Open Enrollment 2021 November 2-13, 2020 - Action Required or Lose Coverage - Whitley County Consolidated ...
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Open Enrollment
2021
November 2-13, 2020
Action Required or Lose Coverage
November
Sun Mon Tue Wed Thur Fri Sat
2 3 4 5 6 7
8 9 10 11 12 13
Review medical benefit options
and complete enrollment for 2021 Benefits!
OPEN ENROLLMENT
November 2-13, 2020
Your benefits are an important part of your employment
package. Your employer provides for your medical and
prescription benefits through the School Employees’ Benefit
Trust (SEBT).
ENROLLMENT WINDOW: All employees eligible for
Read inside for benefit coverage may enroll online for 2021 medical benefits during
options and how to enroll open enrollment. If you do not enroll or make changes during
this time frame, you must wait until the next open enrollment
period or until you experience a special enrollment/qualifying
Medical Plan Options event.
PPO: Network Deductible (NWD) WHAT IF I WANT TO KEEP MY SAME PLAN?
High Deductible Health Plan 1: HDHP1 If you review your information and do not want to make
High Deductible Health Plan 2: HDHP2 changes, you need to do nothing and your current eligibility
(Min. Value) and benefit elections will roll over to 2021.
WHAT IF I DECLINE COVERAGE IN THE HEALTH PLAN(S)?
Levels of Coverage Available Participation is optional. To decline any or all of the health
plans, you are required to complete a waiver online during open
Employee only enrollment.
Family
CAUTION:
The start date and your cost of
coverage depends on your contract Failure to complete online enrollment will result in an
with your employer. automatic waiver and will result in a loss of coverage
if currently enrolled.
PLEASE NOTE ADDITIONAL INFORMATION:
The rest of this brochure provides IMPORTANT information
regarding the enrollment process, plan options and eligibility
requirements for coverage under the plans for you and your
dependent spouse and children. If there is any discrepancy
between the information in this brochure and any official plan
document, the official plan document will control.
All Plan communications will be provided electronically to you
for review throughout the Plan Year, unless you notify your
Employer's Treasurer/Business Office/Benefit Representative
with a request to provide all or some plan communications in
paper hard-copy.
SEBT—Plan Year 2021 22
Who’s
Who’s Eligible?
Eligible? Mid-Year Changes
Dependent Eligibility for Medical Plan
Spouses who meet the criteria and children (up to age 26) are eligible for medical coverage.
Important Criteria
Special Eligibility Requirements for Retiree Coverage
Spouses in the Medical Plan Only Upon retirement, eligible retirees may
Spouses who are eligible for another employer- continue coverage under the Plan for
sponsored medical plan, retiree group, or disability themselves or their eligible spouse provided
medical plan must take that coverage on an individual the retiree or spouse elects in writing to
basis as primary insurance in order to be covered with continue coverage within 90 days from the
the SEBT Plan for secondary insurance, unless the date of retirement. The spouse of a retiree
spouse meets one of the criteria below: must be covered as a dependent under this
Plan for twelve (12) months prior to the
The spouse is also eligible for the SEBT Plan Employee’s retirement in order to be eligible
through his/her participating school. to continue coverage, unless enrollment
The spouse is not eligible for an employer- during that period is a result of a special
sponsored or retiree medical plan. enrollment event. Open Enrollment does
not apply to retiree coverage except to the
The other coverage would cost the spouse extent that a covered retiree or spouse
more than 60 percent of the total premium for decides to change between offered plans.
single coverage of the lowest cost plan.
The retiree and/or dependent spouse may
Premium does NOT include spousal incentives
be required to pay the full cost of such
or other such additional compensation, etc.
coverage. Effective 1-1-18, new retiree’s
forfeited upon enrollment in their own plan.
coverage will not cover dependent children
Note: If your spouse is currently enrolled and there will be no special enrollment/
in other coverage and contributing to a Health qualifying events permitting re-entry of a
Savings Account (HSA), and you enroll them retiree or spouse to the Plan after coverage
in your PPO Plan as secondary, IRS rules ends for whatever reason.
may preclude them from making or receiving
additional HSA contributions. In order to make
or receive HSA contributions, an individual
must only be covered by an HSA-qualified
health plan. For questions regarding spousal
secondary coverage when receiving HSA con-
tributions, please reach out to the Administra-
tive Support Team (AST) at 855-664-0012 or
email AST@planmanagementservice.com.
SEBT—Plan Year 2021 3
Mid-Year Changes
Making Changes When a Special Enrollment/Qualifying
Event Occurs During the Year
Your enrollment elections will remain in place for all of the calendar year enrolled.
You may only make changes to your plan throughout the year if you have a special
enrollment / qualifying event or family status change.
You need to submit the change within 31 days after the qualifying event (and
within 60 days to enroll a newly eligible dependent child). If you go beyond
the time limit, you will have to wait until the next open enrollment period to make
changes or additions.
Examples of a special enrollment / qualifying event (family status change):
Marriage
Divorce or legal separation
Loss of coverage (not dropping coverage voluntarily)
Death
Qualified Child Medical Support Order (QCMSO)
Legal guardianship
Newborn and adoption
Submit a Change During the Year
Log in to https://sebt-optimalhealth.benelogic.com
with your district-specific User ID and Password.
* Select Make a Change
Fraud Notice
Misrepresentation of eligibility through facts or verification documents may constitute fraud.
Coverage under the plan and/or employment can be terminated and the employee will be
responsible for the refund of claims paid in error.
SEBT—Plan Year 2021 4
Medical Plan Options
Medical Plan Options
Which Medical Plan is Right For You and Your Family?
Preferred
Provider With the PPO, you pay more out of your paycheck to “buy” the coverage,
PPO Organization and then less out of your pocket because you pay flat copays for routine
(NWD) (Network Deductible office visits and prescriptions. The PPO has the lowest deductible.
Plan)
Consumer With the HDHP1 plan, you pay less out of your paycheck to “buy” the
HDHP1 Directed coverage, and more out of your pocket for services.
High Deductible
Health Plan
Consumer The HDHP2 (Min. Value) plan has the highest deductible. Once the
HDHP2 Directed deductible is met, the Plan pays at 100%. There are no copays. This
High Deductible plan offers basic coverage and includes additional exclusions, such as:
(Min. Value) Health Plan No out-of-network coverage except for emergencies.
(Minimum Value) No coverage for treatment of temporomandibular joint dysfunction (TMJ).
No coverage for chiropractic care.
IRS tax deferred vehicle: The HDHP1 and HDHP2 (Min. Value) options are qualified HDHPs that can be used in conjunction
with an HSA (Health Savings Account). This account is owned by the employee and may be acquired through your local banker.
This provides a means for the employee to defer, tax free, money into an account to pay for covered services not paid by the Plan
and subject to your own out-of-pocket expenses. There are IRS stipulations applied when an HSA is used. If you or your employ-
er contribute toward the HSA, you cannot be covered under more than one (1) plan for the tax period the contribution is made. For
more HSA information, you may reference the US Department of the Treasury website at www.home.treasury.gov.
Which Plan Option is Right for Me?
Enter information from your plan
Plan Name_____ Plan Name _____
and/or your spouse’s plan
Worse Case Likely Case Worse Case Likely Case
Annual Payroll Deduction
Total Copays:
Office $ $ $ $
ER $ $ $ $
Urgent $ $ $ $
RX-retail $ $ $ $
RX-mail $ $ $ $
Deductible: $ $ $ $
Coinsurance: $ $ $ $
$ /person $ $ /person $
Not to Exceed Max Out-of-Pocket Limit $ /family $ /family
Combined Total Annual Cost Estimate $ $ $ $
Potential Tax Savings * $ $ $ $
Net Total Annual Cost Estimate
After Tax Savings Estimate
* If selecting an HDHP option, you can defer tax free dollars into an HSA (Health Savings Account). Depending on your income, the
amount you def
er can be multiplied by your tax bracket (e.g.,15-25%) to see your tax savings estimate. Consulting your tax advisor is best option.
HSA 2021 Contribution Limits: For HDHP1 Plan and HDHP2 Plan: $3,600 for single coverage, $7,200 for family coverage.
HSA catchup contributions for 55 and older is $1,000.
SEBT—Plan Year 2021 5
Summary of In-Network Medical Plan Options 2021
Summary of In-Network Medical Plan Options 2021
Search for in-network PPO HDHP 1 HDHP 2
UMR/UHC providers at www.umr.com NWD (Min. Value)
Medical
Preventive Care Covered at 100% Covered at 100% Covered at 100%
Annual Deductible $1,000 /person
This is the dollar amount you must pay first in a year $2,000 /family $3,000 /person $7,000 /person
before the plans begin paying specified benefits. Copays are not subject $6,000 /family $14,000 /family
to the deductible.
Doctor Office Visit $30 copay /primary care
Primary care includes family practice, internist, Ded, then Plan Ded, then Plan
$60 copay /specialist
pediatrician, OB/GYN, mental health and chiropractor. pays 80% pays 100%
30% / if chiro manipulation
$30 copay /office visit charge Ded, then Plan Ded, then Plan
Urgent Care
30% /if no office visit charge pays 80% pays 100%
$200 copay Ded, then Plan Ded, then Plan
Emergency Room (waived if admitted) pays 80% pays 100%
Inpatient and Outpatient Ded, then Plan Ded, then Plan Ded, then Plan
Services pays 70% pays 80% pays 100%
$150 Rx deductible
Deductible applies Deductible applies
Prescription Drugs applies to brand drugs
to Medical and Rx to Medical and Rx
($300 total for family)
$15 copay /generic
Retail 30% coinsurance /brand Ded, then Plan Ded, then Plan
Up to a 30-Day Prescriptions ($40 min/$75 max) pays 80% pays 100%
Express Scripts National Pharmacy Network Nationwide network which includes Walmart, Meijer and more. (Walgreens is excluded.)
$30 copay /generic
Mail Order or Smart90 $75 copay /brand Ded, then Plan Ded, then Plan
Up to 90-Day Prescriptions (deductible waived) pays 80% pays 100%
Express Scripts Home Delivery or Long-term maintenance medication up to 90-day supply filled either through Express Scripts
Smart90 Standard Pharmacy Network Home Delivery or a Smart90 Standard retail pharmacy which includes Walmart, Meijer and more.
(CVS and Walgreens are excluded.)
Specialty 50% Coinsurance Ded, then Plan Ded, then Plan
Up to 30-Day Prescriptions ($150 min / $300 max) pays 80% pays 100%
Annual Maximum
Out-of-Pocket $5,750 /person $7,000 /person
Includes medical and rx deductibles, coinsurance, $4,500 /person
$9,000 /family $11,500 /family $14,000 /family
and copays. This is the most you will pay toward your
in-network medical and prescription expenses.
Footnotes:
HDHP2 (Min. Value) has unique exclusions (e.g. No benefits for out-of-network services unless emergency.) Review list on page 5.
HDHP1 and HDHP2 (Min. Value) are adjusted annually as provided under IRS Code to be eligible as a Qualified HDHP (High Deductible Health Plan).
This chart is a summary for comparison purposes. Refer to the most recent Benefit Book for complete description of Plan benefits.
Services provided at the District’s Health & Wellness Centers are offered at no cost to plan members.
SEBT—Plan Year 2021 6
Pharmacy
Pharmacy Benefit
Benefit
Our Prescription Plan offers two choices to fill long-term maintenance medications.
A maximum of three courtesy fills are allowed at retail (up to a 30 day supply) for
a new maintenance drug. After that, a 90 day supply of the drug must be filled at
the Express Scripts Home Delivery Pharmacy or at a retail pharmacy in the
Smart90 Standard Retail Pharmacy Network.
Express Scripts Home Delivery Smart90 Standard Retail
Pharmacy Pharmacy Network
You may conveniently fill your long-term If you prefer a retail option to fill your
maintenance prescriptions through home long-term maintenance medications,
delivery from the Express Scripts Pharmacy. you may fill at a retail pharmacy in
the Smart90 network.
FREE standard shipping
There is a select group of retail
Access to a pharmacist 24/7 pharmacies in the Smart90 network,
such as Kroger, Walmart, Meijer and
Automatic refill reminders so you’re
more.
less likely to miss a dose
A 90-day prescription is required.
Extended Payment Plan available
Just call 866-275-0044 and they will
contact your doctor to get your new
prescription, or go to
www.express-scripts.com
One less card to carry with the Express Scripts mobile app.
Search “Express Scripts” in your mobile app store.
SEBT—Plan Year 2021 7
District Health & Wellness Centers
SEBT provides access to quality health care that is dedicated to improving and maintaining
the health and wellness of the employees, spouses, and dependents eligible to participate.
For more details, visit:
Adams Central Eastbrook
Bluffton-Harrison Mississinewa
North Adams Oak Hill
We are committed to improving and maintaining
South Adams ACTIVATE Clinic: the health of employees and their families.
Southern Wells 2707 S. Western Avenue
Marion, IN 46953 Health center services include primary/acute
ACTIVATE Clinic: 765-697-9142 care, preventive care, medication dispensing,
926 W 500 S laboratory services,
Berne, IN 46711
Northern Wells
260-849-4296
Region 8 Services are offered at no cost to the participant.
A $30 copay may apply for members actively
Mississinewa Whitley County contributing to an HSA.
ACTIVATE Clinic: ACTIVATE Clinic: The Health Center is available to covered
1500 South B Street, Ste 1 2932 West Ludwig Road employees and their dependent spouses and
Elwood, IN 46036 Fort Wayne, IN 46818 children over two years old.
765-557-8696 260-755-1304
Members may keep their existing primary care
physician in addition to using the Health Center.
All health information within the center remains
confidential.
Lewis Cass
LOGANSPORT MEMORIAL
HOW TO USE YOUR HEALTH CENTERS
Clinic: Call to schedule an appointment.
3400 E. Market Street You can usually get an appointment
Logansport, IN 46947
574-722-9633 on the same or next day.
SEBT—Plan Year 2021 88
Enrollment Instructions–
Enrollment page 1
Instructions
ALERT !
Employees must log in to portal to elect or waive benefits.
No action is an automatic waiver.
Before You Enroll:
If you are enrolling a dependent for the first time, you will need
to gather information about you and your dependents:
- Social Security Number
- Date of Birth
- Other medical coverage information that you and your dependents may have
- Other required documentation to verify eligibility (see page 10)
Log in to the Employee Portal https://sebt-optimalhealth.benelogic.com
Use your district-specific UserID to Sign In to your account.
First letter of first name, last name, last 4-digits of Social Security Number @employer
For Example
SEBT ADAMS CENTRAL jdoe1234@adamscentral
SEBT BLUFFTON HARRISON jdoe1234@bhmsd
SEBT EASTBROOK jdoe1234@eastbrook
SEBT MISSISSINEWA jdoe1234@mississinewa
SEBT NORTH ADAMS jdoe1234@northadams
SEBT NORTHERN WELLS jdoe1234@nwcs
SEBT OAK HILL jdoe1234@oakhill
SEBT REGION 8 jdoe1234@region8
SEBT SOUTH ADAMS jdoe1234@southadams
SEBT LEWIS CASS jdoe1234@lewiscass
SEBT SOUTHERN WELLS jdoe1234@swraiders
SEBT WHITLEY jdoe1234@whitley
Enter your password. If you cannot remember password, click “Forgot UserID/Password?”
If first time to log in, your Initial Password is:
Date of birth (For Example, mmddyyyy)
Then change your password and answer security questions.
Instructions to Enroll or Waive Coverage:
Follow the instruction wizard to elect your benefits or to waive coverage.
Review your benefit elections.
Click the “Submit” button to save your elections.
Click “Submit” again to finalize your elections.
Click “View Confirmation” to print the Enrollment Summary for your records.
SEBT—Plan Year 2021 99Enrollment Instructions—page 2
Instructions to Enroll or Waive Coverage:
Follow the instruction wizard to elect your benefits or to waive coverage.
Review your benefit elections.
Click the “Submit” button to save your elections.
Click “Submit” again to finalize your elections.
Click “View Confirmation” to print the Enrollment Summary for your records.
Quick Enroll:
If an employee is not intending to make a change and just needs to verify their benefits and covered de-
pendents are correct, they will click the “Quick Enroll” button. If during verification they choose to make a
change, the system will allow it by clicking on the edit pencil.
Step-by-Step:
This feature will walk the employee through the benefit election wizard, similar to how they enrolled during
the initial eligibility. They will be able to review, elect, or change their benefits one at a time.
There is a on the log in page and that will open a help page. It will also allow the member to view a
video, guiding them through the Benelogic process.
NEED ASSISTANCE?
Employee Portal Login Required Documentation
Benelogic Client Services Administrative Support Team (AST)
866-324-0818 855-664-0012
Email: Email:
info@sebt-optimalhealth.benelogic.com AST@planmanagementservice.com
SEBT—Plan Year 2021 10Required Uploads Needed
for Medical Plan Coverage
Employees are required to verify the eligibility of spouses
and dependents in the medical plans.
Complete the following three steps to upload documents to your Online Employee File Cabinet
https://sebt-optimalhealth.benelogic.com
Step 1: Obtain the Required Documentation for each dependent.
Obtain Required Documentation for Spouse
One of these documents is required each year for medical and dental coverage.
Firstpage of your last Federal IRS 1040 tax return with spouse’s name listed (sanitized,
blacking out financials and all but the last 4-digits of SSNs)
If filing “head of household,” Employee and Spouse will be required
Spouse to complete Affidavits.
If married in the current year and have not yet filed together, provide Marriage License.
A spousal eligibility questionnaire must be completed during your online enrollment. The
online Questionnaire may prompt you to upload a signed Spousal Employer Verification
Form (available in the online Resource Tab) to complete your medical coverage enrollment.
Obtain the Applicable Required Documentation for Dependents
Birth Child Birth Certificate. Provide one time.
Adopted Child Legal adoption documentation. Provide one time.
Legal
Proof of legal guardianship or “Qualified Child Medical Support Order”
Guardianship
(QCMSO). Provide one time unless there is a change.
for Child
Divorce Decree to identify primary medical coverage for dependent. Provide one time unless
Step Child there is a change.
Birth Certificate. Provide one time.
“Disability Certification for Dependent Children” (available in the online Resource Tab).
Disabled
This may be required every five years.
Dependent
Birth Certificate. Provide one time.
Step 2: Upload your document by first scanning and saving to your computer or portable drive.
(PDF, PNG, JPG, or BMP only)
Step 3:
Log on to https://sebt-optimalhealth.benelogic.com with your district-specific UserID and Password.
From the Home Page, select Upload a Document, then click Add a File.
Locate your file on your computer/device, add a document description to the file name, then Save to continue.
NOTE: Only eligible dependents may be enrolled in your benefit plan. (Refer to your Plan’s Benefit Book or Personnel office if unsure of
guidelines). Dependent proof of eligibility may be required; such as birth certificate, custody, or guardianship papers (for children eligibility)
and/or first page of your last filed 1040 tax return (for spouse eligibility) with the financial information and all but the last 4-digits of the SSN
blacked out. Failure to provide proof of eligibility upon request, or failure to enroll a spouse into their own employer's sponsored coverage, if
eligible, will result in the recovery of all benefits paid on behalf of that spouse/dependent by your Plan.
SEBT—Plan Year 2021 11Link totoallAllContacts
Link Resourcesat
andour Website
Updates on Website
www.sebtoptimalhealth.com
Need Help With:
Medical Plan UMR
Coverage, claims, find a
Accessing the UMR Network www.umr.com
medical doctor or other 800-207-3172
healthcare provider, and (For claims incurred prior to 1/1/2020,
order ID cards contact www.alliedbenefit.com,
866-455-8727)
Prescription Drug www.express-scripts.com
Coverage, claims, and Express Scripts, Inc.
preferred formulary 866-275-0044
Benelogic Email:
SEBT Employee Portal Benelogic Member Services info@sebt-optimalhealth.benelogic.com
Enrollment, special Employee Portal:
enrollment events, https://sebt-optimalhealth.benelogic.com
and change requests 866-324-0818
Claim and Benefit Tony Zickgraf
Questions tzickgraf@planmanagementservice.com
Support in understanding SEBT Plan Management 260-244-5830
benefit options, resolving Support
claims or benefit issues Rebecca Kohler
rkohler@planmanagementservice.com
855-664-0012 Ext 2589
Employee Assistance
Program (EAP)
Confidential Counseling, www.Guidanceresource.com
ComPsych
Financial Resources, Company Wed ID: ONEAMERICA3
Legal Support, Work-Life 855-387-9727
Solutions
AST Email:
Enrollment and Eligibility Administrative Support Team AST@planmanagementservice.com
855-664-0012
Review Your Benefit Book and Certificate to Preserve Coverage
Medical Coverage
Please refer to the Resource tab on the SEBT Employee Portal, https://sebt-optimalhealth.benelogic.com:
Annual Member Notices
Summary of Benefits and Coverage (SBC)
Medical Benefit Book
All Plan communications will be provided electronically to you for review throughout the Plan Year, unless you
notify your Employer's Treasurer/Business Office/Benefit Representative with a request to provide all or some
plan communications in paper hard-copy.
Life Insurance Coverage
Please visit your local Treasurer or Business Office for information of your Life Insurance, including the Life Insurance
Certificate.
SEBT—Plan Year 2021 12You can also read
