a complete explanation of Employee Benefits and Costs

EMPLOYEE BENEFITS
House Officers
Effective January 1, 2016
HEALTH INSURANCE: Effective Date of Coverage: Date of hire
Wake Forest Baptist Health provides three Health Insurance Plans through MedCost Benefit Services – the Optimum Plan,
the Prime Plan, and the Select Plan. All plans are self-insured, meaning that Wake Forest Baptist Health pays your claims
for both health care and prescription drugs, and are administered by MedCost (http://www.medcost.com).
Health Insurance Bi-Weekly Cost
Wake/Cornerstone Exclusive Wake Health Choice
$22.15
$43.85
$74.77
$139.98
$85.85
$161.54
Level of Coverage
Employee Only
Employee plus Child(ren)
Employee plus Spouse
Employee plus WORKING Spouse
Family
Family plus WORKING Spouse
Individual
Deductible
Family Deductible
Individual OOP
Family OOP
Routine Physical
Well Child
Care/Immunization
Pediatrician
OBGYN
Primary Care
Physician
Specialist – No
referral required
Urgent Care
Inpatient Hospital
Care
Outpatient
Hospital Care
Surgeon/Physician
$217.95
$240.00
$274.62
$119.18
$121.38
$156.00
$194.87
$219.23
$253.85
Wake Health /
Cornerstone
Wake Health Choice Plus
$49.85
$152.31
$184.62
Health Choice
Health Choice Plus
WFBH
$750
MedCost
N/A
WFBH
$2,000
MedCost
$3,500
WFBH
$1000
MedCost
$2,500
$1,500
$2,500
$5,000
$ 0 copay
$ 0 copay
N/A
N/A
N/A
$ 0 copay
$ 0 copay
$3,500
$5,000
$7,000
$ 0 copay
$ 0 copay
$5,500
$6,850
$13,700
$ 0 copay
$ 0 copay
$2,500
$3,000
$6,000
$ 0 copay
$ 0 copay
$5,000
$6,850
$13,700
$ 0 copay
$ 0 copay
$0 copay
$0 copay
$0 copay
$15 copay
$50 copay
N/A
$0 copay
$20 copay
$0 copay
$15 copay
$75 copay
$35 copay
$0 copay
$20 copay
$0 copay
$15 copay
$75 copay
$35 copay
$10 copay
N/A
$20 copay
$75 copay
$20 copay
$75 copay
$10 copay
10% after
deductible
10% after
deductible
10% after
deductible
$35 copay
N/A
$10 copay
40% after
deductible
40% after
deductible
40% after
deductible
$35 copay
50% after
deductible
50% after
deductible
50% after
deductible
$10 copay
20% after
deductible
20% after
deductible
20% after
deductible
$35 copay
30% after
deductible
30% after
deductible
30% after
deductible
N/A
N/A
You are responsible for 100% of out-of-network charges. *OOP=Out of Pocket Maximum
Drug Tier Type
Generic
Preferred
Non-Preferred
WFBMC Pharmacy (30 day Supply)
$10
$25
$50
Retail Network Pharmacy (30 day supply)
$20
$35 + 35% of remaining cost, up to $80 max
$60 + 40% of remaining cost, up to $120 max
Prescription Drug Program: Enrollment in any of our Health Plans automatically provides you with prescription drug
coverage. Maintenance and Specialty Medications must be filled at one of the seven Medical Center Pharmacies. Generic
use is mandatory. (You pay the difference if brand is requested when generic is available)
DENTAL PLAN: Effective Date of Coverage: Date of hire
There are two dental plans and the provider is MedCost (http://www.medcost.com). Both plans are open access and
cover all of the “reasonable and customary charges” for preventative services such as basic exams, cleanings, X-rays and
other basic services
Coverage Level
Employee Only
Employee plus Child(ren)
Dental Coverage Bi-Weekly Cost
High
$8.44
$20.44
Low
$4.44
$10.22
$18.67
$9.78
$24
$12.44
Dental Plan Features
High Option
$1750 Per Person
$50 (3x Family)
100% deductible waived
80% after deductible
50% after deductible
50%, $2000 lifetime max
Low Option
$750 Per Person
$50 (3x Family)
100% deductible waived
80% after deductible
Not Covered
Not Covered
Employee plus Spouse
Family
Coverage
Annual Maximum
Calendar Year Deductible
Preventive Services
Basic Services
Major Services
Orthodontia
VISION: Effective Date of Coverage: Date of hire
Employees and dependents enrolled in the Health Care Plan are automatically enrolled in the annual eye exam portion of
the Vision Plan. Employees may only enroll in the vision plan if the employee and covered dependents are also enrolled in
one of our Health Care Plans. Those who want coverage for glasses and contacts must enroll in the Vision Plans.
Vision Materials Coverage Bi-Weekly Cost
High Option
Coverage
Employee Only
$3.55
Employee plus child(ren)
$5.76
Employee plus Spouse
$7.63
Vision Material Benefit Coverage
Amount
Standard Lenses (per Pair)
Single Lens
Covered in full up to $100
Covered in full up to $100
Bifocal Lens
Family
Frames-Standard
up to $175.00
Contact Lenses
up to $175.00
$10.48
Trifocal Lens
Covered in full up to $100
Health Care Spending Account: Effective Date of Coverage: Date of hire
Employees can elect to contribute pre-tax money through payroll deductions for any IRS approved health care, dental,
vision care expenses not paid by any other health care plan. You can contribute up to $2550 annually. Plan runs from
January 1st to March 15th of the following year. Claims for eligible expenses incurred during the plan year must be received
by March 31st of the following year.
Dependent Care Spending Account: Effective Date of Coverage: Date of hire
Employees can contribute up to $5,000 a year pre-tax (or up to $2500 if you are married and file separate tax returns) to
cover dependent care expenses for children under age 13 (or an elderly parent you’re your home) incurred so that you
and your spouse, if you are married, can work or attend school full-time.
*Please note spending elections do not roll over to the next year.
DISABILITY INSURANCE: Effective Date of Coverage: 91st day from date of hire
The hospital provides a group Long Term Disability Insurance plan via The Standard Insurance Company at no cost to you.
Benefits cover 66 2/3% of salary to a maximum of $3,000/month if disabled and unable to work for 90 days. During
training, the hospital makes available access to special GME negotiated discounts via Mensh Insurance to offer individual
own occupation plans from major carriers. All Residents/Fellows have access to an even greater discount with guaranteed
issue individual policies upon Graduation. Contact Mensh Insurance http://www.menshinsurance.com/wake/ for further
details.
TERM LIFE INSURANCE: Effective Date of Coverage: 91st day from date of hire
The hospital provides basic term life insurance equal your annual salary rounded to the next highest thousand. This benefit
is provided at no cost to you.
ADDITIONAL SUPPLEMENTAL TERM LIFE INSURANCE: Effective Date of Coverage: 91st day from date of hire
Additional life insurance may be purchased for an amount of an additional one, two, three or four times your annual
salary. The bi-weekly deduction cost for this additional life insurance is based on age and the amount of coverage.
Dependent Life Insurance may be purchased for your spouse and dependent children with the following coverage
amounts:
Level of Coverage
Coverage Amount
Employee Cost
= $ 0.90 / Bi-Weekly Cost
Spouse
-$10,000
= $ 1.80 / Bi-Weekly Cost
Spouse
-$25,000
Child(ren)
-$10,000
= $ 0.45 / Bi-Weekly Cost
Child(ren)
-$25,000
= $ 1.13 / Bi-Weekly Cost
RETIREMENT SAVINGS PLAN:
Wake Forest Baptist Health provides a tax-deferred saving plan that provides the opportunity to invest pre-tax dollars.
You have the option of investing up to the current annual maximum of $18,000 of your income. At the end of the
residency program, this money may remain in the plan and continue to grow or be transferred to another 403b plan, 401K
plan, or an IRA account.
ADDITIONAL BENEFITS:
Action Health - Employee Wellness Program
Child Care Center & Referral (336) 716-0300
Credit Unions
Elder Care Choices – (336) 748-2171
Employee Assistance Program
Employee Health Services
Fitness Center (Located in Comp Rehab)
Fitness Center (Located in Comp Rehab)
Food Service Discounts
Jury Duty Pay
Parking – Paid by NCBH
Unemployment Insurance
Voluntary Benefits
Workers' Compensation
Additional information on Discounts is listed under “Discounts” on the left panel of the Medical Center home page under “Quick
Links”
The self-service website may be accessed from desktop computers or at the kiosks located in Human Resources, by the
Cafeteria, first floor Watlington Hall and on the ground floor in the hall connecting Reynolds Tower to Meads Hall.
To view your personal benefits information click on “Self-Service”. You will be prompted for your I.D. and password. Your
I.D. is the same as your I.D. and password for your e-mail account. You may call the Help Desk (716-Help (4357)) for a
password. On the self-service website, you may: View your paycheck, Change your address, phone number and federal
tax information.
For benefits information and the Summary Plan Descriptions which provide details of each of the benefits plans, go to the
Medical Center intranet. Click on Human Resources – Hospital – Benefits – Benefits Service Guide.
*Please note that this is a summary of benefits. In the event of differences between this summary and the Summary Plan
Description (SPD), the SPD prevails.
YOUR GROUP DISABILITY INSURANCE PLAN
All residents and fellows will be insured by a group Long Term Disability Insurance plan via
The Standard Insurance Company. Benefits cover 66 2/3% of salary to a maximum of
$3,000/month, with benefits payable to age 65. This benefit amount was increased recently
compared to previous levels as Wake Forest continues to ensure that benefits remain in line
with the rising pay scale for residents. So, if you earn $47,000, for example, you would have
66 2/3% of that income insured – which becomes $2,600/month. It’s not until you reach an
annual income of $54,000 that you would exceed the maximum of $3,000 in monthly benefit.
If you are among the vast majority of students who complete training, you will be fully insured
in this group plan at the 66 2/3% replacement.
ABOUT US
Mensh Insurance is excited to be working with Wake Forest Baptist Health to provide Disability
Insurance coverage for you as a medical resident. We want you to know that we are here to
answer any questions regarding your insurance while you are at Wake Forest and beyond.
Mensh Insurance is a Winston-Salem, NC based independent insurance company. We’ve
served over 1,000 customers throughout the United States. In addition to Disability Insurance,
we offer Life Insurance a well as long Term Care and Health Insurance. Danny Mensh
became President of Mensh Insurance in 2007. Danny specializes in Disability Insurance and
is a member of the National Association of Insurance and Financial Advisors, the National
Association of Health Underwriters, and The American Association for Long Term Care
Insurance. Danny is also certified in Long Term Care and maintains his CLTC designation
Individual Policies: Guaranteed Issue For Graduating Residents
This Guaranteed Issue feature will only be available to those within 180 Days of their
Graduation date though anyone may apply for the discounts at any time during their training
and lock in the younger age rates and protection. In order to secure your own individual policy,
all carriers, including The Principal, require a review of your medical history. This process will
require a phone interview, blood/urine exam, and possible review of medical records.
Individual Policies: Non Graduating Residents
GME Disability Insurance programs across the country change from year to year concerning
requirements, eligibility, contracts and pricing. Since we remain independent, we continue to
monitor these changes and work with HR at Wake Forest Baptist Health. In order to keep the
most flexible plans available for you as Residents and Fellows we will continue to bring the
best policies with maximum discounts from all top carriers.
Why Consider Coverage Now?
Depending on your cash flow and financial needs we can help you secure benefits as low as
$1500/month and up to $7500/month. The advantage to securing a policy now is to lock in
your current age and fixed rate for life with the opportunity to increase benefit as your income
increases.
SAMPLE MONTHLY RATES BELOW ARE THE SAME FOR MALE AND FEMALES ALL QUOTES BELOW INCLUDE: $5000 Monthly Benefit (with ability to increase to $15,000) Benefits Payable to age 67 Noncancellable / guaranteed renewable
MEDICAL SPECIALTY
Internists, Radiologists, Gastroenterologists, Psychiatrists, Immunologists, Allergists, Pulmonologists, Pathologists, Pediatricians Surgeons, Anesthesiologists, Emergency Room, Cardiologists, ENT, Ortho, Ophthalmologists AGE 25 Add Cost of Living and Catastrophic Benefits Add Cost of Living and Catastrophic Benefits Own Occupation Residuual / Partial Benefits 90 day elimination period AGE 30 AGE 35 AGE 40 $81.44 $97.34 $110.83 $145.96 $114.53 $133.43 $151.42 $145.96 $96.79 $116.62 $132.59 $173.75 $134.06 $157.76 $178.82 $229.56 324 N. Spring Street Winston‐Salem, North Carolina 27101 Office: (336) 631‐5503 Fax: (336) 631‐5504 Toll Free: (888) 582‐33334 [email protected] www.menshinsurance.com Spending Accounts
Flexible Spending Accounts (FSA)
The Medical Center offers two flexible spending accounts (FSA) that let you
put money aside to pay yourself back on a tax-free basis for certain health,
Rx, and dental care expenses and dependent care expenses.
■ The Health Care Spending Account lets
you contribute to an account and reimburse
yourself tax-free for up to $2,550 in expenses not
reimbursed under any health care plans.*
The spending accounts are voluntary — you decide
whether you want to participate. You must actively
elect to contribute each year — prior year elections will
not automatically carry over to the next plan year.
■ A Dependent Care Spending Account
provides a way for you to reimburse yourself taxfree for day-care expenses for your children under
age 13 and other qualifying dependents. You can
contribute up to $5,000 a year, or $2,500 if you are
married and file separate tax returns.*
Important: Plan Spending Account Contributions Carefully
The IRS requires that you use all your spending account money for expenses incurred within the
calendar year. Wake Forest Baptist Medical Center is not allowed to return unused amounts to you,
so plan carefully. You forfeit any money left in your account after all eligible expenses have been paid.
(Remember, however, that you have three months after the end of the year to submit claims incurred
during the prior year.)
Health Care Spending Account
You can use your Health Care Spending Account to pay for expenses not paid by other plans, including:
• Health and dental deductibles and copayment amounts.
• Expenses that exceed plan limits (or that are not paid by the plan), such as hearing exams and
hearing aids, orthodontia and vision expenses (exams, eyeglasses and contact lenses).
Eligible Expenses
Generally, any health expenses that are considered tax deductible are eligible expenses under the Health Care
Spending Account. Eligible expenses can include fees for:
• acupuncture (with letter of
medical necessity)
• animal trained to aid deaf person
• artificial limbs
• autoette (a type of three-wheeled
wheelchair)
• birth control pills
• Braille books and magazines
• chiropodists
• chiropractors
• Christian Science practitioners
• contact lenses, solutions
and enzymes
• contraceptive devices
(prescription)
• cosmetic surgery (only if it
corrects a congenital deformity
or disfigurement because of
accident or disease)
• crutches
• dental expenses
• dentures
• dermatologists
• drug addiction therapy
• eye examinations
• eyeglasses
• hearing aids
• hospital expenses
• insulin
• legal abortions
• legal fees (medically related)
• mileage (@24¢ per mile) to/from
physician’s office for treatment
• note taker to deaf
• nursing home (medical
portion only)
• nursing services
• obstetricians
• occupational therapy
• ophthalmologists
• optician
• optometrists
• orthodontia (only for services
that have been performed during
the plan year)
• orthopedic shoes
• orthopedists
• osteopaths
• oxygen
• patterning exercises given to
mentally handicapped children
• pediatrician
• physician’s fee
• physiotherapist
• podiatrists
• prenatal care
• prescription drugs
• psychologists
•
•
•
•
•
•
•
•
•
•
•
•
•
•
psychotherapy
sanitarium stays
seeing-eye dogs
smoking cessation programs and
prescription anti-smoking drugs
special home for mentally
disabled
surgical fees
telephone equipped for deaf
person
transplants
tuition at special school or
specially trained tutor for disabled
vaccines
vasectomy
weight reduction program
(prescribed by doctor to
alleviate a diagnosed medical
condition or obesity)
wheelchair
X-ray fees
For these expenses to be
eligible, they must be considered
medically necessary and
prescribed by your physician,
dentist or vision care doctor.
Ineligible Health Care Expenses
Health and dental premiums, either yours or your
spouse’s, cannot be reimbursed through the Health
Care Spending Account. In addition, elective cosmetic
surgery and similar expenses are not allowable expenses
according to the Internal Revenue Service.
Other common ineligible expenses include:
• anti-baldness drugs
• cost of dancing or swimming lessons, even if
recommended by your doctor
• dental procedures to whiten your teeth
• diaper service
• donations to volunteer ambulance companies
• electrolysis
• expenses for trips, even if for general health
improvement
• funeral and burial expenses
• hair transplant
• health club dues
• household help
• illegal operations and treatment
• maternity clothes
• toothpaste, cosmetics and toiletries
• over-the-counter (OTC) drugs and medical supplies
How the Health Care Spending
Account Works
The Health Care Spending Account is designed to reimburse you for eligible health care expenses you already
have paid. Here’s how the process works:
■ Each year during the enrollment period, you decide
how much you want to contribute to the Health Care
Spending Account (if any), up to $2,550.
■ Each pay period, money is deducted from your pay
before taxes and contributed to your Health Flex Care
Spending Account.
■ A no-cost debit card is available. This Health Flex
Debit Card can be used to pay for health services by
direct access to your Spending Account, similar to a
bank debit card. It eliminates you paying then having
to be reimbursed for out-of-pocket expenses.
■ You can also file a paper claim for an eligible expense.
You submit a spending account claim form to the
Spending Account Claims Administrator. Attach an
Explanation of Benefits from the insurance company
or the bill for the health care expenses not covered by
a health care plan.
■ You then will be reimbursed for your eligible expenses
up to the full amount you signed up to contribute for
the plan year. Health Care Spending Account checks
are processed weekly.
The plan year runs from January 1 to March 15 of the
following year. Claims for eligible expenses incurred
during the plan year must be received by March 31
of the following year. Money not claimed within that
timeframe is required by law to be forfeited.
Please note
Payroll Contribution Period:
January 1 to December 31
Incurred Expense Period:
January 1 to March 15 of following year
Reimbursement Period:
January 1 to March 31 of following year
The money in your Health Care Spending Account can
be used only for eligible health or dental expenses—not
for day-care expenses. Also, the money in the account
can be used only for that year’s expenses, based on the
date you received health care services.
Dependent Care (Day Care) Spending Account
This account lets you pay yourself back for day-care expenses you incur so that you (and your
spouse, if you are married) can work. For purposes of this plan, your eligible dependents are:
• Children under age 13 who qualify as dependents on your federal income tax return.
• Children and other dependents of any age who are physically or mentally unable to care
for themselves and who qualify as dependents.
• Services of a gardener or chauffeur.
• Transportation to get dependents to or from day
Dependent care expenses that can be reimbursed
care provided outside your home.
through your Dependent Care Spending Account include
• Expenses incurred while you and/or your spouse are
costs you may pay for child care or for care of dependent
not working, including vacations.
adults who live with you at least eight hours a day. Tax
• Payments to a housekeeper while you’re home sick.
laws require that this care is necessary to allow you and
• Payments to a dependent to care for another dependent.
your spouse to work or attend school full time.
• Pre-payment for services not received while covered.
You can be reimbursed through your Dependent Care • Expenses for overnight camps.
Spending Account for:
• Kindergarten expenses.
Eligible Dependent Care Expenses
• Payments to licensed nursery schools, day-care
centers, or individuals for care of preschool children.
• Payments for before-school care or after-school care
for children from first grade through age 12.
• Payments to providers outside the home
for care of disabled dependent(s).
• Services of a housekeeper, maid or cook if services
were partly for the care of a child under age 13 or a
disabled dependent. This includes meals, lodging
and payroll taxes of the housekeeper.
• Payments to relatives for care of qualifying
dependent(s); however, the relative cannot
be your dependent or your child if under 19
as of the end of the year.
• Payments (in lieu of regular day care) to summer
day camp or other summer programs, but not
overnight camps.
Ineligible Dependent Care Expenses
Some common ineligible expenses include:
• Expenses for education of a qualified dependent.
• Expenses for food, clothing, supplies, activity fees
or entertainment for a dependent.
• Child support payments.
How the Dependent Care
Spending Account Works
The Dependent Care Spending Account is designed to
reimburse you for day-care expenses you have already
paid. Here’s how the process works:
■ Each year during the enrollment period, you decide
how much you want to contribute to the account
(if any). You can contribute up to $5,000 annually.
■ Each pay period, money is deducted from your pay
before taxes and contributed to your Dependent Care
Spending Account.
■ When you have an eligible expense, you pay it.
Then you submit a spending account claim to the
Spending Account Claims Administrator. You must
include your day-care provider’s Social Security
number or taxpayer’s identification number.
■ You will be reimbursed for your eligible expenses
up to the amount you have contributed to your
Dependent Care Spending Account by that time in
the plan year. Dependent Care Spending Account
claims are processed weekly.
Making Mid-year Changes
If you have a change in your status during the year,
you can stop, start, increase or decrease your
contributions. Examples of “qualifying status changes”
include changes in:
• Legal marital status: through marriage, death of
spouse, divorce, legal separation or annulment.
• Number of dependents: through birth, adoption,
placement for adoption or death of dependent.
• Employment status: through termination or
commencement of employment by the employee,
spouse or dependent.
• Work schedule: through a switch between parttime and full-time work, commencement or return
from an unpaid leave of absence, or an increase or
reduction in hours of employment by the employee,
spouse or dependent.
• Dependent status: through satisfying or ceasing
to satisfy the age, or other requirements to qualify
as a covered dependent under the plan.
You must notify the Benefits Office in Human
Resources of any change in your status within 31 days
of the event if you wish to change your elections.
For details on eligibility and termination rules, refer to
the summary plan description booklet.
Non-Qualifying Family
Status Changes
If any events other than those listed as “qualifying
status changes” occur, you cannot change your
elections during the year. Some examples of events that
don’t allow you to change your elections are:
• The cost is too high/you didn’t realize how much
was going to come out of your paycheck.
• You found a better deal.
• You decided you don’t like the coverage.
• You need more money in your paycheck to pay off
a loan, mortgage or credit card.
How to Enroll in Health Benefits
Please follow the instructions below to enroll in health benefits. For cost information about your benefit
options, please refer to the table on page 6.
If you are considered a full-time (30 hours or more) or part-time employee (20-29 hours), you can enroll
in health, dental and vision plans. Benefits are pick and choose, so you must carefully elect the coverage
that best suits your health care needs. Dependent coverage must be completed through the enrollment
process with Full Name, Date of Birth, Gender, SS#.
Please be aware of enrollment deadlines:

31 days after hire date: Enrollment in medical, dental, vision and spending account benefits
must be completed within 31 days of your hire date. Coverage is retroactive, and is effective on
the date of hire.
Make your benefit selections carefully, as you will not be able to change your benefit choices until the
next annual open enrollment period, unless you have a qualifying life event (such as marriage, divorce or
birth of a child). You must notify the Benefits Department within 31 days of the qualifying change.
Computer Access for Benefits Enrollment
You can complete your online benefits enrollment at work, home or on any computer with Internet access
by going to the Medical Center’s Intranet at intranet.wakehealth.edu. If you do not have computer access
in your immediate work area, you can complete your enrollment at any of the following Employee
Computer Kiosks in locations throughout the Medical Center:
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A1 Dean - Lobby
Ardmore Cafeteria - ActionHealth corner
Ardmore Cafeteria - In back, near patio exit
Ardmore, 2 Sub-Basement - Dietary Breakroom
Cancer Center, 2nd Floor - Breakroom near Allegacy Kiosk
Gray Building, 1st Floor - Carpenter Library
Comp Rehab - Basement Lobby
Meads Hall, Ground Floor - ActionHealth information area
Nutrition (Commons) Building, M Floor - Environmental Services Breakroom
Piedmont Plaza 1, 4th Floor - Human Resources Lobby
Reynolds Tower, 1 Sub-Basement - Laundry Breakroom
Reynolds Tower, 1 Sub-Basement - Outside Elevators
Sticht Center, Ground Floor - Breakroom Area
Watlington Hall - Left of pedestrian entrance
1
Off-site Login Instructions: If you access the Intranet from home or another off-site location, you will
need to log in using the username and password that you received at the beginning of New Employee
Orientation.
How to Enroll
Complete your online benefits enrollment by completing the steps below. Start these steps from
the Intranet home page: intranet.wakehealth.edu. (If accessing from home, see Off-site Login
Instructions above.)
Step 1: Click the HR tab
Step 2: Click on PeopleSoft
Step 3: Click on PeopleSoft Self Service – Human Resources
2
Step 4: Login with your User ID and Password, which you received at the beginning of New Employee
Orientation.
Step 5: Click on Main Menu
Step 7: Navigate to Self Service / Benefits / Benefits Enrollment
3
Step 7: Click Select to begin benefits enrollment.
Step 8: Click the Edit button next to each benefit option to view benefit details.
4
Step 9: After each choice, click Save to hold your choice until you are ready to submit your final
enrollment.
Step 10: Confirm your choice for each selection, and click Save again.
Step 10: Review the table summarizing estimated costs for your benefit choices. Click Submit to send
your final choices to the Benefits Department.
Benefits Help
For questions about your benefits, call 336-716-3334 or email [email protected]. For technical
assistance with the Intranet or PeopleSoft, contact the IT Service Desk at 336-716-4357 (available 24/7).
5
BENEFITS PARTICIPATION GUIDELINES
House Staff
1. Enrollment Period
• When you complete and submit this form, it will be recorded as your benefits election until the next Open Enrollment period. You may make changes
once the form has been submitted to the Benefits Department, but when the 31-day enrollment period is over, you will not be able to make changes to
your enrollment unless you have a Qualified Family Status Change.
• According to Internal Revenue Service (IRS) rules, you have 31 days from your first day of eligibility (date of hire or date of qualifying job status
change) to enroll in your elected benefits. If you do not enroll (by returning this form to the Benefits Department) within the 31 day election period, you
will not have health, dental, vision, supplemental life, or short term disability coverage through Wake Forest Baptist Health, and will not be able to enroll in
those Wake Forest Baptist Health plans until the next Open Enrollment (usually in November, with elections effective the first of the following year),
unless you have a Qualified Family Status Change or a Qualfied Job Class Change.
• Qualified Family Status Changes include (1) Marriage, (2) Divorce or Legal Separation, (3) Birth or Adoption, (4) Loss of a Dependent's Eligibility, (5)
Change in spouse's employment status, (6) Significant change in spouse's employer's benefit coverage, and (7) Court Orders or Decrees.
• Qualified Job Class Changes are those that affect eligibility for benefits and include Full-Time to Part-Time status, Full-Time to Limited Benefits status,
Full-Time to Job Share status, etc.
• Supplemental life insurance and dependent life insurance does not require Evidence of Insurability (EOI) for employees who enroll when they first
become eligible for coverage. If coverage is waived during the first 31 days of eligibility, the insurance company will require EOI for later enrollments and
the insurance company may deny coverage based on the EOI information.
2. Enrollment process
• You may elect coverage for yourself and eligible dependents on a benefit-by-benefit basis. Eligible dependents are your spouse, dependent children
from birth until age 26, or disabled, children who incurred their disabilities while otherwise eligible for health benefits.
• If dependent coverage is elected, the dependent will be covered the day the employee's coverage begins.
• Coverage ends for most benefits at midnight on the last day of the pay period in which the individual’s employment terminates or the employee has a
classification change to an ineligible class. If, for any reason, you do not pay your required employee contributions, coverage will end at midnight of the
last day of the 4th consecutive pay period following the last payment receipt. Coverage for short term disability, long term disability, basic and
supplemental life insurance, and accidental death and dismemberment terminates on the last day of employment.
• Note that, unlike the definition for eligible dependents given above, eligible dependents for Dependent Care Flexible Spending Accounts are limited by
the IRS to children under age 13 or mentally or physically disabled dependents.
• Please complete all sections of the enrollment form. If you do not indicate a benefit election within a section, the benefit will be considered to have
been waived for the balance of the calendar year (unless there is a qualifying family or job status change).
• If requested, you must provide a Certificate of Coverage for you and your eligible dependents to cover any pre-existing conditions.
3. Deductions
• The premiums you pay for your health, dental, and vision benefits are paid through payroll deduction from your salary on a pre-tax basis (before taxes
are calculated). The premiums you pay for supplemental life insurance are paid on a post-tax basis.
• In exchange for allowing you to pay your premium with pre-tax dollars, Internal Revenue Code regulations do not allow you to cancel or change your
coverage election outside of the Open Enrollment period unless you experience a qualified family status change as defined under the IRS Code.
• Your benefit change must be consistent with your status change and you must contact the Benefits Department (336-716-3334 or
[email protected] ) within 31 days of the event to make any corresponding benefit changes.
• Wake Forest Baptist Health pays the full cost of long term disability coverage for eligible employees. According to current IRS rules, long term disability
benefits are taxable to the employee if the disability occurred while the premium was being paid by Wake Forest Baptist Health.
• Employee contributions (deductions) are not withheld until the first pay check following your participation date.
• The rates in this enrollment form are current year rates and are subject to change. Cost of insurance for all coverages which are deducted from your
paycheck may increase or decrease in the future based upon factors such as the claims experience and insurance contract renewals.
4. Flexible Spending Accounts
• Only eligible expenses incurred on or after the later of your hire date or January 1, 2015 through March 15, 2016 (for medical) or December 31, 2015
(for dependent care) can be claimed for reimbursement from your 2015 Flexible Spending Account(s).
5. Dependents
• If you have a Qualified Family Status Change or a Qualified Job Class Change and elect to change your benefits coverage as a result, the premium
changes will be effective the date the change happened. In other words, increases or decreases to your premium will be made back to the date of the
status change (provided, of course, that notification was given within the IRS guidelines).
• In the event of a change in eligibility for any of your dependent(s), applicable contribution refunds will be made, provided the Plan receives notification
of an enrollment change within 31 days of a Qualifying Event which results in a reduction of contributions.
• If, after the 31-day status change period, dependents are found to be ineligible for coverage, enrollment levels will be adjusted to reflect eligibile
dependents, however, if a reduction in premium results, refunds of over-paid premiums will be limited to two pay periods.
• Any claims paid on behalf of an ineligible individual must be reimbursed to the Plan before an employee contribution refund will be made.
6. Insurance Rate Tables
Supplemental Life and Accidental Death and Dismemberment Rates per $1000 of coverage
Age
Under 35
35-39
40-44
Rate
0.052
0.064
0.093
Age
45-49
50-54
55-59
Rate
0.141
0.223
0.345
Age
60-64
65-69
70 +
Rate
0.418
0.643
1.043
Important Note: The Benefits Participation Guidelines are based on IRS regulations and the Wake Forest Baptist Health Benefit plan documents (the
source documents). If there is any discrepancy between this document and the IRS regulations or the plan documents, the source documents apply.
EMPLOYEE RIGHTS AND RESPONSIBILITIES
UNDER THE FAMILY AND MEDICAL LEAVE ACT
Basic Leave Entitlement
Use of Leave
FMLA requires covered employers to provide up to 12 weeks of unpaid, jobprotected leave to eligible employees for the following reasons:
•
For incapacity due to pregnancy, prenatal medical care or child birth;
•
To care for the employee’s child after birth, or placement for adoption
or foster care;
•
To care for the employee’s spouse, son or daughter, or parent, who has
a serious health condition; or
•
For a serious health condition that makes the employee unable to
perform the employee’s job.
An employee does not need to use this leave entitlement in one block. Leave
can be taken intermittently or on a reduced leave schedule when medically
necessary. Employees must make reasonable efforts to schedule leave for
planned medical treatment so as not to unduly disrupt the employer’s
operations. Leave due to qualifying exigencies may also be taken on an
intermittent basis.
Military Family Leave Entitlements
Eligible employees with a spouse, son, daughter, or parent on active duty or
call to active duty status in the National Guard or Reserves in support of a
contingency operation may use their 12-week leave entitlement to address
certain qualifying exigencies. Qualifying exigencies may include attending
certain military events, arranging for alternative childcare, addressing certain
financial and legal arrangements, attending certain counseling sessions, and
attending post-deployment reintegration briefings.
FMLA also includes a special leave entitlement that permits eligible
employees to take up to 26 weeks of leave to care for a covered
servicemember during a single 12-month period. A covered servicemember
is a current member of the Armed Forces, including a member of the
National Guard or Reserves, who has a serious injury or illness incurred in
the line of duty on active duty that may render the servicemember medically
unfit to perform his or her duties for which the servicemember is undergoing
medical treatment, recuperation, or therapy; or is in outpatient status; or is on
the temporary disability retired list.
Substitution of Paid Leave for Unpaid Leave
Employees may choose or employers may require use of accrued paid leave
while taking FMLA leave. In order to use paid leave for FMLA leave,
employees must comply with the employer’s normal paid leave policies.
Employee Responsibilities
Employees must provide 30 days advance notice of the need to take FMLA
leave when the need is foreseeable. When 30 days notice is not possible, the
employee must provide notice as soon as practicable and generally must
comply with an employer’s normal call-in procedures.
Employees must provide sufficient information for the employer to
determine if the leave may qualify for FMLA protection and the anticipated
timing and duration of the leave. Sufficient information may include that the
employee is unable to perform job functions, the family member is unable to
perform daily activities, the need for hospitalization or continuing treatment
by a health care provider, or circumstances supporting the need for military
family leave. Employees also must inform the employer if the requested
leave is for a reason for which FMLA leave was previously taken or certified.
Employees also may be required to provide a certification and periodic
recertification supporting the need for leave.
Employer Responsibilities
Benefits and Protections
During FMLA leave, the employer must maintain the employee’s health
coverage under any “group health plan” on the same terms as if the employee
had continued to work. Upon return from FMLA leave, most employees
must be restored to their original or equivalent positions with equivalent pay,
benefits, and other employment terms.
Use of FMLA leave cannot result in the loss of any employment benefit that
accrued prior to the start of an employee’s leave.
Eligibility Requirements
Employees are eligible if they have worked for a covered employer for at
least one year, for 1,250 hours over the previous 12 months, and if at least 50
employees are employed by the employer within 75 miles.
Definition of Serious Health Condition
A serious health condition is an illness, injury, impairment, or physical or
mental condition that involves either an overnight stay in a medical care
facility, or continuing treatment by a health care provider for a condition that
either prevents the employee from performing the functions of the
employee’s job, or prevents the qualified family member from participating
in school or other daily activities.
Subject to certain conditions, the continuing treatment requirement may be
met by a period of incapacity of more than 3 consecutive calendar days
combined with at least two visits to a health care provider or one visit and a
regimen of continuing treatment, or incapacity due to pregnancy, or
incapacity due to a chronic condition. Other conditions may meet the
definition of continuing treatment.
Covered employers must inform employees requesting leave whether they
are eligible under FMLA. If they are, the notice must specify any additional
information required as well as the employees’ rights and responsibilities. If
they are not eligible, the employer must provide a reason for the ineligibility.
Covered employers must inform employees if leave will be designated as
FMLA-protected and the amount of leave counted against the employee’s
leave entitlement. If the employer determines that the leave is not FMLAprotected, the employer must notify the employee.
Unlawful Acts by Employers
FMLA makes it unlawful for any employer to:
•
Interfere with, restrain, or deny the exercise of any right provided under
FMLA;
•
Discharge or discriminate against any person for opposing any practice
made unlawful by FMLA or for involvement in any proceeding under
or relating to FMLA.
Enforcement
An employee may file a complaint with the U.S. Department of Labor or
may bring a private lawsuit against an employer.
FMLA does not affect any Federal or State law prohibiting discrimination, or
supersede any State or local law or collective bargaining agreement which
provides greater family or medical leave rights.
FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered
employers to post the text of this notice. Regulations 29
C.F.R. § 825.300(a) may require additional disclosures.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
For additional information:
1-866-4US-WAGE (1-866-487-9243) TTY: 1-877-889-5627
WWW.WAGEHOUR.DOL.GOV
U.S. Department of Labor | Employment Standards Administration | Wage and Hour Division
WHD Publication 1420 Revised January 2009
Employee Benefit Contact Information
Benefits Department:
Customer Service 336-716-3334
Email [email protected]
Fax 336-716-6832
Health / Dental / COBRA/ Flex Spending Accounts - MedCost Benefit Services:
Customer Service 1-800-795-1023
www.medcost.com
Vision - MedCost (open access vision coverage for materials):
Customer Service 1-800-795-1023
www.medcost.com
Life Insurance -CIGNA:
Customer Service 800-36-Cigna
www.cigna.com
Disability Insurance - Mensh Insurance:
Customer Service 336-631-5503
Disability www.menshinsurance.com/wake/
Prescriptions:
Ardmore Tower Outpatient Pharmacy
Cancer Center Pharmacy
Piedmont Plaza Pharmacy
Downtown Health Plaza
336-716-3363
336-713-6808
336-716-5800
336-713-9800
Retirement Savings Plan
Transamerica Retirement Solutions 336-716-2000
wfbmc.trsretire.com
TIAA-CREF 800-842-2776
tiaa-cref.org/wfbmc
Child Care - Childrens Choice Learning Center:
Customer Service 336 716-0300
Elder Care Choices - Senior Services, Inc.:
Customer Service 336-748-0300
Website seniorservicesinc.org/ElderCareChoices/
Credit Unions:
Allegacy Federal Credit Union
Customer Service
Website
Summit Credit Union
Customer Service
Website
Forms on Infinet:
Address Change Form
Enrollment Change Form
Dental Claim Forms
Health Claim Forms
Vision Claim Forms
1-800-782-4670 or 336-774-3400
www.allegacyfcu.org
336-722-3065 or 336-722-1095
www.summitcu.org