Reimbursement Account Services

2016
Plan Year
Educated Choices
Table of Contents
Welcome .....................................................................................................................................................................2 Glossary .................................................................................................................................................................. 2‐3 Open Enrollment Updates ..........................................................................................................................................4 Public Act 152 .............................................................................................................................................................5 Educated Choices Online Enrollment Informa on ................................................................................................ 6‐7 Insurance Carrier Contact Informa on .......................................................................................................................8 Resources for your Educated Choices.............................................................................................................. 8‐9 
Women’s Health & Cancer Rights Act ...........................................................................................................9 
HIPAA Reminder No ce .................................................................................................................................9 
Mental Health Parity No ce ..........................................................................................................................9 
Dependent Eligibility Requirements ..............................................................................................................9 Medical and Prescrip on Drugs Benefits ........................................................................................................... 10‐12 Dental and Vision Benefits ....................................................................................................................................... 13 Benefit Summaries ............................................................................................................................................. 14‐42 Life Insurance Protec on ......................................................................................................................................... 43 
Employee Life Insurance ............................................................................................................................. 43 
Personal Health Statement/Evidence of Insurability Requirement (EOI) .................................................. 43 
Accidental Death and Dismemberment (AD&D) ........................................................................................ 44 
Dependent Life Insurance ........................................................................................................................... 44 Disability Protec on ................................................................................................................................................ 46 
Short‐Term Disability .................................................................................................................................. 46 
Long‐Term Disability ................................................................................................................................... 46 Reimbursement Account Services ........................................................................................................................... 47 
Health Savings Accounts (HSA) ................................................................................................................... 47 
Flexible Spending Accounts (FSA) ............................................................................................................... 47 
Benefits MasterCard ................................................................................................................................... 48 
Health Care Reimbursement Account ........................................................................................................ 51 
Types of Expenses Eligible for Reimbursement under your Healthcare Flexible Spending Account .... 52‐54 
Health Care Reimbursement Account Worksheet ..................................................................................... 55 
Dependent Care Reimbursement Account ................................................................................................. 56 
Dependent Care Eligibility Requirements .................................................................................................. 57 
Comparing the Federal Tax Credit/Dependent Care Reimbursement Account ................................... 58‐59 
Important Educated Choices Informa on Summary ................................................................................. 60 Every effort has been made to ensure the accuracy and completeness of the benefit descrip ons contained within this workbook. However,
if statements in this workbook differ from the applicable contracts, cer ficates and riders, then the terms of those contracts, cer ficates
and riders prevail.
Welcome to your 2016 Educated Choices
Annual Enrollment!
Educated Choices is an innova ve, progressive flexible benefit plan that gives you the choice to select your benefits from a menu of op ons, based on your employment agreement. Each year, you have the opportunity to select the right benefit combina on for you and your family. New Changes Using Your Benefit Educa on Materials This workbook contains informa on you need to know about Educated Choices. It provides an informa ve overview of your benefit op ons and is designed to help you in selec ng your benefits. In addi on to this workbook, several other benefit educa on resources have been included in your Enrollment package. Please review these materials carefully so your choice in benefits will be an Educated Choice. Newsle er and all open enrollment materials will be online.
Packets will no longer be delivered to your building. In an
effort to keep costs down we are migra ng to this new
process.
Tax Savings The Educated Choices benefit plan maximizes the tax advantages available under current federal and state tax laws, allowing you to contribute pretax dollars toward your benefit plan op ons. The pretax dollars you spend are not considered part of your taxable income and are excluded from your W‐2 wages. Please note your pay will be taxed appropriately based on your Educated Choices selec ons. Federal tax laws may affect the tax‐exempt status of certain benefits. You will be no fied of any such changes in the future. 
Pre‐Enrollment Le er – outlines Open Enrollment details, including how and when to enroll 
Summary of Benefits – details benefit op ons available to you, based on your employment agreement 
Frequently Asked Ques ons (FAQs) – provides answers to commonly asked ques ons about the Educated Choices
enrollment process 
HSA FAQs – provides answers to commonly asked ques ons about the Health Savings Account enrollment process 
Married Couples Health Risk Assessment Flyer 
Open Enrollment Event Flyer/FSA Reminder Educated Choices Glossary
It may be helpful for you to review some of the common terms used throughout this workbook to increase your understanding of the Educated Choices program. 
Approved Amount – The fee that BCBSM approves as the “reasonable and customary” fee for a specific service in a par cular geographic loca on. 
Benefit Dollars – The credits available to an employee which are used to purchase benefit op ons offered through Educated Choices. 
Benefits‐At‐A‐Glance/Summary of Benefits – An easy to read summary of in‐network and out‐of‐network deduc bles, co‐
pays and dollar maximums for certain covered services under the plan. It is a summary, not an all‐inclusive list of the benefit plan. A complete descrip on of benefits can be found in the cer ficates and riders for each plan. 
Brand‐name drugs – Prescrip on drugs that are patent protected. When the patent expires, other manufacturers can produce the generic equivalent of the brand and sell it under a generic name. See Tier 2 and Tier 3 descrip ons on page 18. 2016 2 Educated Choices Glossary

Co‐payment – The fixed amount or percentage of expenses you share with the insurance carrier. 
Coverage Status – This is the number of individuals eligible to be covered under your health plan (single, two
‐person or family). 
Deduc ble – The expense you incur before the plan or insurance carrier begins paying your covered expenses. The deduc bles are met each calendar year for medical. Vision deduc bles will vary according to your employment agreement (outlined in your Summary of Benefits). 
Effec ve Date – All Educated Choices benefits will be effec ve on January 1, 2016 for the full calendar year. 
Eligible Dependent – This includes your spouse and eligible dependents between the ages of 1 day‐26 years, regardless of marital, student and financial status. 
Formulary – A regularly updated list of medica ons reviewed by the Blues’ Pharmacy and Therapeu cs Commi ee that represents the clinical judgment of Michigan Physicians, pharmacists and other health care experts in the diagnosis and treatment of disease and preserva on of health. 
Full Scope Flexible Spending Account (FSA)– a saving op on for employees who are at least age 65 and enrolled in Medicare, or not enrolled in a Health Savings Account (HSA). The Full Scope FSA permits reimbursement for expenses associated with medical, dental and vision services. 

Generic drugs – Non‐brand name drugs that produce the same effects in the body as the equivalent brand‐name drugs. The Food and Drug Administra on requires that generic drugs have the same ac ve ingredients as the equivalent brand‐name drugs. They may differ from brand‐name drugs in color and shape. Since the major difference between brand‐name and generic drugs is price, your prescrip on will be filled with the generic equivalent when medically appropriate. See Tier 1 descrip on on page 18. Health Savings Account (HSA) – A tax‐advantaged medical savings account available to taxpayers in the United States who are enrolled in a high‐deduc ble health plan (HDHP). This money remains the property of the subscriber even if employment is terminated. This is
not an op on for someone who is not enrolled with a
High Deduc ble Health Plan or someone who is age 65
or over and enrolled in Medicare. 2016 
Health Equity is the provider for the Health Savings
Account. You can access these funds using your benefit
debit VISA or through the online banking system. This is
your personal bank account. Your employer has no access
to these funds. 
High Deduc ble Health Plan (HDHP) – a health insurance plan with lower premiums and higher deduc bles than a tradi onal health plan. 
In‐Network – This means your doctor or facility par cipates in and accepts the High Deduc ble Health Plan and has agreed to a reduced fee schedule. 
Life Status Change – If you have a life status change (e.g., your spouse’s employment changes or is terminated involuntarily, or you have a birth, marriage, death of a dependent or spouse, or divorce in your family), you may be able to add or drop certain types of coverage for dependents. If you have any ques ons as to what is considered an acceptable status change, please contact your Benefits Coordinator within thirty (30) days of the life status event. Mid‐plan year life status changes require a
mee ng with the Benefits Coordinator. Please contact her
within 30 days of the life event to schedule an
appointment. Health Savings Account Changes may be
made every 30 days and also require a mee ng with the
Benefits Coordinator. A life status event does not need to
occur to make this type of change to payroll deduc ons. Note: Mid‐plan year changes cannot be made via online
enrollment systems, email or through voice message
systems. 
Op ons – The choices you have in each benefit area. 
Out‐of‐Network – This means your doctor or facility is not
part of and does not accept the Simply Blue PPO HSA plan. Out‐of‐network services will be covered at a lower percentage, you will be responsible for the difference. 
Out‐of‐Pocket Maximum – The most you would pay in a plan year for eligible medical expenses, excluding
deduc bles. 
Plan Year – The current Educated Choices Plan Year is January 1 through December 31 of each year. Each fall, you will make your selec ons for the following calendar year. 
Pricetag – This is the cost to you of a benefit op on. The pricetag represents the actual cost of providing you and/or your family with that benefit op on. 3 Open Enrollment Updates
Educated Choices Plan Provisions Other benefits based on your salary, such as the 403(b) and Michigan Public Schools Re rement Service Credit, will not be affected if you convert your salary to purchase addi onal benefits. Conver ng your salary to purchase benefits may have a slight effect on the benefits you and your family will receive from Social Security since these benefits are based on your FICA taxable income. Medical Plan Deduc ble IRS regula ons state, in 2016, High Deduc ble Health Plans (HDHP) must have minimum deduc ble amounts of $1,300 for single coverage and $2,600 for family coverage. For the 2016 plan year, Bloomfield Hills Schools will con nue to offer the HDHP through BCBS with the Health Savings Account (HSA) through Health Equity. Waiver of Medical Insurance Forms
If you choose to decline the medical coverage offered by Bloomfield Hills Schools, you will not need to complete a waiver form. Instead, you will be able to waive coverage during the online enrollment process if you decline to enroll into a medical op on. unable to locate the form please contact the Benefits Coordinator at [email protected]. Please note that, for all employees who turned in a Health Risk
Assessment form, you will not be able to view this credit in the
online enrollment system, however it will be detailed on your
online confirma on statement. Your Choices Bloomfield Hills Schools understands that the benefit decisions you make today may not be right for you in future years. Therefore, you have an opportunity each year in the fall to make changes in benefits for the upcoming calendar year. The
available choices, as outlined in
your employment agreement,
are displayed on your Summary
of Benefits. The funding of
op ons by Bloomfield Hills Schools can be viewed on the
online enrollment system. If you have any ques ons regarding your enrollment, benefit coverage or op ons described herein, please contact: Sarah Dare, Benefits Coordinator
[email protected]
(248) 341‐5431
Karen Healy, Director
Human Resources and Payroll [email protected] (248) 341‐5432
Health Risk Assessment Credit Bloomfield Hills Schools will con nue to offer a credit to employees and spouses (if applicable), who par cipate in the annual Health Risk Assessment. In order to be eligible to receive the Health Risk Assessment credit for Plan Year 2016, the completed form must be submi ed to the Benefits Coordinator no later than September 10, 2015. The Health Risk Assessment may be completed any me between August 6, 2014 and September 10, 2015. Forms received a er the due date will not qualify for any rebate. There will be no excep ons. These forms are available on the Bloomfield Hills Schools Intranet under Human Resources, Benefits. If you are 2016 4 Public Act 152 State Legislature changed the funding of benefits for public school employees. Bloomfield Schools elected to comply with the law with the “hard cap”. Governor Snyder signed a new law that limits public employer contribu ons to employee health insurance, effec ve with each collec ve bargaining agreement that expires on or a er January 1, 2012. This law will apply to all public schools in the state. The “Publicly Funded Health Insurance Contribu on Act” provides two mechanisms that limit employer contribu ons to healthcare: a “hard cap” and an op onal “80/20” plan. The Act applies to “medical benefit plans” that provide payment of medical benefits, including, but not limited to, hospital and physician services, prescrip on drugs, and related benefits. The Act does not apply to dental or vision care plans. The Default Limit: The Hard Cap The Act is dra ed to apply a maximum that a public employer may pay towards public employee health care costs. The limit on a public employer’s total contribu on for employee health insurance for 2016 has not yet been released. However, the limits for 2015 were equivalent to: 
$5,992.30 mes the number of employees with single coverage, plus 
$12,531.75 mes the number of employees with Two Person or Employee + Spouse coverage, plus 
$16,342.66 mes the number of employees with Employee + Child(ren) or Family coverage. The State of Michigan releases the annual Hard Cap each year, so
the new informa on on these limits will be included online during
the annual open enrollment process. The amount necessary to purchase health insurance for employees that exceeds this “cap” must be paid by employees. 2016 5 Q: What employers are affected by the Act? The new law applies broadly to “public employers.” The Act applies to local units of government, poli cal subdivisions of the state, and “any intergovernmental, metropolitan, or local department, agency, or authority, or other local poli cal subdivisions.” Also included are school districts, community or junior colleges, and certain other ins tu ons of higher educa on. Q: What employer costs count toward the cap? The annual premium or illustra ve rate and any payments for reimbursements of co‐pays, deduc bles, or payments into Health Savings Accounts, Flexible Spending Accounts, or similar accounts used for health care are included as employer costs. The amounts for the hard cap will appear in your Educated Choices enrollment packets. Q: Will the caps ever change? Yes. The State Treasurer will adjust the caps each October 1 based on the change in the medical care component of the U.S. Consumer Price Index. The newly adjusted caps will be effec ve January 1 of each year. The medical care component of the Consumer Price Index has risen 12‐15% a year the past few years, so it is likely that caps will rise significantly. Educated Choices Online Enrollment
Instructions
The Educated Choices Online enrollment system is an easy, convenient way to enroll in your benefits using your computer. The enclosed Pre‐Enrollment Le er will guide you through the enrollment process. Please note, enrollment is mandatory. Enrollment System Preparing for Enrollment The Educated Choices Online enrollment system is available 24 hours a day, seven days a week during the enrollment period. Open Enrollment will be held: Please review your Educated Choices newsle er, workbook, and Summary of Benefits. When you have decided on each of your Educated Choices
benefit op ons, gather dependent informa on, including Social Security numbers and dates of birth. You are now ready to enroll! 
October 8, 2015 through October 15, 2015 for an
effec ve date of January 1 through December 31,
2016. It is very important for you to note these dates. Please plan to enroll during the designated enrollment period. Once you have enrolled using the Web site, you have almost completed the enrollment process. Dependents not newly
enrolled but between the ages of 20 and 26 will require
each employee to provide an electronic acknowledgement
while enrolling. In addi on to the electronic verifica on
you are also required to provide a copy of the birth
cer ficate for dependents turning 19 years old during
calendar year 2016. You must return the required
documenta on to the Benefits Coordinator no later than
October 29, 2015. Failure to provide adequate
documenta on will result in your child being removed from
coverage effec ve January 1, 2016. Comple ng Your Enrollment 

The system will ask you to verify your email address(es). Please be sure to include your email address; this is required for you to receive a confirma on email once your enrollment is complete. 
You will be able to review, update, add or delete your dependent informa on. This informa on determines your coverage status (single, two‐person, or family) for your medical, dental and vision choices. Review this informa on carefully. 
Con nue to the benefit elec on screen where you will make your elec on choices. The online enrollment system will show your payroll deduc ons per pay period. Deduc ons are taken over a 20 pay cycle for the Plan Year January 1 through December 31, 2016. 
Once you have confirmed your elec ons in the online system, your enrollment is complete! You will be offered the opportunity to receive an email Process for Life Insurance Beneficiaries It is extremely important to declare one or more beneficiaries for the life insurance benefits you receive as an employee of Bloomfield Hills Schools. Your beneficiary informa on is being stored online in the enrollment system. During the enrollment process, you will be asked to enter beneficiary informa on for your employee life insurance policies. Note
that you must go online during the annual enrollment
period indicated in this workbook and confirm a beneficiary. 2016 To enroll, logon to the Educated Choices Web site at h ps://www.nextgenera onenrollment.com/nge/bhsd. Instruc ons for how to login, including your “Username” and “Password”, can be found on your pre‐enrollment email included with your enrollment materials. 6 Educated Choices Online Enrollment
Instructions
confirma on and receive a congratulatory message. Be sure to turn in any required documenta on and print your confirma on statement. 
If you need to make changes to your benefit selec ons, you may return to the Educated Choices online enrollment system as many mes as you wish within the annual enrollment period. Confirma on Statement Process At the end of the enrollment period, a confirma on email
will be sent to your email address on file in the enrollment
system. It will provide a link for you to click and review
your confirma on statement online. Addi onally, a
postcard will be mailed to your home with the web address
where your confirma on statement can be viewed. Please review your confirma on statement carefully to ensure that your selec ons were recorded correctly. The dependents listed on your confirma on statement will dictate to the insurance providers the covered par cipants under your plan. change(s) to your voluntary life elec on over the guaranteed issue amount. You will need to complete this medical ques onnaire and return the fully completed form to the life insurance carrier. Please do not send a fully completed Personal Health Statement to the Human Resources Department. Also, please note, increased life insurance amounts remain pending un l wri en approval is received from the carrier. You have un l January 1, 2016 to submit the PHS to the carrier. Failure to do so will result in your request being closed. If you need to make changes or correc ons a er the annual enrollment period, you will have a designated change period during which you may log back onto the online system to record your changes. The designated change period is October 26, 2015, through November 2, 2015. If you make a change, you will receive a new confirma on email and postcard. The last change
you make before the enrollment deadline will determine the
benefits you receive.
While online….
You will receive a Personal Health Statement (PHS) if you made 2016 7 Insurance Carrier Contact Information
If you need to contact the carriers directly, customer service phone numbers and Web site addresses are listed below.
Medical, Prescrip on, Dental and Vision Coverage Health and Dependent Care Reimbursement Accounts Blue Cross/Blue Shield of Michigan BCBS PPO HSA Plan Customer Service: 1‐800‐637‐2227 Web site: www.bcbsm.com Health Savings Account (HSA) Next Genera on Enrollment, Inc. (NGE) Phone: 1‐866‐369‐1387 Fax: 1‐888‐267‐0839 Web site: www.nextgenera onenrollment.com Employee and Dependent Life Insurance Protec on,
AD & D, and Short and Long Term Disability Health Equity Customer Service: 1‐866‐346‐5800 Hours of Opera on: 24/7 365 days per year Web site: www.healthequity.com Lincoln Financial Customer Service Phone: 1‐800‐487‐1485 Customer Service Email: [email protected] Claims Phone: 1‐800‐423‐2765 Web site: www.lfg.com Additional Resources for your Educated Choices
BC/BS Secure Member Services Women’s Health & Cancer Rights Act
The online Secure Member Services will help you learn more about:  Managing Your Health  Personalized Health Care  Managing Your Claims  Medica on Guides and Brochures  Helping Members Save Money  Establishing an Advance Direc ve  Member Publica ons  Member Forms  Member FAQs h p://www.bcbsm.com/member On October 21, 1998, Congress passed the Women’s Health & Cancer Rights Act. This law requires group health plans that provide coverage for mastectomy to provide coverage for certain reconstruc ve services. These services include:  Reconstruc on of the breast upon which the mastectomy has been performed  Surgery/reconstruc on of the other breast to produce a symmetrical appearance  Prostheses  Treatment for physical complica ons during all stages of mastectomy, including lymph endemas In addi on, the plan may not:  Interfere with a woman’s rights under the plan to avoid these requirements  Offer inducements to the health provider, or assess penal es against the health provider, in an a empt to interfere with the requirements of the law Addi onal BC/BS Member Services Blue Cross Blue Shield of Michigan also offers BlueSafe Coupons that provide in‐store discounts; Weight Watchers discounts; Naturally Blue discounts. You can contact Blue Cross Blue Shield by calling
Customer Service at 1‐800‐637‐2227 OR logging online at www.bcbsm.com
2016 8 Additional Resources for your Educated Choices
However, the plan may apply deduc bles and co‐pays consistent with other coverage provided by the plan. This law also requires that wri en no ce of the availability of the coverage be delivered to all plan par cipants. This no ce serves to fulfill that requirement. August 1, 2012 ushered in a new provision of the health reform law that makes addi onal preven ve health services — from contracep on to HPV tes ng — available for free to an es mated 47 million women. Preven ve services that will be covered without co‐pay include: Contracep ve methods and counseling: All Food and Drug Administra on approved contracep ve methods, steriliza on procedures, and pa ent educa on and counseling for all women with reproduc ve capacity, as prescribed by a Physician* (see note). HIPAA Reminder No ce Bloomfield Hills Schools sponsors a group health plan. As such, members of the District’s workforce may have access to the individually iden fiable health informa on of Plan par cipants (1) on behalf of the Plan itself; or (2) on behalf of the District, for administra ve func ons of the Plan. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its regula ons restrict the District’s ability to use and disclose Protected Health Informa on (PHI). Protected Health Informa on means any informa on rela ng to the past, present or future physical or mental condi on of an individual that iden fies the individual or can be used to iden fy the individual. It is the District’s policy to comply fully with HIPAA requirements. Consequently, if you become a covered par cipant under the group health plan, you have a right under HIPAA to receive a No ce of Privacy Prac ces for Protected Health Informa on. To request a copy, please contact the Benefits Coordinator. 2016 9 Mental Health Parity and Addic on Equality Act
of 2008 The Mental Health Parity and Addic on Equality Act of 2008 (the “Act”) was passed by Congress on October 3, 2008 as part of the Emergency Economic Stabiliza on Act of 2008. Under the Act, group health plans that provide mental health or substance use disorder benefits must now provide coverage for those benefits at levels equal to (or greater than) the plan’s coverage for medical and surgical benefits. This law also requires that wri en no ce of the availability of the coverage be delivered to all plan par cipants. This no ce serves to fulfill that requirement. Eligible Dependent Requirements Coverage in the Educated Choices
medical, dental and vision plans is for you, your spouse and your eligible dependents. Due to Health Care Reform regula ons, children are eligible un l the end of the month that they reach age 26. During the enrollment process, you will need to enter your eligible dependent’s Social Security number (SSN) and date of birth. Note that BC/BS must have an accurate
SSN on file for your dependents in order to process
claims. Eligible dependents between the ages of 19 and 26 must meet the requirements listed below and can be covered through the end of the month in which they turn 26. This is regardless of student, financial, marital or dependency status. Overage dependent children of the subscriber or the subscriber’s spouse are eligible provided such children are:  Between 19‐26 years old  Related by blood, marriage or legal adop on Please note: Coverage provisions for dependent children
may vary based on insurance carrier. Medical and Prescription Drug Benefits
Medical Plan Coverage This sec on outlines the medical plan offered through Educated Choices, Blue PPO HSA ‐ Plan. Medical Plan Deduc ble IRS regula ons state, in 2016, High Deduc ble Health Plans (HDHP) must have minimum deduc ble amounts of $1,300 for single coverage and $2,600 for family coverage. For the 2016 plan year, Bloomfield Hills Schools will con nue to offer the HDHP through BCBS with the Health Savings Account (HSA) through Health Equity. The deduc ble for our medical plan is $1,300 single/$2,600 family. Please refer to your employment agreement for addi onal
informa on regarding the benefits available to you. Simply Blue HSA/Integrated Drug The BCBS HDHP plan has an in‐network op on that gives you access to quality medical services. Obtaining services from an in‐network provider reduces the cost as these doctors and hospitals have agreed to provide medical services at reduced rates. You decide whom you want to see at the me of service. If you select an in‐network doctor or hospital from the online directory, your covered benefits are typically greater and your cost is usually less. However, the in‐network deduc ble is higher than tradi onal health plans and there is a deduc ble for out‐of‐network services that must be met each calendar year. Prescrip on Drugs have a co‐pay and include contracep ves. Prescrip on Drugs have a mail order and retail, 90‐day supply op on with a reduced co‐pay. Services provided by an out‐of‐network provider may not be covered. You are responsible for deduc ble fees incurred for
services provided. Being covered by this HDHP may also allow you to contribute to a Health Savings Account (HSA). An HSA is a tax‐advantaged medical savings account available to taxpayers in the United 2016 States who are enrolled in a high‐deduc ble health plan (HDHP). The funds contributed to an HSA are not subject to federal income tax at the me of deposit. Unlike a flexible spending account (FSA), HSA funds roll over and accumulate year to year if not spent. HSAs are owned by the individual, which differen ates them from company‐owned Health Reimbursement Arrangements (HRA) that are an alternate tax‐
deduc ble source of funds paired with either HDHPs or standard health plans. HSA funds may currently be used to pay for qualified medical expenses at any me without federal tax liability or penalty. Withdrawals for non‐medical expenses are treated very similarly to those in an individual re rement account (IRA) in that they may provide tax advantages if taken a er re rement age, but they incur penal es if taken earlier. More informa on on HSAs can be found on the FAQ sheet included in your enrollment materials. The IRS regulates the maximum contribu on limits for HSA accounts. Below are the details for the plan year. 2016 HSA Limits (January 1 through December 31, 2016)  For Single Coverage – $3,350  For Family Coverage ‐ $6,750 HSA par cipants between age 55 and 64 who are not enrolled in Medicare, have the op on to contribute an addi onal $1,000
annually.
In order to be eligible for a health savings account, you must be able to answer no to all of the following ques ons: 1. Are you currently enrolled in Medicare? 2. Are you or your spouse enrolled in another medical plan that is not a high‐deduc ble health plan? 3. Per IRS regula ons, one cannot be enrolled into a Health Savings Account (HSA) and a Health Care Flexible Spending Account (FSA) at the same me. On January 1, will you or your spouse be enrolled in an FSA or have money le in an FSA? 4. Will you be claimed as a dependent on another person’s tax return this year? For full details of this medical plan, please review the summary of benefits included with your materials. 10 Medical and Prescription Drug Benefits
generic equivalents may also be available. If you want to know if you can have your prescrip on changed to a Tier 1 or Tier 2 medica on, speak with your physician to see if a change is appropriate for you. BCBSM’s Custom Formulary Quick Guide for Members lists commonly prescribed medica ons available under each er. You can find the Custom Formulary Quick Guide for Members at www.bcbsm.com.From the Member Page: Medicare Enrolled Staff or Family Members If you or a family member are enrolled with Medicare, a copy of the enrollment card must be forwarded to the Benefits Coordinator during annual open enrollment. BCBS and the Center for Medicare/Medicare Services (CMMS) coordinate benefits with Bloomfield Hills School District being the primary payee. It is cri cal that we have the correct informa on to submit to these servicing agencies in order for claims to be properly paid. If you or a family member become enrolled with Medicare during the plan year, a copy of the enrollment card should be forwarded to the Benefits Coordinator at that me. 
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Prescrip on Drugs A drug you are taking may not be covered under this prescrip on drug plan. You should check the Custom Formulary
Quick Guide for Members prior to your new plan’s effec ve date to see if your medica on is covered. If it isn’t covered, contact your physician to have your prescrip on changed, if determined appropriate, to a covered drug. You have a triple‐ er drug plan. BCBSM’s formulary, a list of covered medicines, is divided into three ers by drug type. What you pay depends on what er your drug is in. Tier 1 – Generic Tier 1 drugs are generic drugs. They require the lowest
co‐payment, making them the most cost effec ve op on for treatment. Many prescrip on drugs are available as generics. Duplica on of Coverage/Dual Medical Coverage Tier 2 – Formulary Brand Tier 2 drugs are brand‐name drugs. Tier 2 drugs are also safe and effec ve but require a higher co‐
payment than Tier 1 drugs. Tier 3 – Non‐formulary Brand Tier 3 drugs are brand‐name drugs not included in Tier 2. These drugs require the highest co‐payment. You may also have to pay the difference between the cost of the Tier 3 non‐formulary brand‐name drug and the generic if a generic equivalent is available but the brand is dispensed. Generic equivalents or formulary brand‐name alterna ves are available for many of these Tier 3 drugs. Similar drugs with 2016 Click on Prescrip on Drugs Click on Approved Drug Lists (Formularies) Click on Custom Formulary Click on Download the Custom Formulary Quick Guide (PDF) You have the ability to enroll with Dual Medical Coverage. However, if you are enrolled with the District’s High Deduc ble Health Plan with a Health Savings Account you are not eligible to be enrolled through a Non‐High Deduc ble Health Plan with your spouse or parent. If you are enrolled with a Non‐High Deduc ble Health Plan, you are eligible to enroll in the BHSD medical coverage in addi on to enrolling in the medical coverage provided through the medical plan provided by your spouse’s employer. (However, you will not be eligible to enroll with the health savings account). To do this you will be required to provide the district with the following informa on:  Spouse’s Employer’s Name  Address of Carrier  Employee and Spouse’s Name  Group Number  Insured’s Name and Social Security Number  I.D. Number  Name of Carrier  Effec ve Date of Coverage 11 Medical and Prescription Drug Benefits
Medical Opt‐Out You can opt‐out of medical coverage for yourself and your dependents as indicated in your employment agreement. If you involuntarily lose your other medical coverage, this plan allows you to select a Bloomfield Hills Schools’ medical plan. However, you must no fy the Benefits Coordinator within
30 days of your loss of coverage in order to opt back into a
medical plan. Mid‐plan year life status changes require a
mee ng with the Benefits Coordinator. Please contact the
Benefits Coordinator within 30 days of the life event to
schedule an appointment. Voluntary changes can only be
made once per year during the Educated Choices open
enrollment. If you choose to decline the medical coverage offered by Bloomfield Hills Schools, you will not need to complete a waiver form. Instead, you will be able to waive coverage during the online enrollment process if you decline to enroll into a medical op on. To enroll in the Medical Opt‐Out plan online, you will first need to decline the Medical HDHP op on. If you qualify for the opt‐out credit, you will be directed to the Medical Opt‐
Out plan page where you will need to enroll into the opt‐out 2016 plan. Make sure to check the box next to each of your dependents. This informa on is used to determine who would be eligible for medical coverage and the value of your opt‐out amount (single, two‐person or family). Bloomfield Hills Schools will add the cash credit to each paycheck through the flex plan year payroll process (no contribu ons made in July and August). Your Medical Plan Choices The available choices, as outlined in your employment
agreement, are displayed on your Summary of Benefits.
The funding of op ons by Bloomfield Hills Schools can be
viewed on the Online enrollment system. Important Provisions to Note  Chiroprac c services are covered under the Simply Blue PPO HSA HDHP plan. Please note that co‐pays may apply and visits may be limited to a specific number per year.  Please verify par cipa ng doctors and hospitals by using the Web sites or phone numbers listed in the Insurance Carrier Contact Informa on sec on of this workbook. 12 Dental and Vision Coverage
Dental Plan Coverage Dental plans encourage you
and your eligible dependents to
seek quality dental care on a
regular, preven ve basis as
part of a total health care
program. When par cipa ng in the dental plan, you have
the flexibility to select your own den st. Covered Services Dental services are divided into categories and reimbursements are based on “reasonable and customary” charges or schedules. 
Class I Preven ve – Benefits include examina ons, cleanings and periodic X‐rays 
Class II Basic Services – Benefits include fillings, root canal therapy, extrac ons, oral surgery, repair of dentures and bridges and periodontal services 
Class III Major Services – Benefits include inlays, crowns, bridges and dentures 
Class IV Orthodon a Services – Benefits, if applicable to your employment agreement, may include services, treatment and procedures for the alignment or correc on of teeth, up to age 19 Vision Plan Coverage Eyesight is important to your well being. Your current vision plan helps you maintain quality eye care.. When par cipa ng in the vision plan, you have the flexibility to select your own optometrist or ophthalmologist. Covered Services The vision plan offers you the following
benefits:  Eye exam screening and analysis  Correc ve lenses or contact lenses  Frames A deduc ble is required for each eye exam and for new lenses and frames (combined). Limita ons The following expenses are not covered:  Surgical or medical care for treatment of eye disease and/or injury 
Sunglasses (plain or prescrip on); photo‐sensi ve, an ‐reflec ve or aniseikonic glasses; or other nted glasses of any kind to the extent that the charges exceed the charge for clear lenses or safety lenses or goggles 
Addi onal cost for progressive lenses 
Expenses incurred for cosme c or fashion reasons 
Replacement of lost, stolen or broken lenses or frames Your Dental Plan Choices The available choices, as outlined in your employment
agreement, are displayed on your Summary of Benefits
included in your Open Enrollment Packet. The funding of
op ons by Bloomfield Hills Schools can be viewed on the
Enrollment system.
Your Vision Plan Choices The available choices, as outlined in your employment
agreement, are displayed on your Summary of Benefits
included in your Open Enrollment Packet. The funding of
op ons by Bloomfield Hills Schools can be viewed on the
Enrollment system.
2016 13 2016 14 2016 15 2016 16 2016 17 2016 18 2016 19 2016 20 2016 21 2016 22 2016 23 2016 24 2016 25 2016 26 2016 27 2016 28 2016 29 2016 30 2016 31 2016 32 2016 33 2016 34 2016 35 2016 36 2016 37 2016 38 2016 39 2016 40 2016 41 2016 42 Life Insurance and Disability Protection
Life Insurance Protec on Example One: Elec ng new coverage Bloomfield Hills Schools con nues to offer Life Insurance through Lincoln Financial. This protec on is provided to eligible staff in the form of Employee Life Insurance, Accidental Death & Dismemberment Insurance and op onal Dependent Life Insurance. Please refer to your work agreement to determine if you are eligible for District provided employee life insurance. Mrs. Jones is a Bloomfield Hills Schools employee and currently does not have Addi onal Employee Life Insurance coverage. During annual enrollment, Mrs. Jones elects Addi onal Employee Life Insurance coverage in the amount of $50,000. A er annual enrollment, Mrs. Jones will be mailed a Personal Health Statement with her Confirma on Statement package. A er comple ng her Personal Health Statement and submi ng it to the carrier, Mrs. Jones will be advised as to whether the amount (in this example, $50,000) was approved or denied. If the addi onal coverage is approved, Mrs. Jones will receive a new Confirma on Statement summarizing the new coverage amount of $50,000, effec ve upon approval. If the coverage amount of $50,000 is denied, Mrs. Jones’ current No Coverage elec on will remain in effect. Employee Life Insurance This benefit provides protec on for your family in the event of your death. Through the Educated Choices program, you may be eligible to receive basic Employee Life Insurance coverage based on your employment agreement (shown on your Summary of Benefits). You may also elect any level of addi onal insurance as outlined below: Choices Your choices for addi onal coverage may include: $ 5,000 $ 75,000 $175,000 $ 10,000 $100,000 $200,000 $ 25,000 $125,000 $225,000 $ 50,000 $150,000 $255,000 $275,000 Detailed Informa on Regarding Personal Health
Statements (Evidence of Insurability‐EOI) Personal Health Statements (Evidence of Insurability‐EOI) may be required, based on your addi onal Employee Life Insurance elec on. You will have un l January 1, 2016 to submit your Evidence of Insurability to Lincoln Financial, or your request will be declined. If you elect an addi onal Employee Life Insurance op on requiring comple on of a Personal Health Statement, the coverage and associated payroll deduc on will not begin un l your request for coverage is approved or denied by the carrier. If you do not submit an EOI form by January 1, 2016, your request for the addi onal coverage will be terminated. 2016 Example Two: Elec ng to increase coverage Mr. Smith is a Bloomfield Hills Schools employee and currently has $50,000 in Addi onal Employee Life Insurance coverage. During annual enrollment, Mr. Smith elects to increase his Addi onal Employee Life Insurance coverage amount by one level — to $75,000. A er annual enrollment, Mr. Smith will be mailed a Personal Health Statement with his Confirma on Statement package. A er comple ng his Personal Health Statement and submi ng it to the carrier, Mr. Smith will be advised as to whether the amount (in this example, $75,000) was approved or denied. If the addi onal coverage is approved, Mr. Smith will receive a new Confirma on Statement summarizing the new coverage amount of $75,000, effec ve upon approval. If the coverage amount of $75,000 is denied, Mr. Smith’s current coverage amount of $50,000 will remain in effect. Please note: If you elect an Addi onal Employee Life Insurance
op on requiring a Personal Health Statement to be completed,
the coverage and associated payroll deduc on will not begin
un l your request for coverage is approved or denied by the
life insurance carrier. 43 Life Insurance and Disability Protection
Please also note that you will have un l January 1 of each
year to complete and submit your Personal Health
Statement to the carrier. The request for addi onal
coverage will be terminated if the EOI form is not
submi ed by January 1, 2016. Schedule of Benefits Both Hands or Both Feet .................................... 100% Sight of Both Eyes .............................................. 100% One Hand and One Foot..................................... 100% Imputed Income One Hand and Sight of One Eye ......................... 100% When you purchase insurance in excess of $50,000, you are subject to the IRS’ imputed income rules. Imputed income is the value of your life insurance over $50,000. You are required to pay federal and state income taxes and Social Security tax on this “excess” amount. The amount of tax you pay is based on your age. The value of the life insurance in excess of $50,000 will be reported on your W‐2. One Foot and Sight of One Eye .......................... 100% One Hand or One Foot ......................................... 50% Sight of One Eye ................................................... 50% Limita ons Benefits will not be paid for a loss: Considera ons for Enrollment 
caused by suicide or self‐inflicted injuries When choosing the level of life insurance that is right for you, consider your family situa on. 
caused by or resul ng from war or any act of war, declared or undeclared 
to which sickness, disease or myocardial infarc on, including medical or surgical treatment thereof, is a contribu ng factor 
sustained during the Insured’s commission or a empted commission or an assault or felony 
to which the Insured’s acute or chronic alcoholic intoxica on is a contribu ng factor 
How many people depend on your income? 
In your household, is your income primary or secondary? 
If you died, what major expenses would con nue, such as a mortgage on your home or tui on for your children’s college educa on? 

Do you have any other sources of income, such as personal life insurance benefits, Social Security or pension benefits? How long would your basic employee life policy sustain your family? Bloomfield Hills Schools will provide you with basic AD&D coverage (shown on your Summary of Benefits). Benefit Dollars
Accidental Death and Dismemberment (AD&D) Dependent Life Insurance AD&D coverage is provided to protect you or your family in case of your accidental death or the loss of a limb or your eyesight. Benefits Dependent Life Insurance is a voluntary benefit offered through Educated Choices
on an a er‐tax basis. This insurance is designed to assist you financially in the event that your spouse or child(ren) dies. In the event of your accidental death, your beneficiary would receive 100 percent of your basic coverage. In the event of a loss resul ng from an injury, you would be en tled to payment based on the following schedule: Choices You can choose from the following op ons:  $10,000 spouse/$10,000 child(ren)  $10,000 spouse 2016 44 Life Insurance and Disability Protection
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



$10,000 child(ren) $5,000 spouse/$5,000 child(ren) $5,000 spouse $5,000 child(ren) No Coverage Limita ons All employees must be ac vely at work to be eligible for the life insurance plan. Accelerated Death Benefit The accelerated death benefit allows an employee to elect 75% of their life insurance benefit up to a maximum of $500,000; the payout will be made in a lump sum. This benefit is payable to the Insured one me only and permanently reduces the Insured’s death benefit, including any amount of eligible benefit under the waiver of premium and/or conversion provisions, if applicable. In order to qualify for this benefit, the Insured must have been covered under this Rider for a minimum of 60 days and cer fied as terminally ill. Terminally ill refers to an illness or physical condi on, when cer fied by a duly licensed physician ac ng within the scope of his license, is reasonably expected to result in death in less than 12 months. The applica on for this benefit must be made in wri ng (the Accelerated Benefit form) and include the beneficiary’s signed acknowledgment and agreement to the payment of this benefit. Eligible Dependent Requirements If a child dies from the 1st day of birth to age 14 days the benefit will be $500.Between the ages of 15 days and the end of the month they turn age 26 years, the benefit will be $5,000 or $10,000, depending on the op on chosen. Please note: Dependent children may be covered under
your dependent life insurance plan through the end of the
month in which they turn age 26.
2016 Benefit Dollars Bloomfield Hills Schools does not provide Benefit Dollars for the purchase of this benefit. The tax laws require that this benefit be deducted from your salary on an a er‐tax basis. Detailed Informa on Regarding Personal Health
Statements (Evidence of Insurability‐EOI) Personal Health Statements (Evidence of Insurability‐EOI) may be required, based on your Dependent Life Insurance elec on. If you elect a Dependent Life Insurance op on requiring comple on of a Personal Health Statement, the coverage and associated payroll deduc on will not begin un l your request for coverage is approved or denied by the carrier. Personal Health Statements are not required for children. Example One: Elec ng new coverage for a spouse Mrs. Adams is a Bloomfield Hills Schools employee and currently does not have Dependent Life Insurance coverage. During annual enrollment, Mrs. Adams elects Dependent Life Insurance coverage in the amount of $5,000 Spouse. A er annual enrollment, Mrs. Adams will be mailed a Personal Health Statement (for her spouse) with her Confirma on Statement. A er comple ng the Personal Health Statement and submi ng it to the carrier, Mrs. Adams will be advised as to whether the amount (in this example, $5,000 Spouse) was approved or denied. If the addi onal coverage is approved, Mrs. Adams will receive a new Confirma on Statement summarizing the new coverage amount of $5,000 Spouse, effec ve upon approval. If the coverage amount of $5,000 is denied, Mrs. Adams’ current No Coverage elec on will remain in effect. Example Two: Elec ng new coverage for a child Mr. Roberts is a Bloomfield Hills Schools employee and currently does not have Dependent Life Insurance coverage. During annual enrollment, Mr. Roberts elects Dependent Life Insurance coverage in the amount of $10,000 Child(ren). 45 Life Insurance and Disability Protection
A er annual enrollment, Mr. Roberts will receive a Confirma on Statement, summarizing the new coverage amount of $10,000 Child(ren). A Personal Health Statement is not required. Example Three: Increasing coverage for a spouse or child Mr. White is a Bloomfield Hills Schools employee and currently has $5,000 Spouse / $5,000 Child(ren). During annual enrollment, Mr. White elects Dependent Life Insurance coverage in the amount of $10,000 Spouse / $10,000 Child(ren). A er annual enrollment, Mr. White will be mailed a Personal Health Statement, for his spouse only, with his Confirma on Statement. A Personal Health Statement is not required for child(ren). A er comple ng the Personal Health Statement and submi ng it to the carrier, Mr. White will be advised as to whether the amount (in this example, $10,000 for his spouse) was approved or denied. If the addi onal coverage is approved Mr. White will receive a new Confirma on Statement summarizing the new coverage amount of $10,000 Spouse and $10,000 child(ren), effec ve upon approval. If the coverage amount of $10,000 spouse is denied Mr. White’s current amount of $5,000 Spouse and new amount of $10,000 child(ren) will be in effect. Considera ons for Enrollment 
Do you have a working spouse? 
If your spouse is employed, does he or she have any life insurance protec on through his or her employer? 
Do you currently have life insurance coverage for your children? 
How would you handle burial expenses in the event of the death of a family member? Short‐Term Disability Bloomfield Hills Schools may provide Short‐Term Disability coverage to you at no cost. The specific features of your Short‐Term Disability plan (as defined in your employment agreement) are outlined in your Summary of Benefits. At this me, addi onal levels of coverage are not available through Educated Choices. Long‐Term Disability Bloomfield Hills Schools may provide Long‐Term Disability coverage to you at no cost. The specific features of your Long‐Term Disability plan (as defined in your employment agreement) are outlined in your Summary of Benefits. At this me, addi onal levels of coverage are not available through Educated Choices. Benefits Bloomfield Hills Schools will provide you (if eligible) with a disability benefit equal to a percentage of your basic monthly earnings, not to exceed your maximum monthly benefit as outlined in your employment agreement. The minimum monthly benefit is the greater of $100, or 10 percent of employee’s gross disability payment. Upon approval from the carrier, payments begin a er you sa sfy a “wai ng period” following the onset of your disability. If you become disabled prior to age 60, payments con nue un l you die, recover or reach age 65. Disabili es beginning a er age 60 are paid by a schedule based on your age when the disability began. Social Security and other income benefits paid to you and your
family are included in the percentage amount. This disability
plan makes up the difference between these amounts and the
guaranteed percent of pay.
2016 46 Reimbursement Account Services
Health Savings Accounts How Do Flexible Spending
Reimbursement Accounts Work? How Does It Work? 
You determine the amount you want to contribute to each account for the plan year on an annual basis. A minimum contribu on of $150 is required. Contribu ons for the plan year are limited to a maximum of $2,550 for the Health Care Reimbursement Account and a maximum of $5,000 for the Dependent Care Reimbursement Account. 
Your per‐pay deposit/contribu on is withheld from each paycheck before taxes are calculated. 
You pay expenses at the me of purchase with your Benefits MasterCard; or 
You incur and submit expenses for reimbursement via fax or mail. The reimbursement is tax free. Step 1: Enroll in an HSA‐eligible health plan – Your Employer will offer you an HSA‐eligible health plan. This is a health care plan that does not pay for health care expenses un l you pay a set amount as a deduc ble. Your plan will cover you a er you meet your deduc ble. Step 2: Access your HSA – Once you’ve selected your health plan, you will receive a welcome kit with informa on on how to access and use your Healthy Blue HSA. Step 3: Contribute to your HSA – Contribu ons to your HSA can be made by you, your employer or both. Rela ves and friends can also contribute to your HSA. The maximum HSA contribu on allowed for 2016 is $3,350 for single coverage and $6,750 for family coverage. These dollar amounts are adjusted annually by the federal government. If you are 55 or older, you are eligible for an addi onal $1,000 catch‐up contribu on each year un l you enroll in Medicare. The money in your account will automa cally roll‐over from year to year and remain in your account un l you use it. Those staff age 65 or older and enrolled with Medicare are not eligible for par cipa on in a health savings account. Step 4: Use your money – You control how the money in your HSA is spent. You may use the money to cover your copayment and deduc ble requirements for services covered through your health plan or to pay for qualified medical expenses not covered by your health plan. It’s important to know what is considered a qualified medical expense. It’s also important to keep your receipts, in case you need to defend your spending for a tax audit. If you use money in your HSA for something other than a qualified medical expense, you’ll have to pay income taxes on that amount. You’ll also have to pay a 20 percent tax penalty (unless you are disabled or have a ained age 65). If you are age 65 or older and enrolled in Medicare, you are not eligible to par cipate in the HSA. Step 5: Invest your money – You may invest the money in your account if you choose. The same types of investments permi ed for an individual re rement account are allowed for an HSA. You can grow your savings by inves ng in a wide variety of mutual funds.
2016 47 Flexible Spending Account (FSA) Changes Employees who enroll into the HDHP and the HSA are not eligible to enroll into the FSA plan. NOTE: Employees age 65 or older (and are enrolled in Medicare) that enroll into the HDHP are not eligible to enroll into the HSA. However they may enroll into the FSA Plan. Bloomfield Hills Schools may be funding a por on of their FSA should they elect. REMEMBER: You must re‐enroll annually for your Health Care Reimbursement and Dependent Care Reimbursement account(s); elec ons do not automa cally rollover.
Reimbursement Account Services
FSA Plan Year
Our FSA plan year is January 1 through December 31. Re rement, Leave of Absence and Termina on — Based upon IRS
rulings, should your employment terminate mid‐plan year, you have 60
days from your date of termina on to submit eligible expenses. These
claims must be incurred prior to your termina on date, for both health
care and dependent care reimbursement. Claims received a er the 60‐
day period will be denied. The current plan year ends December 31,
2015. If you have not terminated employment, you have 60 days (un l
March 1, 2016) to submit eligible expenses for the current plan year.
Mid‐plan year life status changes require a mee ng with the Benefits
Coordinator. Please contact the Benefits Coordinator within 30 days of
the life event to schedule an appointment. Benefits MasterCard The Benefits MasterCard works like a debit card against your Flexible Spending Account and streamlines the reimbursement process so you do not have to wait to be reimbursed. It is accepted at most large retailers. You will not be required to submit receipts when using the Benefits MasterCard but for recordkeeping purposes you should retain all receipts. If you are currently enrolled into the flexible spending account and already have a debit MasterCard, please retain your current card for use during the new plan year. Your new elec on will be loaded onto that card. If your current card is expiring this year, you will receive a new card in the mail prior to the start of the plan year. If you are new to the flexible spending account this year, a card will be ordered for you and will arrive at your home shortly before the start of the plan year, however please be aware that it will not be effec ve un l the start of the plan year. If you would like to order a card for your spouse, you may do so during your enrollment. Your Benefits MasterCard will arrive at your home address in a plain white envelope. Also, you will not have to ac vate your card, it will automa cally ac vate on the first swipe. NOTE: Your FSA Benefits MasterCard is not the same as the
HealthyBlueHSA Visa® Debit card. If you enroll into the Flexible
Spending Account you will receive a Benefits MasterCard, if you enroll
into the Health Savings Account you will receive the HealthyBlueHSA
Visa® Debit card.
2016 48 How to Receive Reimbursement 1. Use your Benefits MasterCard to pay for eligible expenses at the me of purchase; no receipt submission for reimbursement is required at the me of purchase. 2. If you do not use your Benefits MasterCard, once you pay an expense for health care or dependent care services you may request reimbursement. 3. To submit manual claims for reimbursement you may use the online system. You will complete and print the online form to include with your receipts. 4. Access the NGE online system at www.nextgenera onenrollment.com. Once
there, Click on “Par cipants” and then click
on “FSA/ HRA/HSA Plan Par cipants”. Finally,
click on “Submi ng For Reimbursements”. 5. You may also submit expenses for reimbursement via fax, mail or by email to clientservices@ nextgenera onenrollment.com. 6. A er your request is processed a reimbursement check will be mailed to your home. If you are enrolled for direct deposit, the reimbursement will be deposited to your bank account. 7. Each par cipant is responsible for keeping records to support these expenses, including those purchased with the Benefits MasterCard. You may be asked to substan ate Benefits MasterCard purchases with receipts. If you fail to do so upon request please note your account may be inac vated un l such me you supply NGE with the required claim documenta on. Reimbursement Account Services

At A Glance ‐ Reimbursement Accounts Bloomfield Hills Schools offers you the opportunity to par cipate in Health Care and Dependent Care Reimbursement Accounts, and Health Savings Accounts. A Reimbursement Account is a tax‐free way of paying for eligible out‐of‐pocket health care and dependent care expenses. By par cipa ng in these accounts you have the opportunity to pay for these expenses using pretax dollars — you do not pay federal, state or Social Security taxes on the dollars you contribute. As a reimbursement par cipant, you will have access to a reimbursement administra on system. The NGE and Health Equity systems will provide services to help you manage your reimbursement account(s). 
Review elec on informa on and manage your account using the Benefit Center. Representa ves will be able to assist you with your Reimbursement Account ques ons. For FSA call toll free at 1‐866‐ 369
‐1387.For HSA call toll free 1‐866‐346‐5800. 
Access detailed FSA account informa on online at — www.nextgenera onenrollment.com. Once there, Click on “Par cipants” and then click on “FSA/HRA/ HSA Plan Par cipants”. Finally, click on “FSA/HRA/ HSA System Login”. Access detailed HSA account informa on at www.healthequity.com.
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2016 View a detailed Explana on of Benefits for FSA reimbursements, including line‐by‐line detail of each claim submi ed, status of each claim processed, and denial informa on. How to Enroll with FSA and HSA Accounts Enrollment in the Reimbursement Account(s) is part of your annual Educated Choices online enrollment process outlined on pages 6‐7 of this workbook. Planning Carefully The following IRS regula ons apply to Reimbursement Accounts: Access detailed HSA account informa on at www.bcbsm.com. Once there, type in your username and password at Member Secured Services. Select the Healthy Blue HSA/HRA/FSA tab and click “My Health Blue HSA/HRA/FSA Account”. If you have never logged on before, select that you are logging on for the first me as a member. Be prepared to enter your first and last name, the last four digits of your Social Security number, birth date and the zip code of your current residence. This informa on is used to iden fy you as the actual account holder. If you have ques ons related to your Healthy Blue account, including how to log on and how to best use your accounts, please contact Health Equity at (877) 284‐9840. Print your personalized FSA Health Care or Dependent Care Flexible Spending Reimbursement Form and link to contribu on and reimbursement schedules. 49 
Once you decide to par cipate in the Health Care and/or the Dependent Care Reimbursement Account(s), your enrollment must remain in effect un l the end of the plan year. Each year you will have an opportunity to enroll again. 
The “Use it or Lose It” rule applies to both Health Care
and Dependent Care Reimbursement Account(s). Any
balance in the Reimbursement Account(s) that is not
used for eligible expenses must be forfeited. You will
have 60 days a er the end of the plan year or the date
you are no longer enrolled in the plan (whichever
comes first) to submit eligible expenses incurred
during that same year for reimbursement. 
You may change your payroll deduc on amount for your Health Care and/or Dependent Care Reimbursement Account(s) during the plan year, only if you have a life status change. IRS‐approved changes
include a change in marital status, death of spouse or
child, birth or adop on of a child and termina on of
employee’s or spouse’s employment. 
As you know, the benefit you may receive from the Social Security program is based in part on the amount of Social Security tax you pay. With any Reimbursement Account, you will pay slightly lower Social Security taxes. The effect on the benefits you or your family may receive from Social Security should be minimal. Reimbursement Account Services
Tax Savings The following table shows the approximate dollar amount you may save by using the Health Care and/or Dependent Care Reimbursement Account(s), depending on your combined tax bracket. Tax Savings by Combined Tax Bracket (rounded) Federal Tax Rate 15.00% 25.00% 28.00% State Tax Rate 4.25% 4.25% 4.25% FICA Tax Rate 6.2% 6.2% 6.2% 25.45% 35.45% 38.45% Combined Tax Rate Account Deposit
2016 Es mated Tax Savings
$150 $38 $53 $58 $200 51 71 77 $500 127 177 192 $1,000 255 355 385 $1,500 382 532 577 $2,000 509 709 769 $2,500 636 886 961 $3,000 764 1,064 1,154 $3,500 891 1,241 1,346 $4,000 1,018 1,418 1,538 $4,500 1,145 1,595 1,730 $5,000 1,273 1,773 1,923 50 Reimbursement
Account Services
Health Care Reimbursement Account Expenses payable through the Health Care Reimbursement Account may include charges for contact lenses, eyeglasses, dental expenses, deduc bles and co‐payments. In fact, any dental, vision or hearing expenses that would otherwise qualify as a deduc on on your income tax return will qualify for reimbursement, provided the expense is not paid by another benefit plan. Medical expenses are also eligible for reimbursement provided that you are not enrolled into an HSA. A detailed lis ng of eligible expenses is provided in this sec on of the workbook. Es ma ng Health Care Expenses To es mate how much money the Health Care Reimbursement Account or HSA may help you save, make a list of medical, dental, vision or hearing expenses not covered by any insurance program that you expect to incur during the plan year January 1, 2016 through December 31, 2016. Es mate the dollar value of these expenses and mul ply the total by your combined tax rate for federal, state and Social Security taxes to es mate your savings. The following examples illustrate possible tax savings incurred by par cipa ng in the Health Care Reimbursement Account. Example Two: (Married Par cipant) Mr. and Mrs. Smith, a working couple with a combined income of $120,000, pay approximately 38.45% in taxes (28% federal, 4.25% state, and 6.2% FICA [rounded]). They have the following expenses: Example One: (Single Par cipant) Mary Jones is single, earning $27,000 and has approximately a 25.45% tax rate (15% federal, 4.25% state, and 6.2% FICA [rounded]). She has the following expenses: Eligible Expenses
Amount Prescrip on Drug Copays $150 Eligible Over‐the‐Counter Expenses $100 Lasik Surgery $2,000 Dental Expenses $100 Total Out‐Of‐Pocket Expenses $2,350 By paying for expenses through the Health Care Reimbursement Account, Mary Jones could save approximately $598.07 per year ($2,350 x 25.45%). Eligible Expenses
Amount Prescrip on Drug Copays $150 Eligible Over‐the‐Counter Expenses $50 Lasik Surgery $2,000 Total Out‐Of‐Pocket Expenses $2,200 By paying for expenses through the Health Care Reimbursement Account, Mr. and Mrs. Smith could save approximately $845.90 per year ($2,200 x 38.45%). The reimbursable expense lis ng included in this workbook along with the worksheets on the following pages will help you to determine how much to contribute to this account. 2016 51 Reimbursement Account Services
Health Care Reimbursement Account
Lis ng of Allowable and Disallowable Expenses Dental & Orthodon c Care Allowable expenses:  Dental treatment  Ar ficial teeth/dentures  Braces, orthodon c devices Expenses specifically disallowed by the IRS or courts:  Teeth whitening  Toothbrushes and toothpaste, even if special type is recommended by den st Therapy Treatments
Allowable expenses:  X‐ray treatments  Treatment for alcoholism or drug dependency  Legal steriliza on  Acupuncture  Vaccina ons  Hair transplant  Physical therapy (as a medical treatment)  Fee to use swimming pool for exercises prescribed by physician to alleviate specific medical condi on such as rheumatoid arthri s  Speech therapy  Smoking cessa on programs and prescribed drugs to alleviate nico ne withdrawal Expenses specifically disallowed by the IRS or courts:  Physical treatments unrelated to a specific health problem (e.g., massage for general well being)  Any illegal treatment  Cosme c surgery  Treatment for baldness (unless it is for a specific medical condi on and not for cosme c purposes)  Electrolysis (unless it is for a specific medical condi on and not for cosme c purposes) Fees/Services
Allowable expenses:  Physician’s fees and hospital services  Nursing services for care of a specific medical ailment  Cost of a nurse’s room and board if paid by the taxpayer
where nurse’s services qualify  Social Security tax paid with respect to wages of a nurse
where nurse’s services qualify  Services of chiropractors  Chris an Science prac oner fees  Diagnos c tests Expenses specifically disallowed by the IRS or courts:  Payments to domes c help, companion, babysi er, chauffeur,
etc. who primarily render services of a non‐medical nature  Nursemaids or prac cal nurses who render general care for
healthy infants  Fees for exercise, athle c, or health club membership when there
is no specific health reason for needing membership  Marriage counseling provided by clergyman Hearing Expenses
Allowable expenses:  Hearing aids and hearing aid ba ery  Hearing aid repair  Special telephone equipment 2016 52 Reimbursement Account Services
Health Care Reimbursement Account
Lis ng of Allowable and Disallowable Expenses Medicine and Drugs
Expenses specifically disallowed by the IRS or courts: Allowable expenses:  Medicine and drugs for personal, general health, or cosme c
 Medicine and drugs that require a prescrip on purposes  Insulin  Dietary supplements if for general health  Prescribed over the counter medicine and drugs when used to
alleviate or treat personal injuries or sickness (including
antacids, an histamines, aspirin/pain relievers, cold
medicines, acne medicine, etc.) Medical Equipment
Allowable expenses:  Blood Sugar test kits  Wheelchair or autoe e (cost of opera ng/maintaining)  Crutches (purchased or rented)  Special ma ress & plywood boards prescribed to alleviate
arthri s  Oxygen equipment and oxygen used to relieve breathing
problems that result from a medical condi on  Ar ficial limbs  Support hose (if medical necessary)  Wigs (where necessary to mental health of individual who
loses hair because of disease)  Excess cost of orthopedic shoes over cost of ordinary shoes  Breast pumps for nursing mothers Expenses specifically disallowed by the IRS or courts:  Wigs, when not medically necessary for mental health  Vacuum cleaner purchased by an individual with dust allergy  Mechanical exercise device not specifically prescribed by
physician Physicals
Allowable expenses:  Physicals and other well visits  Immuniza ons Expenses specifically disallowed by the IRS or courts:  Physicals for employment purposes Vision Care
Allowable expenses:  Optometrist’s or ophthalmologist’s fees  Eyeglasses and prescrip on sunglasses  Insurance for replacement of lost or damaged contact lenses  Contact lens and contact lens solu ons 2016 
53 Laser eye surgery Reimbursement Account Services
Health Care Reimbursement Account
Lis ng of Allowable and Disallowable Expenses Assistance for the Handicapped Allowable expenses:  Cost of guide for a blind person  Cost of note‐taker for a deaf child in school  Cost of Braille books and magazines in excess of cost of
regular edi ons  Seeing eye dog (cost of buying, training and maintaining)  Household visual alert system for deaf person  Excess costs of specifically equipping automobile for
handicapped person over cost of ordinary automobile; device
for li ing handicapped person into automobile  Special devices, such as tape recorder and typewriter, for a
blind person Miscellaneous Charges
Allowable expenses:  X‐rays  Expenses of services connected with dona ng an organ  Excess cost of medically prescribed diet  The cost of a medically prescribed weight loss program  Breast reconstruc ve surgery following mastectomy as part
of treatment for cancer  Contracep ves  Fer lity treatments  Medical records charges  Bandages  Lacta on supplies for nursing mothers  Cost of transporta on (e.g.) mileage) primarily for and
essen al to medical care Expenses specifically disallowed by the IRS or courts:  Expenses of divorce when doctor or psychiatrist recommends
divorce  Cost of toiletries, cosme cs, and sundry items (e.g., soap,
toothbrushes)  Cost of special foods taken as a subs tute for regular diet, when
the special diet is not medically necessary or taxpayer cannot
show cost in excess of cost of a normal diet  Maternity clothes  Diaper service  Dis lled water purchased to avoid drinking fluoridated county
water supply  Installa on of power steering in automobile  Pajamas purchased to wear in hospital  Mobile telephone used for personal calls as well as calls to
physician  Union dues for sick benefits for members  Contribu ons to state disability funds  Auto insurance providing medical coverage for all persons injured
in or by the taxpayer’s automobile, where amounts allocable to
taxpayer and dependent is not stated separately  Long‐term care services  Funeral expenses Insurance
Allowable expenses:  None 2016 Expenses specifically disallowed by the IRS or courts:  Health insurance premiums (including individual and non‐
employer sponsored coverage)  Long term care insurance premiums 54 Reimbursement Account Services
Health Care Reimbursement Account Worksheet
This worksheet can help you plan and prepare for your enrollment decisions. It is designed so you can es mate the amount of eligible expenses you could have reimbursed through the Health Care Reimbursement Account. Minimum Annual Contribu on: $150
Maximum Annual Contribu on: $2,550 Expected Out‐of‐Pocket Expenses
For the 1/1/2016—12/31/2016 Plan Year
General Eligible Expenses
Medical Deduc bles, Copayments and Above‐Plan Limits $ __________________ Lab and X‐Ray Deduc bles & Copayments $ __________________ Dental Deduc bles, Copayments and Above‐Plan Limits $ __________________ Orthodon a $ __________________ Vision Expenses (Eye Exams, Glasses, Contact Lenses) $ __________________ Other Eligible Expenses
Vision Care $ __________________ Hearing Care $ __________________ Other: _____________________ $ __________________ Total Health Care Expenses (Not Covered Under Other Health Plans) $ __________________ Es mated Tax Savings
1. Total Health Care Expenses $ __________________ 2. Federal Income Tax: Wage Base Table Below __________________ % 3. Social Security Tax Rate 6.2% 4. State Income Tax Rate 4.25% 5. City Income Tax (if Applicable 6. Total Tax Rate (Add Lines 2, 3, 4 and 5) 7. Es mated Tax Savings (Mul ply Line 1 By Line 6) __________________ % __________________ % $ __________________ 2015 Wage Base Table
Wages Paid in 2015—Single
Wages Paid in 2015—Married Filing Jointly
Adjusted Gross Income
Adjusted Gross Income
Over
Tax Rate
$9,225 10.0% $9,225 $37,450 15.0% $37,450 $90,750 25.0% $90,750 $189,300 $189,300 $411,500 $0 $413,200 and over But Not Over
Over
But Not Over
Tax Rate
$18,450 10.0% $18,450 $74,900 15.0% $74,900 $151,200 25.0% 28.0% $151,200 $230,450 28.0% $411,500 33.0% $230,450 $411,500 33.0% $413,200 35.0% $411,500 $464,850 35.0% 39.6% $464,850 and over $0 39.6% Above are federal rates in effect for 2015. Please note that the informa on contained in this table is a summary and is not intended as tax advice or as an authorita ve
IRS reference. 2016 55 Reimbursement Account Services Dependent Care Reimbursement Account This account will reimburse you for childcare or dependent care expenses to enable you and your spouse to work outside the home. This includes the cost of a childcare center, a babysi er or a person to care for a disabled dependent, spouse or parent. You can pay a rela ve to take care of your child(ren) or to care for a disabled spouse or parent. However, you cannot pay a dependent (a teenage daughter, for example) to take care of another dependent. A detailed lis ng of eligible dependents and expenses is
provided in this sec on of the workbook. If you decide to u lize the Dependent Care Reimbursement Account, you cannot use
the Federal Tax Credit for the same expenses. Es ma ng Dependent Care Expenses If you are or will be incurring Dependent Care expenses, the following examples may help to show you how the Dependent Care Reimbursement Account can save you tax dollars. Please note the maximum amount you may contribute on an annual basis to the
Dependent Care Reimbursement Account is $5,000 per household ($2,500 for married couples filing separately). Example One: (Single Par cipant) John Miller is a single parent earning $27,000 and has approximately a 25.45% tax rate (15% federal, 4.25% state, and 6.2% FICA [rounded]). Each year, John Miller pays $3,600 for day care expenses. When Mr. Miller has paid the day‐care expense and has the funds in the account, he can submit a receipt in order to be reimbursed for that expense. By paying for expenses through the Dependent Care Reimbursement Account, John Miller could save approximately $916.20 per year ($3,600 x 25.45%). Example Two: (Married Par cipant) Mr. and Mrs. Roberts, a working couple with a combined income of $120,000, pay approximately 38.45% in taxes (28% federal, 4.35% state, and 6.2% FICA [rounded]). Each year, Mr. and Mrs. Roberts pay approximately $5,000 for day care expenses. When Mr. and Mrs. Roberts pay the day care expenses and have the funds deposited in the Dependent Care Reimbursement Account, they can submit a receipt in order to be reimbursed for that expense. By paying for expenses through the Dependent Care Reimbursement Account, Mr. and Mrs. Roberts could save approximately $1,922.50 per year ($5,000 x 38.45%). Remember you may need to reduce the number of weeks you use day care by the number of holidays, vaca on days and
unscheduled days you have allo ed each year. The worksheets on the following pages will help you determine if the Dependent Care Reimbursement Account is more advantageous for you than the Federal Income Tax Credit. A detailed lis ng of eligible expenses is included in this sec on of the workbook. 2016 56 Reimbursement Account Services
Dependent Care Reimbursement Account Eligibility Requirements
A key criteria for eligibility is that you are employed and covered under this plan at the me your eligible dependent receives care. You must also meet one of the following requirements for eligibility: 
Your spouse is working or looking for employment. 
You are a single parent or guardian. 
At a me when you are employed, your spouse is a full‐ me student at least five months during the year. 
Your spouse is mentally or physically disabled and unable to provide for his/her own care. 
You are legally separated or divorced and have custody of your child even though you may not be able to consider your child a dependent. For the period that the child resides with you, this Dependent Care Reimbursement plan can be used to pay for child‐care services. An Eligible Dependent is a qualifying individual spending at least eight hours a day in your home and is one of the following:  Your dependent under age 13 for whom you claim an exemp on on your income taxes. (If your dependent turns 13 during the plan year, expenses are no longer eligible for reimbursement). A child under the age of 13 for whom you have custody if divorced or legally separated. 
Your spouse if mentally or physically unable to provide self care. 
Your dependent, regardless of age, who is mentally or physically unable to provide self care even if you cannot claim an exemp on for this dependent on your income taxes. 2016 57 Eligible expenses for reimbursement include:  Care received inside or outside your home by someone other than your spouse, a person listed as a dependent on your income tax return, or one of your children under age 19. The child‐care provider must claim the payments they receive as income. 
Care received from a qualifying child day‐care center or adult or dependent care center. 
Care provided by a housekeeper as long as the services provided, in part, are the care of a qualified dependent. 
Care provided through nursery, preschool, a er‐school, or summer day camp programs. Taxes for wages spent on eligible dependent care can also be submi ed for reimbursement. Ineligible Expenses  Dependent care for a child age 13 or over. 
Non work‐related babysi ng. 
Schooling in kindergarten and beyond. 
Overnight camp. All submi ed receipts are processed and reviewed prior to reimbursement per the Internal Revenue Code Sec on 125 and 129. Reimbursement Account Services
Dependent Care Reimbursement Account Comparing the Federal Tax Credit and the Dependent Care Reimbursement Account To see whether the Dependent Care Reimbursement Account approach or the Federal Tax Credit approach is be er for you, complete the following worksheets: Worksheet A Federal Tax Credit for Dependent Care Expenses (1) $_______ (2) $_______ (3) $_______ (4) _______% (5) $_______ 1. Es mate your annual dependent care expenses (Note: Cannot exceed the lesser of your income, your spouse’s income, or $5,000). 2. Determine expenses eligible for the Federal Tax Credit. (maximum of $6,000; $3,000 for one child). 3. Es mate the total Adjusted Gross Income for you and your spouse. 4. Enter Tax Credit Percentage from Table 1 below based on Adjusted Gross Income. 5. Mul ply line 4 by the smaller of line 1 or line 2.This is your es mated Federal Tax Credit. 2015 Child and Dependent Care Credit Table
Table 1
Adjusted Gross Income
Up to $15,000 Tax Credit Percentage
35% Adjusted Gross Income
$29,001 ‐ $31,000 Tax Credit Percentage
27% $15,001 ‐ $17,000 34% $31,001 ‐ $33,000 26% $17,001 ‐ $19,000 33% $33,001 ‐ $35,000 25% $19,001 ‐ $21,000 32% $35,001 ‐ $37,000 24% $21,001 ‐ $23,000 31% $37,001 ‐ $39,000 23% $23,001 ‐ $25,000 30% $39,001 ‐ $41,000 22% $25,001 ‐ $27,000 29% $41,001 ‐ $43,000 21% $27,001 ‐ $29,000 28% $43,001 and over 20% Please note that the informa on contained in this table is a summary and is not intended as tax advice or as an authorita ve
IRS reference.
Compare the results of this worksheet with the Dependent Care Reimbursement Account Worksheet to determine which op on may be the be er choice for you. 2016 58 Reimbursement Account Services
Dependent Care Reimbursement Account Comparing the Federal Tax Credit and the Dependent Care Reimbursement Account Worksheet B Calcula ng Tax Savings Using the Dependent Care Reimbursement Account (DCRA)
(1) $___________ (2) ___________% (3) ______7.65% (4) ______4.25% (5) _________% (6) $___________ 1. Enter the amount of your contribu on to your DCRA (Note: Cannot exceed the lesser of your income, your spouse’s income, or $5,000) 2. Enter Marginal Tax Rates from Table 2 below. (Use the combined Adjusted Gross Income for you and your spouse) 3. Social Security & Medicare Tax 4. Michigan State Income Tax 5. Add Lines 2, 3, and 4. 6. Mul ply Line 1 by Line 5.This is your es mated tax savings. 2015 Wage Base Table 2
Wages Paid in 2015—Single
Wages Paid in 2015—Married Filing Jointly
Adjusted Gross Income
Adjusted Gross Income
Over
Tax Rate
$9,225 10.0% $9,225 $37,450 15.0% $37,450 $90,750 25.0% $90,750 $189,300 $189,300 $411,500 $0 $413,200 and over But Not Over
Over
But Not Over
Tax Rate
$18,450 10.0% $18,450 $74,900 15.0% $74,900 $151,200 25.0% 28.0% $151,200 $230,450 28.0% $411,500 33.0% $230,450 $411,500 33.0% $413,200 35.0% $411,500 $464,850 35.0% 39.6% $464,850 and over $0 39.6% Above are federal rates in effect for 2015. Please note that the informa on contained in this table is a summary and is not intended as tax advice or as an authorita ve
IRS reference.
Comparing the Calcula ons
Generally speaking, if your Tax Rate (Table 2) is greater than your Tax Credit Percentage (Table 1), the Dependent Care Reimbursement Account provides you with greater tax savings. If your Tax Credit Percentage (Table 1) is greater than your Tax Rate (Table 2), the Federal Tax Credit approach may be the be er choice for you. 2016 59 2016 Annual Open Enrollment Statement
2106 Annual Open Enrollment Statement
Use your online 2016 Annual Open Enrollment Statement to help make your Educated Choices for the 2016 plan year. Please be sure to check these points: 
Have you reviewed your medical benefit plan op ons carefully? Please review the Considera ons
for Enrollment in the Medical sec on of this workbook. 
Have you thought about purchasing Addi onal Employee Life Insurance or Op onal Dependent Life Insurance? Please review the Considera ons for
Enrollment in the Employee Life Insurance and
Dependent Life Insurance sec ons of this workbook. 
Confirma on Email and Postcard At the end of the enrollment period, a confirma on email will be sent to your email address on file in the enrollment system. It will provide a link for you to click and review your confirma on statement online. Addi onally, a postcard will be mailed to your home with the web address where your confirma on statement can be viewed. Please review this statement VERY CAREFULLY to ensure that your selec ons were processed correctly. If you have any ques ons regarding your benefit coverage or op ons described herein, please contact: Sarah Dare
Benefits Coordinator [email protected] (248) 341‐5431 Is your annual deposit for the Health Care Reimbursement Account, Health Savings Account and/or Dependent Care Reimbursement Account displayed correctly for the upcoming plan year? Karen Healy
Director, Human Resources and Payroll [email protected] (248) 341‐5432 A er reviewing your 2016 Annual Open Enrollment Statement, please logon to the Educated Choices Web site to select your benefit op ons. Your elec ons will then be recorded and processed. The contents of this booklet are intended for use as an easy to read summary only. It does not
cons tute a contract. Addi onal limita ons and exclusions may apply. For an official descrip on of
benefits, please refer to each carrier’s official cer ficate/benefit guide. For more informa on,
please contact the Human Resources Department.
2016 60 As a self-funded group, you are solely responsible for compliance with the federal Summary of Benefit and Coverage (SBC) rules, including SBC creation and
distribution. BCBSM does not assume any responsibility for SBC rule compliance relating to your group health plan, or for creation or disclosure of compliant
SBCs. This SBC template document is being provided as an example that may contain useful information concerning your BCBSM administered coverage as you
create your own group health plan’s SBC. This SBC template document being provided is not fully compliant with the SBC federal rules. It is your responsibility
to work with your legal counsel to ensure proper compliance with the federal SBC rules. This SBC template document does not constitute legal, tax, actuarial,
accounting, benefit design, compliance or other advice. BCBSM disclaims any liability or responsibility for any non-compliance by your group health plan with
SBC rules and regulations relating to creation, disclosure or other requirements. You should also note that there may be additional special circumstances which
may be applicable to your specific group health plan situation which may affect SBC content, including but not limited to account type arrangements such as
flexible spending accounts (FSA), health reimbursement arrangements (HRA), and health savings accounts, (HSA), or for example, wellness programs, reference
based pricing or benefits, or coverage not administered by BCBSM, or whether the coverage provides minimum essential coverage. If you have an ASC Plan
Modification, it may be defined here in only a limited way.
BLOOMFIELD HILLS BD OF ED
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: Beginning on or after 2016-01-01
Coverage for: Individual/Family
Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document
at www.bcbsm.com or by calling the number on the back of your BCBSM ID card.
Important Questions
Answers
In-Network
Out-of-Network
Why this Matters:
You must pay all the costs up to the deductible amount before this plan begins to pay
$1,300 Individual/ $2,600 Individual/ for covered services you use. Check your policy or plan document to see when
What is the overall deductible?
$2,600 Family
$5,200 Family
the deductible starts over (usually, but not always, January 1st). See the chart starting
on page 2 for how much you pay for covered services after you meet the deductible.
Are there other deductibles for
No.
specific services?
You don’t have to meet deductibles for specific services, but see the chart starting on
page 2 for other costs for services this plan covers.
The out-of-pocket limit is the most you could pay during a coverage period (usually
Is there an out-of-pocket limit
$2,300 Individual/ $4,600 Individual/ one year) for your share of the cost of covered services. This limit helps you plan for
on my expenses?
$4,600 Family
$9,200 Family
health care expenses. (The limit includes your deductible and any RX co-pays you may
incur).
Premiums, balance-billed charges, any
What is not included in
pharmacy penalty and health care this Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
the out-of-pocket limit?
plan doesn’t cover.
Is there an overall annual limit
The chart starting on page 2 describes any limits on what the plan will pay for specific
No.
on what the plan pays?
covered services, such as office visits.
Does this plan use a network
of providers?
Do I need a referral to see
a specialist?
Are there services this plan
doesn’t cover?
If you use an in-network doctor or other health care provider, this plan will pay some
Yes. For a list of in-network providers,
or all of the costs of covered services. Be aware, your in-network doctor or hospital may
see www.bcbsm.com or call the
use an out-of-network provider for some services. Plans use the term innumber on the back of your BCBSM
network, preferred, or participating for providers in their network. See the chart
ID card.
starting on page 2 for how this plan pays different kinds of providers.
No.
You can see the specialist you choose without permission from this plan.
Yes.
Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan
document for additional information about excluded services.
Group Number 007002956 All
Questions: Call the number on the back of your BCBSM ID card or visit us at www.bcbsm.com. If you aren’t clear about any of the underlined terms used in this
form, see the Glossary. You can view the Glossary at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call
the number on the back of your BCBSM ID card to request a copy.
SBC000000593990
2 of 9
• Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
• Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the
plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven’t
met your deductible.
• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than
the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and
the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
• This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts.
Common
Medical Event
If you visit a health
care provider’s office
or clinic
If you have a test
If you need drugs to
treat your illness or
condition
Some plans may have a
separate out of pocket
maximum for
prescription drug
coverage, for more
Your cost if you use a
In-Network Provider Out-of-Network Provider
Primary care visit to
20% co-insurance after
No Charge after deductible
treat an injury or illness
deductible
20% co-insurance after
Specialist visit
No Charge after deductible
deductible
No Charge after deductible 20% co-insurance after
Other practitioner office for chiropractic and
deductible for chiropractic
visit
osteopathic manipulative
and osteopathic manipulative
therapy
therapy
Preventive care/
No Charge
Not Covered
screening/immunization
Services You May
Need
Diagnostic test (x-ray,
blood work)
No Charge after deductible
Imaging (CT/PET
scans, MRIs)
No Charge after deductible
$5 co-pay for retail 30-day
Generic or prescribed
supply; $10 co-pay for retail
over-the-counter drugs
or mail order 90-day supply
Preferred brand-name
drugs
$25 co-pay for retail 30-day
supply; $50 co-pay for retail
or mail order 90-day supply.
20% co-insurance after
deductible
Limitations & Exceptions
---none-----none--Limited to a combined maximum of 24 visits per
member per calendar year for chiropractic and
osteopathic manipulative therapy
Limited Services
---none---
20% co-insurance after
---none--deductible
In-Network co-pay plus an
For information on women's contraceptive
additional 20% of the
coverage, contact your plan administrator. 90-day
BCBSM approved amount for supply not covered out-of-network. Specialty
the drug
drugs limited to a 30-day supply per fill.
In-Network co-pay plus an
additional 20% of the
90-day supply not covered out-of-network.
BCBSM approved amount for Specialty drugs limited to a 30-day supply per fill
the drug
Note Prescriptions are subjected to the $1300/$2600 annual deductible. Once the deductible has been met, then the RX co-pays
apply. Deductible and Rx copays count towards your plans Out-of-Pocket Limit
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Common
Medical Event
Services You May
Need
information please
contact your plan
administrator
Non-preferred brandname drugs
Your cost if you use a
In-Network Provider Out-of-Network Provider
In-Network co-pay plus an
$50 co-pay for retail 30-day
additional 20% of the
90-day supply not covered out-of-network.
supply; $100 co-pay for retail
BCBSM approved amount for Specialty drugs limited to a 30-day supply per fill
or mail order 90-day supply.
the drug
Facility fee (e.g.,
ambulatory surgery
No Charge after deductible
If you have outpatient center)
surgery
Physician/surgeon fees No Charge after deductible
20% co-insurance after
deductible
---none---
20% co-insurance after
deductible
---none---
No Charge after deductible
No Charge after deductible
---none---
No Charge after deductible
No Charge after deductible
---none---
No Charge after deductible
20% co-insurance after
deductible
---none---
Facility fee (e.g., hospital
No Charge after deductible
room)
20% co-insurance after
deductible
---none---
Physician/surgeon fee
No Charge after deductible
20% co-insurance after
deductible
---none---
Mental/Behavioral
health outpatient
services
No Charge after deductible
20% co-insurance after
deductible
---none---
Mental/Behavioral
No Charge after deductible
health inpatient services
20% co-insurance after
deductible
---none---
Substance use disorder
No Charge after deductible
outpatient services
20% co-insurance after
deductible
---none---
Substance use disorder
No Charge after deductible
inpatient services
20% co-insurance after
deductible
---none---
Prenatal: No Charge
Postnatal: No Charge after
deductible
20% co-insurance after
deductible
---none---
Emergency room
services
If you need immediate Emergency medical
medical attention
transportation
Urgent care
If you have a hospital
stay
If you have mental
health, behavioral
health, or substance
abuse needs
If you are pregnant
Limitations & Exceptions
Prenatal and postnatal
care
Note Prescriptions are subjected to the $1300/$2600 annual deductible. Once the deductible has been met, then the RX co-pays
apply. Deductible and Rx copays count towards your plans Out-of-Pocket Limit
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Common
Medical Event
If you need help
recovering or have
other special health
needs
Services You May
Need
Your cost if you use a
In-Network Provider Out-of-Network Provider
Limitations & Exceptions
Delivery and all
inpatient services
No Charge after deductible
20% co-insurance after
deductible
---none---
Home health care
No Charge after deductible
No Charge after deductible
---none---
Rehabilitation services
No Charge after deductible
20% co-insurance after
deductible
Physical, Occupational, Speech therapy is limited
to a combined maximum of 30 visits per member,
per calendar year.
Habilitation services
Not Covered
Not Covered Not Covered
---none---
Skilled nursing care
No Charge after deductible
No Charge after deductible
Limited to a maximum of 90 days per member per
calendar year.
Durable medical
equipment
No Charge after deductible
No Charge after deductible
---none---
Hospice service
No Charge
No Charge
---none---
If your child needs
Eye exam
dental or eye care
For more information on
Glasses
pediatric vision or dental,
contact your plan
Dental check-up
administrator
Not Covered under Medical; Not Covered under Medical;
Not Applicable to Medical Plan
Refer to your vision plan
Refer to your vision plan
Not Covered under Medical; Not Covered under Medical;
Not Applicable to Medical Plan
Refer to your vision plan
Refer to your vision plan
Not Covered under Medical; Not Covered under Medical;
Not Applicable to Medical Plan
Refer to your dental plan
Refer to your dental plan
Note Prescriptions are subjected to the $1300/$2600 annual deductible. Once the deductible has been met, then the RX co-pays
apply. Deductible and Rx copays count towards your plans Out-of-Pocket Limit
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Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
•
Acupuncture
•
Hearing aids
•
Routine eye care (Adult)
•
Cosmetic surgery
•
Infertility treatment
•
Routine foot care
•
Dental care (Adult)
•
Long-term care
•
Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
•
Bariatric surgery
•
Chiropractic Care
•
•
Coverage provided outside the United States.
See http://provider.bcbs.com
If you are also covered by an account-type
plan such as an integrated health flexible
spending arrangement (FSA), health
reimbursement arrangement (HRA), and/or a
health savings account (HSA), then you may
have access to additional funds to help cover
certain out-of-pocket expenses – like the
deductible, co-payments, or co-insurance, or
benefits not otherwise covered
•
Non-Emergency care when traveling outside the U.S
•
Private-duty nursing
Note Prescriptions are subjected to the $1300/$2600 annual deductible. Once the deductible has been met, then the RX co-pays
apply. Deductible and Rx copays count towards your plans Out-of-Pocket Limit
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Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while
covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at the number on the back of your BCBSM ID card. You may also contact your state
insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S.
Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions
about your rights, this notice, or assistance, you can contact Blue Cross®and Blue Shield®of Michigan by calling the number on the back of your BCBSM ID card.
Or, you can contact Michigan Office of Financial and Insurance Regulation at www.michigan.gov/ofir or 1-877-999-6442. For group health coverage subject
to ERISA, you may also contact Employee Benefits Security Administration at 1-866-444-EBSA (3272).
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide
minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health
coverage does meet the minimum value standard for the benefits it provides. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage
provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does
not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs,
through another carrier.)
Language Access Services
For assistance in a language below please call the number on the back of your BCBSM ID card.
SPANISH (Español): Para ayuda en español, llame al número de servicio al cliente que se encuentra en este aviso ó en el reverso de su tarjeta de identificación.
TAGALOG (Tagalog): Para sa tulong sa wikang Tagalog, mangyaring tumawag sa numero ng serbisyo sa mamimili na nakalagay sa likod ng iyong pagkakakilanlan
kard o sa paunawang ito.
CHINESE (中文): 要获取中文帮助，请致电您的身份识别卡背面或本通知提供的客户服务 号码。
NAVAJO (Dine): Taa’dineji’keego shii’kaa’ahdool’wool ninizin’goo, beesh behane’e naal’tsoos bikii sin’dahiigii binii’deehgo eeh’doodago di’naaltsoo bikaiigii
bichi’hoodillnii.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Note Prescriptions are subjected to the $1300/$2600 annual deductible. Once the deductible has been met, then the RX co-pays
apply. Deductible and Rx copays count towards your plans Out-of-Pocket Limit
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About these Coverage
Examples:
These examples show how this plan might
cover medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information about
these examples.
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $6,230
 Patient pays $1,310
 Amount owed to providers: $5,400
 Plan pays $3,900
 Patient pays $1,500
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Co-pays RX
Co-insurance
Limits or exclusions
Total
$1,300
$10
$0
$0
$1,310
Patient pays:
Deductibles
Co-pays RX
Co-insurance
Limits or exclusions
Total
$1300
$200
$0
$0
$1,500
Please note: Coverage examples are calculated
based on individual coverage and calculations
may not include a coinsurance maximum.
8 of 9
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
•
•
•
•
•
•
•
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S. Department
of Health and Human Services, and aren’t
specific to a particular geographic area or
health plan.
The patient’s condition was not an excluded
or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only on
treating the condition in the example.
The patient received all care from innetwork providers. If the patient had
received care from out-ofnetwork providers, costs would have been
higher.
What does a Coverage Example
show?
For each treatment situation, the Coverage
Example helps you see how deductibles,
co-payments, and co-insurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
No. Treatments shown are just examples.
The care you would receive for this condition
could be different, based on your doctor’s
advice, your age, how serious your condition
is, and many other factors.
Does the Coverage Example
predict my future expenses?
No. Coverage Examples are not cost
Can I use Coverage Examples to
compare plans?
Yes. When you look at the Summary of Benefits
and Coverage for other plans, you’ll find the same
Coverage Examples. When you compare plans,
check the “Patient Pays” box in each example. The
smaller that number, the more coverage the plan
provides.
Are there other costs I should consider
when comparing plans?
Yes. An important cost is the premium you pay.
Generally, the lower your premium, the more you’ll
pay in out-of-pocket costs, such as
co-payments, deductibles, and co-insurance.
You should also consider contributions to accounts
such as health savings accounts (HSAs), flexible
spending arrangements (FSAs) or health
reimbursement accounts (HRAs) that help you pay
out-of-pocket expenses.
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your own
costs will be different depending on the care
you receive, the prices your providers charge,
and the reimbursement your health plan
allows.
Questions: Call the number on the back of your BCBSM ID card or visit us at www.bcbsm.com. If you aren’t clear about any of the underlined terms used in this
form, see the Glossary. You can view the Glossary at http://www.dol.gov/ebsa/pdf/SBCUniformGlossary.pdf or call
the number on the back of your BCBSM ID card to request a copy.
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