent children - even if they are not covered as your dependents. Refer to
Internal Revenue Code Section 152 to determine if your spouse and/or child is an eligible
dependent.
Can couples establish a “joint” HSA and both make contributions, including “catch-up”
contributions?
“Joint” HSAs are not permitted. Each spouse should consider establishing an HSA in his or her own
name. This allows you to both make catch-up contributions when you are age 55 or older.
For more information on HSAs, visit:
• irs.gov - search Publication 969 for a detailed explanation of HSAs
• hsacenter.com - view videos, presentations, and frequently asked questions
22FLEX SPENDING ACCOUNTS
You may have the opportunity to pay for out-of-pocket Medical, Dental, Vision, and/or Dependent
Care expenses with pre-tax dollars through the Flexible Spending Account (FSA).
Note: If you will be funding an HSA, you cannot participate in the Health Care FSA.
Plan Year: November 1, 2021 to October 31, 2022
Health Care Contribution Limit: $2,750
Dependent Care Contribution Limit: $5,000
A Health Care FSA is used to reimburse out-of-pocket health care expenses incurred by you, your
spouse and/or your children; whether you cover them or not. Eligible expenses include deductibles,
coinsurance, copays, etc… Your Health Care pledge is pre-loaded to a debit card; you have
immediate access to the funds and will pay them back throughout the year via payroll deduction.
A Dependent Care FSA is used to reimburse work related expenses; while you or your spouse
work, look for work or attend school full-time or are physically unable to care for your dependent.
Eligible children are under age 13, or a dependent who is physically or mentally not able to care for
himself. Eligible expenses include nanny, nursery school, before care/after care, late pick-up fees,
day camp, or day care. Your Dependent Care pledge is not pre-loaded to a debit card; you can only
access what has been payroll deducted and is in your FSA.
Contributions to your FSA come out of your paycheck before any taxes are taken out. This means
that you don’t pay federal income or FICA taxes on the portion of your paycheck you contribute to
your FSA.
You should contribute the amount of money you expect to pay out-of-pocket for eligible expenses
incurred during the Plan Year: November 1, 2021 to October 31, 2022. If you still have money in
the account at the end of the Plan Year (on October 31, 2022), you will have a 2.5 month
extension to incur additional eligible expenses. Any money remaining in the account when the
extension ends on January 15, 2023 is forfeited; this is the “use-it or lose-it” rule.
Do your homework and consider known expenses. Make an informed decision when you elect your
pledge for the year. FSA elections can only be changed during Open Enrollment or due to a
Qualifying Event.
23HSA VS. FSA
Health Savings Account Flexible Spending Account
HSA FSA
Plan Requirements Qualified HDHP N/A
Cannot be enrolled in any other
Other Requirements N/A
health insurance - including an FSA
Account Owner You Employer
Unreimbursed Medical, Dental and
Vision Unreimbursed Medical, Dental and
Qualified Expenses
As well as some insurance premiums: Vision
Medicare, Long Term Care and Cobra
OTC Medicines Yes Yes
2021:
$3,600 Individual
$7,200 Family
2021 & 2022 Annual Plus $1,000 Catch-Up at age 55
$2,750
Contribution Limits 2022:
$3,650 Individual
$7,300 Family
Plus $1,000 Catch-Up at age 55
Access to Funds Available balance only Up front availability
Yes, but taxable and subject to a
Ability to Use Funds for
20% penalty No
Non-Qualified Expenses
(no penalty after age 65)
Ability to Change Open Enrollment only, or
Same as All Direct Deposit Banking
Pledge due to a qualified event
Rollover of Funds Yes 2.5 Month Extension
Submit receipts when requested by
Recordkeeping Retain receipts in case of IRS audit
Plan Administrator
Legal Spouse and Dependent Legal Spouse and Dependent
Eligible Dependents
Children (IRC Section 152) Children (IRC Section 152)
24BASIC LIFE INSURANCE
Ave Maria University provides employees with group life and accidental death and
dismemberment (AD&D) coverage.
The benefit is one times your annual salary to a maximum of $500,000.
Benefit amounts in excess of $400,000 are subject to Evidence of Insurability
(EOI). Your benefit amount will reduce to 65% at age 70, and to 50% at age 75.
If you leave the company, you may be eligible to convert this benefit to an
individual policy and take it with you. You have 30 days, following your termination
date, to contact Mutual of Omaha regarding your conversion rights.
25VOLUNTARY TERM LIFE
You may purchase additional life insurance. You can also elect coverage for your
legal spouse and/or eligible children. Rates are based on the spouse and all children.
Note: You do not lock in your rate at your purchase age; as you get older, and enter
a new age bracket, your premiums increase.
Employee Minimum Benefit: $10,000
Employee Maximum Benefit: $500,000 - not to exceed 5 times your salary
Employee Guarantee Issue Benefit: $150,000 - not to exceed 5 times your salary
***The Guarantee-Issue benefit is only available for new hires.***
Your benefit amount will reduce to 65% at age 70, and to 50% at age 75.
For a cost of $1.11 per pay, you can elect a $10,000 benefit for your legal spouse
and a $5,000 benefit for each of your eligible children.
Guarantee Issue benefits are only available during your initial, new hire, eligibility
period. If you are a new hire and are applying for a benefit in excess of the
Guarantee Issue benefit, the additional benefit will be subject to approval. You must
provide Evidence of Insurability (EOI). If the additional benefit is denied, you are still
eligible to receive the Guarantee Issue benefit. If approved, the additional benefit
takes effect on the first of the following month.
If you elect voluntary life insurance at hire, but less than $150,000, you may
increase your benefit by up to $10,000 once each annual open enrollment, until you
reach $150,000 in coverage, without underwriting.
If you apply for coverage outside of your initial eligibility period, or if you increase
your benefit by more than $10,000, your application will be subject to approval of
your EOI. Once approved, coverage takes effect on the first of the following month.
You may complete your EOI online at mutualofomaha.com/eoi - reference Group ID
Number G000ASUY.
26VOLUNTARY TERM LIFE
27SHORT TERM DISABILITY
Benefits Begin On the 1st day for an off-the-job injury; on the 8th day for an illness
Benefits Payable 66.67% of weekly earnings
Maximum Benefit $750 per week
Benefit Duration 26 weeks
Ave Maria University provides this benefit to all eligible employees, at no cost to the employee.
LONG TERM DISABILITY
Benefits Begin After 180 days for an off-the-job injury or an illness
Benefits Payable 60% of monthly income
Maximum Benefit $10,000 per month
Benefit Duration Social Security Normal Retirement Age
Ave Maria University provides this benefit to all eligible employees, at no cost to the employee.
The disability benefits will be taxable. A Certification of Health Care Provider Form, completed by
you and your provider, must be returned to HR prior to your disability leave. A release to work
note from your physician is required before you can return to work.
28Basic Employee Assistance Program
Life’s not always easy. Sometimes a personal or professional issue can get in the way of
maintaining a healthy, productive life. Your Employee Assistance Program (EAP) can be the
answer for you and your family.
Experienced EAP Staff EAP Benefits
Master’s level professionals who can provide assistance for a >Unlimited telephone access to EAP professionals
variety of personal and professional matters. 24 hours a day, seven days a week
>/15,10$.8(..%(,0* > (.(2+10($44,45$0&($0'3()(33$.
>$/,.:$0'3(.$5,104+,24 > (37,&()13(/2.1:((4$0'(.,*,%.('(2(0'(054
>(*$.$0'),0$0&,$. >(*$.$44,45$0&($0'),0$0&,$.4(37,&(4
>($.5+:.,)(45:.(4
>"13-$0'.,)(53$04,5,104
> (4163&(4)13
>Access to a library of educational articles, handouts and
resources via website
What to Expect
Information gathered by the EAP is confidential – the EAP
does not communicate with your employer about your
situation unless there is a risk of harm to you or others.
Your EAP benefits are provided through your employer.
+(3(,4no cost to you for utilizing EAP services. If
additional resources are needed, your EAP will help locate
appropriate providers in your area.
Benefits that
work SM
Don’t delay if you need help. Visit mutualofomaha.com/eap or call 800-316-2796 for confidential
consultation and resource services.
Insurance products and services are offered by Mutual of Omaha Insurance Company or one of its affiliates. Home Office:
Mutual of Omaha Plaza, Omaha, NE 68175. Mutual of Omaha Insurance Company is licensed nationwide. United of Omaha Life
Insurance Company is licensed nationwide, except New York. Companion Life Insurance Company, Hauppauge, NY 11788-2937,
is licensed in New York. Each underwriting company is solely responsible for its own contractual and financial obligations. Some
exclusions or limitations may apply.
29 �
MUGC9480ALLSTATE BENEFITS
Accident
Initial Hospital Confinement $2,000
Hospital Confinement $800 per day - 90 days max
ICU Confinement $1,600 per day - 90 days max
Dislocations & Fractures Up to $8,000 EE / $4,000 SP / $2,000 CH
Medical Expenses Up to $600 per accident per calendar year
Ambulance $800 Ground / $2,400 Air
Follow-up Accident Treatment $200 per visit - 2 visit max per incident
Common Carrier Accidental Death $500,000 EE / $250,000 SP / $125,000 CH
Accidental Death $100,000 EE / $50,000 SP / $25,000 CH
Accidental Dismemberment Up to $200,000 EE / $100,000 SP / $50,000 CH
Outpatient Physician’s Treatment $50 per visit - limited to 2 visits per person and
- any type of office visit 4 visits per family per calendar year
Coverage Costs Per Pay
Employee $6.70
Employee + Spouse $12.42
Employee + Child/ren $11.36
Employee + Spouse + Child/ren $17.06
30ALLSTATE BENEFITS
Critical Illness
The benefit is $10,000. If diagnosed with a covered condition, you are eligible for the benefit.
Benefits are payable for each covered condition as long as the diagnosis is separated by 90 days.
If you cover your dependents, they are eligible for half of your benefit amount: $5,000.
There’s no additional cost to cover your child/ren through age 26.
Each covered person is eligible to receive a $50 wellness benefit, every calendar year,
when one of 23 specific preventive services is performed.
A second event benefit is payable, once per condition, if the second event is more than 12 months
after the first diagnosis.
Covered Conditions Benefit Percentage
Advanced Alzheimer’s Disease, Advanced Parkinson’s Disease, Coronary
25%
Artery By-Pass Surgery, Carcinoma in Situ1
Invasive Cancer1, Heart Attack, Benign Brain Tumor, Coma, Complete
Blindness, Complete Loss of Hearing, Paralysis, Stroke, Major Organ 100%
Transplant, End Stage Renal Failure
Pre-existing conditions are not covered during the first 12 months of the policy. A condition is
considered pre-existing if it existed in the 12 months prior to the effective date of the policy.
1
The Cancer Critical Illness benefits are payable for a diagnosis of a new or a recurrence of cancer,
as long as you are diagnosed after the effective date of coverage, and have been free of any
symptoms and treatment of cancer for 12 consecutive months immediately preceding the effective
date of coverage, or any 12 consecutive months.
Rates are based on age and tobacco use. Rates are locked in at your purchase age.
See next page for rate table.
Guarantee-issue benefits are only available during your initial, new hire, eligibility. If
you apply for coverage outside of your initial eligibility, you will need to provide
Evidence of Insurability (EOI).
31ALLSTATE BENEFITS
Critical Illness Costs Per Pay
Non-Tobacco Tobacco
Issue Age
Costs per Pay Costs per Pay
EE & EE/CH EE/SP & ESC EE & EE/CH EE/SP & ESC
18-24 $2.16 $3.14 $2.90 $4.24
25-29 $2.24 $3.30 $2.98 $4.40
30-35 $2.82 $4.18 $3.86 $5.74
36-39 $3.70 $5.52 $5.52 $8.22
40-44 $4.88 $7.32 $7.50 $11.26
45-50 $6.82 $10.22 $10.88 $16.26
51-54 $9.38 $13.98 $14.70 $21.82
55-60 $12.42 $18.56 $20.26 $30.24
61-70 $16.60 $24.74 $24.42 $37.90
71+ $24.86 $37.12 $35.94 $54.00
EE = Employee
EE/CH = Employee + Child/ren
EE/SP = Employee + Spouse
ESC = Employee + Spouse + Child/ren
Rates are locked in at your purchase age.
32ALLSTATE BENEFITS
Group Indemnity Medical
Plan 1 Benefits
Initial Hospital Confinement $1,100 - once per person per year
Daily Hospital Confinement $100 - limited to 10 days per year
Daily ICU Confinement $100 - limited to 10 days per year
Plan 2 Benefits
Initial Hospital Confinement $2,200 - once per person per year
Daily Hospital Confinement $200 - limited to 10 days per year
Daily ICU Confinement $200 - limited to 10 days per year
No pre-existing condition limitations. No underwriting required.
Plan 1 Plan 2
Coverage
Costs per Pay Costs per Pay
Employee Only $7.68 $15.36
Employee +Spouse $21.42 $42.84
Employee +Child/ren $13.26 $26.52
Employee + Spouse + Child/ren $22.98 $45.90
33Eligibility & Enrollment
Who is Eligible?
Regular full time employees, working 30 hours or more per week are eligible for Medical, Dental,
Vision, Life, HSA, FSA, Teladoc and Allstate Benefits; Disability benefits are provided to employees
working 35 hours or more per week. Benefits take effect on the first of the month following your
hire date. Your legal spouse and children are eligible to be covered as your dependents. Children
are eligible for Medical and Vision coverage through the end of the year in which they turn age 26,
and through the end of the month in which they turn age 26 for Dental and Allstate Benefits.
Child Voluntary Life benefits end at age 21, or 25 if the child is a full-time student.
Waiving Coverage
If you furnish evidence of other coverage, you are eligible to receive $15 per pay period for waiving
the Medical coverage and $2.50 per pay period for waiving the Dental coverage.
New Hire Enrollment:
Within 30 days of your hire date, you must log into the ADP Workforce Now benefit portal to
select or waive all benefit products. Go to https://workforcenow.adp.com and log in with your User
ID and Password.
Annual Open Enrollment:
Each year, employees have the opportunity to make changes to their benefit selections. During the
annual open enrollment period, all eligible employees must log into the ADP Workforce Now benefit
portal to complete their Open Enrollment selections. The benefits you select during Open Enrollment
will take effect November 1. Go to https://workforcenow.adp.com and log in with your User ID and
Password. The 2021 Open Enrollment selections must be completed no later than Tuesday,
October 12, 2021.
Qualifying Events
You cannot make changes to the benefits you select during your initial eligibility period or annual
open enrollment period - unless you experience a Qualifying Event. You must request a change in
benefits due to a Qualifying Event within 30 days of the event. Qualifying Events include getting
married, divorced, having a baby, losing insurance, as well as gaining insurance. If you think you’re
experiencing a qualifying event, contact HR immediately to request your change before it’s too late.
34ADP Workforce Now
Step 1: Go to the Myself tab and select Benefits
Step 2: Click the START button for Annual OE:
START
Step 3: You will begin with reviewing/editing your Dependents and Beneficiaries:
START
Step 4: You will then walk through each benefit product, making your elections:
If you have questions or trouble accessing the system, please contact the HR
Department via email or phone: Jerilyn Schwarz at Jerilyn.Schwarz@avemaria.edu or
(239) 304-7074; Debbie Lennox at Debbie.Lennox@avemaria.edu or (239) 280-2563.
35#
239-261-3000
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