Health Insurance Election Form

Effective July 1, 2020 I elect: (choose one option only) Employee required co-pays are shown per pay period.

Core Plan (0021)

Simply Blue HRA Plan - In Network $100/$200 Deductible, 0% Coinsurance, $20 Office Visit Co-pay, $20 Chiropractic Co-pay (24 visits), $150 Emergency Room Co-pay, UP Blue, EA. Out-of-Network $200/40%/$4000. ARORx $5/$25/$50 with Contraceptives. BCBSM Dental 100/80/50-$1500 Ortho 50-$1500. EyeMed Vision 24/24/24 $0 Exam $10 Materials. MDLive telemedicine.

Single: $21.90
Two Person: $52.57
Family: $65.71

Simply Blue HRA Plan - In Network $100/$200 Deductible, 0% Coinsurance, $20 Office Visit Co-pay, $20 Chiropractic Co-pay (24 visits), $150 Emergency Room Co-pay, UP Blue, EA. Out-of-Network $200/40%/$4000. ARORx $5/$25/$50 with Contraceptives. BCBSM Dental 100/80/50-$1500 Ortho 50-$1500. EyeMed Vision 24/24/24 $0 Exam $10 Materials. MDLive telemedicine.

Buy Up Plan (0022)

Simply Blue HRA Plan - In Network $100/$200 Deductible, 0% Coinsurance, $20 Office Visit Co-pay, Chiropractic Covered 100% (24 visits), $100 Emergency Room Co-pay, UP Blue, EA. Out-of-Network $200/40%/$4000. ARORx $10/$20/$40 with Contraceptives. BCBSM Dental 100/80/50-$1500 Ortho 50-$1500. EyeMed Vision 12/12/12 $0 Exam $10 Materials. MDLive telemedicine. Employee premium Co-Pay:

Single: $37.78
Two Person: $90.66
Family: $113.33

Simply Blue HRA Plan - In Network $100/$200 Deductible, 0% Coinsurance, $20 Office Visit Co-pay, Chiropractic Covered 100% (24 visits), $100 Emergency Room Co-pay, UP Blue, EA. Out-of-Network $200/40%/$4000. ARORx $10/$20/$40 with Contraceptives. BCBSM Dental 100/80/50-$1500 Ortho 50-$1500. EyeMed Vision 12/12/12 $0 Exam $10 Materials. MDLive telemedicine.

Buy Down Plan (0023)

Simply Blue HRA Plan - In Network $500/$1000 Deductible, 0% Coinsurance, $30 Office Visit Co-pay, $30 Chiropractic Co-pay (24 visits), $150 Emergency Room Co-pay, UP Blue, EA. Out-of-Network $1000/20%/$2750. ARORx $10/$40/$80 with Contraceptives. BCBSM Dental 100/80/50-$1500 Ortho 50-$1500. EyeMed Vision 24/24/24 $0 Exam $10 Materials. MDLive telemedicine. $5.00 per month will be deducted from your Flat HRA balance for plan administration costs. Employee Premium Co-Pay:

Single: $21.90 Includes Flat HRA $25.15
Two Person: $52.57 Includes Flat HRA $65.88
Family: $65.71 Includes Flat HRA $83.34

Simply Blue HRA Plan - In Network $500/$1000 Deductible, 0% Coinsurance, $30 Office Visit Co-pay, $30 Chiropractic Co-pay (24 visits), $150 Emergency Room Co-pay, UP Blue, EA. Out-of-Network $1000/20%/$2750. ARORx $10/$40/$80 with Contraceptives. BCBSM Dental 100/80/50-$1500 Ortho 50-$1500. EyeMed Vision 24/24/24 $0 Exam $10 Materials. MDLive telemedicine. $5.00 per month will be deducted from your Flat HRA balance for plan administration costs.

Modified Buy Down Plan (0023) No Flat HRA

Simply Blue HRA Plan - In Network $500/$1000 Deductible, 0% Coinsurance, $30 Office Visit Co-pay, $30 Chiropractic Co-pay (24 visits), $150 Emergency Room Co-pay, UP Blue, EA. Out-of-Network $1000/20%/$2750. ARORx $10/$40/$80 with Contraceptives. BCBSM Dental 100/80/50-$1500 Ortho 50-$1500. EyeMed Vision 24/24/24 $0 Exam $10 Materials. MDLive telemedicine. Employee Premium Co-Pay:

Single: $0.00
Two Person: $0.00
Family: $0.00

Simply Blue HRA Plan - In Network $500/$1000 Deductible, 0% Coinsurance, $30 Office Visit Co-pay, $30 Chiropractic Co-pay (24 visits), $150 Emergency Room Co-pay, UP Blue, EA. Out-of-Network $1000/20%/$2750. ARORx $10/$40/$80 with Contraceptives. BCBSM Dental 100/80/50-$1500 Ortho 50-$1500. EyeMed Vision 24/24/24 $0 Exam $10 Materials. MDLive telemedicine.

Opt-Out

Employees who elect to opt-out of City health insurance coverage will receive cash compensation in an amount equal to 50% of the current hard cap rate for single subscriber (plus 100% of the single core vision plan premium and 100% of the single dental premium). This amount is subject to required State and Federal taxes beginning with the 1st pay period after July 1, 2020.

Opt-out amount per pay period: $151.20

Employees who elect to opt-out of City health insurance coverage will receive cash compensation in an amount equal to 50% of the current hard cap rate for single subscriber (plus 100% of the single core vision plan premium and 100% of the single dental premium). This amount is subject to required State and Federal taxes beginning with the 1st pay period after July 1, 2020.

Date

Name

First Last

Signature

City of Marquette

Group #007003465

Please make your selection by June 19, 2020.

An employee who fails to make a timely election by June 19, 2020 will be automatically enrolled in the Core Plan.

City of Marquette

Group #007003465

Please make your selection by June 19, 2020. An employee who fails to make a timely election by June 19, 2020 will be automatically enrolled in the Core Plan.

Please make your selection by June 19, 2020.

An employee who fails to make a timely election by June 19, 2020 will be automatically enrolled in the Core Plan.