JOINTLY ADMINISTERED TRUST FUND

FOR THE BENEFIT OF LORAIN CITY SCHOOL DISTRICT EMPLOYEES

2015 Open Enrollment

It’s time for annual open enrollment. Annual open enrollment gives you the opportunity to make individual decisions about your benefits which you and your family rely on for protection. The annual open enrollment period begins November3, 2014, and ends December 3, 2014. All enrollment changes are effective January 1, 2015.

The Trust electednot to increase the 2015 monthly employee contribution for health insurance and defer the $19.52 monthly per capita increase needed to meet the 2015 budget. Instead, the Trust will launch a robust Wellness Program that will require employees to participate in wellness screenings, complete an on-line health risk assessment and participate in wellness activities. Wellness programs requiring employee participation are results-based and have shown to improve both participants’ health and decrease medical costs. It is imperative that all employees and covered family members work at improving their overall health and help reduce the costs of the health care plans offered to make them as affordable as possible and to preserve as much of the current plan designs as possible in the future.

The Trust is required again this year to make benefit enhancements and pay fees to comply with the Affordable Care Act (“ACA”). In addition to the expansion of benefits, the ACA also requires that the Trust pay fees that include:

  • patient-centered outcomes research institute fee ($2.14 per member per year)
  • transitional reinsurance fee ($3.67 per member per month)

After the benefit changes made for 2015 (reflected on the following page) and the required ACA fees are considered, the estimated impact to the 2015 budget is a cost increase of $100,000.00.

Additionally, in 2018 a “Cadillac” plan tax will go into effect which is a 40 percent excise tax on high-cost health insurance plans (plans for which costs exceed annual thresholds defined under the ACA and calculated by the IRS). The Trust continues to monitor the cost of the benefit plan options as regulations are developed by the IRS. These regulations, as well as the impact of the Wellness programs to manage costs, will determine changes necessary toavoid hitting the excise tax threshold to protect both the Trust and employees from incurring this tax. The tax is determined by the cost of the plan and not the plan design itself.

Please read this newsletter carefully so you are aware of:

  • Open Enrollment Period
  • Benefit Changes
  • Wellness Program
  • Payroll Contribution
  • Adult Dependent Eligibility Requirements and Cost
  • Mandatory Spousal Coverage Eligibility Requirements

To help you select the benefit plan that meets you and your family’s needs, refer to the attached Benefit Highlight Sheets. MMO will provide the Summary Benefit of Coverage (SBC) within the next few weeks for each of the plans.

Open Enrollment Period

  • You are not required to complete an enrollment form if you do not wish to make changes to your current health care election.
  • You are required to complete an enrollment form to enroll for coverage, to make a change to your current election, to opt out of dental in Plan A or Plan B, to waive coverage or to add a dependent(s). If you do not return an enrollment form, your current election will remain in effect until the next open enrollment period and you may be required to make a payroll contribution. All changes are effective January 1, 2015.
  • Enrollment forms are available on the Lorain City School website/departments/human resources/human resources forms/health plan trust enrollment form. Adult Dependent Child Certification forms are available in the Human Resource Department. Your completed enrollment form must be returned to Human Resource Department no later than Wednesday, December 3, 2014.
  • All elections will remain in effect until the next open enrollment period. Attached are Benefit Highlights and SBC’s for each of the plans.
  • You may only make a change to this election during the year if you incur a life event/status change. You will be unable to cancel your benefit unless you incur a life event/status change.

Benefit Changes - 2015

To comply with the requirements of the ACAand to preserve as much of the current plan design as possible, the following benefit changes are effective January 1, 2015:

  • The maximum annual out-of-pocket limit (MOOP) on cost sharing will be$6,600for self-only coverage and$13,200for family coverage. Is it important to note that the COINSURANCE maximum for each of the plans will remain unchanged.
  • Pharmacy copays apply to the MOOP.
  • The $50.00 Plan B Prescription Drug Plan deductible has been eliminated.
  • Addition of coverage of behavioral healthcare services in residential treatment centers.

Wellness Plan

You will need to participate in the screenings and complete the Health Risk Assessment each year to be eligible for the incentives being developed for the plan. Your screening results will be compared from year to year to determine if you have reached your biometric goals.

The Trust is launching a three-year wellness plan with the help of Medical Mutual of Ohio. The 2015 wellness plan will include an onsite health screening and health assessment in early March. The wellness activities will include weight watchers and quitline (for smokers). All screenings are confidential and will comply with HIPAA.

In 2016, the incentives associated with the wellness plan will transition from a process-based incentive to a results-based incentive. In 2016, the wellness plan will include an onsite health screening and health assessment in early March. Employee biometric results and health risk assessment will determine your 2017 premium adjustment. The adjustment will be based on your efforts to reach the following:

  • HA completion
  • BMI/Waist Circumference
  • Blood Pressure
  • AIC/Blood Glucose

In 2017 the wellness plan will again include an onsite health screening and health assessment in early March. Employee biometric results will be used to determine your 2018 premium adjustment. The adjustment will be based on your efforts to reach the following:

  • HA completion
  • BM/Waist Circumference
  • Blood Pressure
  • AIC/Blood Glucose
  • LDL/Triglycerides

Medical Mutual of Ohio will administer the results- based program including employee communications, appeals process and final employee credit file. The credit file will contain names of employees who have participated in the screenings, completed the on-line health risk assessment and have reached their biometric goals. This file will be used to provide employees with a health insurance premium credit. Employees who do not participate will not receive a credit and will be required to contribute more for their health insurance.

This is a brief overview of the plan. You will receive more information as the plan is implemented.

2015 Payroll Contribution Change

The table below shows the funding amounts effective January 1, 2015, that employees and the Trust will contribute each month for health benefits. There will be an additional cost if you elect to enroll an over age dependent (age 26-28).

SuperMed Plus Medical Plan A With Dental
Single 2015 / Family2015
Employee Payroll Contribution / $ 104.98 / $ 262.44
Trust Contribution / $559.69 / 1,399.18
Total Monthly Cost / $664.67 / $1,661.62
SuperMed Plus Medical Plan A With Out Dental
Single 2015 / Family2015
Employee Payroll Contribution / $ 99.81 / $ 249.52
Trust Contribution / $534.45 / 1,336.07
Total Monthly Cost / $631.26 / $1,585.59
SuperMed Plus Medical Plan B With Dental
Single 2015 / Family 2015
Employee Payroll Contribution / $ 79.87 / $ 199.66
Trust Contribution / $428.42 / $ 1,071.00
Total Monthly Cost / $508.29 / $1,270.66
SuperMed Plus Medical Plan B With Out Dental
Single 2015 / Family 2015
Employee Payroll Contribution / $ 75.94 / $ 189.83
Trust Contribution / $408.32 / $1,020.75
Total Monthly Cost / $484.26 / $1,210.58
SuperMed Plus Medical Plan C
Single 2015 / Family 2015
Employee Payroll Contribution / No Payroll Contribution / No PayrollContribution
Trust Contribution / $318.82 / $797.03
Total Monthly Cost / $318.82 / $797.03

Dependent Eligibility Requirements

1. Dependents to Age 26 Federal Law

Your dependent must meet the following dependent eligibility requirements:

  • Federal eligibility does not require a dependent child to live with the parent. It does not require a dependent child to be listed on the parent’s tax return and does not require the dependent child to be a full-time student. Both married and unmarried dependent children can qualify for the coverage, although it does not extend to the dependent child’s spouse or children.

2. Dependents to Age 28 Ohio Law

Yourunmarrieddependent must meet the following adult dependent eligibility requirements to receive benefits to the age of 28:

  • Your dependent must be a natural child, stepchild, or adopted child of the employee;
  • a resident of Ohio or a full-time student at an accredited public or private institution of higher education;
  • not employed by an employer that offers any health benefit plan under which the child is eligible for coverage, and
  • not eligible for coverage under Medicaid or Medicare.

The older age child does not have to live with the parent, be financially dependent upon the parent or be a student.

The chart below shows the monthly per dependent cost to add an adult dependent child age 26 to age 28 to your insurance plan. The cost is in addition to your monthly health care payroll contribution. Your dependent will automatically be added to the benefit plan you have enrolled in. For example, if you have elected to enroll in Plan A your over age dependent will be added to Plan A and you will be charged the monthly over age dependent cost for Plan A , in addition to the monthly payroll contribution amount.

MONTHY COST PER OVER AGE DEPENDENT
PLAN A / PLAN B / PLAN C
Dependent Age 26-28 / $344.46 With Dental
$327.24 Without Dental / $263.47 With Dental
$250.29 Without Dental / $165.49

The following is an example of a monthly payroll contribution amount for an employee who currently has a family Plan A with dental and elects to add an over age dependent (26-28)

$262.44+ $344.46 = $606.90 total monthly payroll contribution amount.

The following is an example of the monthly payroll contribution amount for an employee who currently has a single Plan B with dental and elects to add an over age dependent (26-28)

$79.87 + 263.47= $343.84 total monthly payroll contribution.

Mandatory Spousal Coverage Reminder

The Trust has a Mandatory enrollment for spousal coverage policy for medical and prescription drug coverage. If your spouse is employed and has group health care benefits available through his/her employer, he/she is required to participate in his/her employer’s medical and prescription drug plan. This helps ensure that other companies assume the cost of covering their own employees.

If your spouse, who has other health care benefits available, fails to comply with the mandatory enrollment requirements, then benefits under this Plan payable to eligible dependents will be provided the same as if the spouse had so enrolled, and his/her health care plan shall be determined as the primary plan for his/her coverage. If coordination of benefits is not permitted under the other plan, then your non-enrolled spouse shall not qualify as a dependent under this plan.

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Lorain Board of Education Joint Trust

Effective January 1, 2015
Plan A (Section 005)
Group 908009
SuperMed PPO
(Non-Grandfathered) /
Benefits / Network / Non-Network
Benefit Period / January 1st through December 31st
Dependent Age
Older Age Child / 26
28
Removal upon End of Month
Pre-Existing Condition Waiting Period / Does Not Apply
Blood Pint Deductible / 3 pints
3 month Deductible Carryover / Does Apply
Coinsurance / 85% / 65%
Benefit Period Deductible – Single/Family / $250 / $500 / $500 /$1,000
Coinsurance Out-of-pocket Maximum (Excluding Deductible) - Single/Family / $2,250 / $4,500 / $4,500 / $9,000
Maximum Out-of-Pocket Limit– Single/Family1 / $6,600 / $13,200 / Does Not Apply
Physician/Office Services
Office Visit (Illness/Injury) / $30 copay, then 100% / 65% after deductible
Urgent Care Office Visit / $30 copay, then 100% / 65% after deductible
Immunizations- Standard / 85% after deductible / 65% after deductible
Preventive Services
Health Care Reform Preventive Benefits / 100% / 65% after deductible
Routine Physical Exam (Age 21 and over)
(One exam per benefit period) / 100% / 65% after deductible
Well Child Care Services including Exam,
Routine Vision, Routine Hearing Exams,
Well Child Care Immunizations and Laboratory Tests ( To age 21) / 100% / 65% after deductible
Routine Mammogram
(One per benefit period) / 100% / 65% after deductible
Routine Pap Test (One per benefit period) / 100% / 65% after deductible
Outpatient Services
Surgical Services / 85% after deductible / 65% after deductible
Diagnostic Services / 85% after deductible / 65% after deductible
Physical Therapy / Occupational Therapy- Facility and Professional
(40 visits per benefit period, combined) / 85% after deductible / 65% after deductible
Chiropractic Therapy – Professional Only
(12 visits per benefit period) / 85% after deductible / 65% after deductible
Speech Therapy – Facility and Professional
(20 visits per benefit period) / 85% after deductible / 65% after deductible
Cardiac Rehabilitation (36 visits per benefit period) / 85% after deductible / 65% after deductible
Emergency use of an Emergency Room / $115 copay, then 100% (waived if admitted)
Non-Emergency use of an Emergency Room / $115 copay, then 85% / $115 copay, then 65%
Benefits / Network / Non-Network
Inpatient Facility
Semi-Private Room and Board / 85% after deductible / 65% after deductible
Maternity / 85% after deductible / 65% after deductible
Skilled Nursing Facility / 85% after deductible / 65% after deductible
Organ Transplants / 85% after deductible / 65% after deductible
Additional Services
Allergy Testing / 85% after deductible / 65% after deductible
Allergy Treatments / 85% after deductible / 65% after deductible
Ambulance / 85% after deductible / 65% after deductible
Durable Medical Equipment / 85% after deductible / 65% after deductible
Home Healthcare / 85% after deductible / 65% after deductible
Hospice (180 days per lifetime) / 85% after deductible / 65% after deductible
Private Duty Nursing / 85% after deductible / 65% after deductible
Mental Health and Substance Abuse – Federal Mental Health Parity
Inpatient Mental Health and Substance Abuse Services / Benefits paid are based on corresponding medical benefits
Outpatient Mental Health and Substance Abuse Services

1 Maximum Out-of-Pocket refers to the sum of any applicable deductible, coinsurance and copays. Copays do not

accumulate to the Maximum Out-of-Pocket for Non-Network.

This document is only a partial listing of benefits. This is not a contract of insurance. No person other than the

Plan may agree, orally or in writing, to change the benefits listed here. The contract or Benefit Booklet will

contain the complete listing of covered services.

/ The Jointly Administered Trust Fund for the Benefit of Lorain City School District Employees
Group 908009
Plan A (Section 005)
Prescription Drug Program
Effective January 1, 2015
Benefits / Copay / Day Supply
Benefit Period / January 1st through December 31st
Dependent Age Limit
Over Age Child / 26/28
Removal upon end of the month
Retail Program w/ Home Delivery Incentive *
Generic Copayment / $8 / 34
Formulary Copayment / $20 / 34
Non-Formulary Copayment / $40 / 34
Mail Order Program
Generic Copayment / $20 / 90
Formulary Copayment / $50 / 90
Non-Formulary Copayment / $100 / 90

* Home Delivery Incentive: When a member chooses to fill a prescription a fourth time at a retail pharmacy within 180 days, the member will pay twice the normal retail copayment.

Note:Benefits will be determined based on Medical Mutual’s medical and administrative policies and procedures.

This document is only a partial listing of benefits. This is not a contract of insurance. No person other than an officer of Medical Mutual may agree, orally or in writing, to change the benefits listed here. The contract or Summary Plan Description will contain the complete listing of covered services.

Eligible Persons may receive prescription service for the following covered items subject to the exclusions and limitation set forth herein:

Federal legend drugsLupron

State restricted drugsMental health drugs

Anabolic steroidsNon-asteroidal anti-inflammatory drugs

AnorexiantsPre-natal vitamins

Bee sting kitsRetin A under age 25

Cholesterol lowering drugsSyringes and needles on prescription

Compounded prescriptions

Cough and cold preparations

CNS stimulants and amphetamines covered through age 24

Diabetic drugs (oral)

Federal legend smoking cessation products

Federal legend vitamins (adult)

Federal legend vitamins (children)

Genetically engineered drugs

Imitrex (refill vials)

Imitrex auto injector

Immune altering drugs

Insulin on prescription

Exclusions:

Items lawfully obtainable without prescription

Allergy serums

Devices and appliances

Diabetic lancets

Diabetic test strips

Diagnostic drugs

Fertility drugs (injectable)

Fertility drugs (oral)

Viagra

Rhogam

Rogaine and similar drugs

Serums

Yohimbine and similar drugs

Prescriptions covered without charge under Federal, State or local programs, to include Worker’s Compensation

Any charge for the administration of a drug or insulin

Investigational or experimental drugs

Unauthorized refills

Immunization agents, biological sera, blood or plasma

Medication which is to be taken by or administered to an eligible person, in whole or part, while he or she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, skilled nursing facility, convalescent hospital, nursing home or similar institution which operates on its premises or allows to be operated on its premises, a facility for dispensing pharmaceuticals.

Any charge where the usual and customary charge is less than the Eligible Person’s copayment

Any charge above the usual and customary, advertised or posted price, whichever is less than the scheduled amount.

9/21/2018

Dental Benefit Highlights for

Lorain City School District

Client #1048 Plan A

Delta Dental PPOSM (Standard)
Coverage effective January 1, 2012 / PPO Dentist / Premier Dentist / Non-participating Dentist
Plan Pays / Plan Pays* / Plan Pays*
Diagnostic & Preventive
Diagnostic and Preventive Services – includes exams, cleanings, fluoride, and space maintainers / 100% / 80% / 80%
Emergency Palliative Treatment – to temporarily relieve pain / 100% / 80% / 80%
Brush Biopsy – to detect oral cancer / 100% / 80% / 80%
Sealants – to prevent decay of permanent teeth / 100% / 80% / 80%
Bitewing Radiographs – bitewing X-rays / 100% / 80% / 80%
Basic Services
All Other Radiographs – other X-rays / 80% / 60% / 60%
Periodontic Services – to treat gum disease / 80% / 60% / 60%
Endodontic Services – root canals / 80% / 60% / 60%
Relines and Repairs – to bridges and dentures / 80% / 60% / 60%
Oral Surgery Services – extractions and dental surgery / 80% / 60% / 60%
Restorative Services – fillings / 80% / 60% / 60%
Major Services
Prosthodontic Services – includes bridges, implants, and dentures / 80% / 60% / 60%
Orthodontics
Orthodontic Services – includes braces / 100% / 100% / 100%
Orthodontic Age Limit – / 25 / 25 / 25
*Under Delta Dental PPO (Standard), Delta Dental of Michigan’s payment for covered services will be based on the PPO dentist schedule amount. You can go to any licensed dentist, but you could lower your out-of-pocket costs by going to a PPO dentist. PPO dentists agree to charge no more than the PPO schedule amount for covered services. If you go to a non-PPO dentist, you will be responsible for the difference between the PPO schedule amount and the dentist's submitted fee or the amount Delta Dental approves.
Maximum Payment –
PPO Dentist – $1,700 per person total per calendar year on Diagnostic & Preventive, Basic Services, and Major Services. $1,000 per person total per lifetime on Orthodontics.
Premier or Nonparticipating Dentist – $1,200 per person total per calendar year on Diagnostic & Preventive, Basic Services, and Major Services. $1,000 per person total per lifetime on Orthodontics.
Deductible – None.
Please Note: this document is intended as a supplement to your Certificate and Summary of Benefits. Please refer to your Certificate and Summary for policy exclusions and limitations.

PLAN A