Return to flip book view

YourBenefitsEffective January 1 - December 31, 2024

You must request a change to your benefitswithin 30 days of your life event (60 days forchanges involving Medicaid eligibility). Documentation may be required.Your benefits begin on the first day of the monthfollowing 30 days of employment; this is youreffective date. Be sure to submit your selectionswithin your first 30 days of benefits eligibility/withinyour first 30 days of employment. Your benefit selections will be in effect throughDecember 31. When you're first eligible Open Enrollment is your one chance each year toreview your coverage options and make changes toyour benefits.Your choices are in effect from January – Decemberof the following year unless you have a qualifyinglife event. At Open Enrollmentmarriage or divorce, birth or adoption, death of a covered dependent, and a change in eligibility through Medicare,Medicaid, or a spouse or parent's coverage. Qualifying life events allow you to change yourcoverage during the year outside of OpenEnrollment. These include: If you have a qualifying life eventYour benefit plans are in effect January 1 –December 31 each year. In general, there are threetimes you can make benefit selections:Making benefit selectionsGetting startedEligibility Enrolling in coverageFor youYou are eligible for benefits as a full-time employeeworking at least 30 hours per week.Your Spouse or PartnerYou may also cover your eligible dependents whenyou elect coverage for yourself.Covering your familyMedical, dental and vision: until age 26regardless of student or marital statusChild life insurance: until age 21, or 26 if afull-time studentDependent children are eligible:You may cover your legal spouse or domesticpartner.Your children

Balance billingWhen you use an out-of-networkmedical or dental provider, theymay bill you the difference betweenwhat they charge and the amountyour insurance pays.Medical: balance billing is inaddition to – and does not counttowards – your out-of-pocketmaximum.CoinsuranceAfter you’ve met your deductible,you’re sometimes responsible for apercentage of the cost of themedical care, dental care, orprescription medication youreceived. This percentage iscoinsurance.CopayA flat fee you pay each time youreceive a copay-eligible medical,dental, or vision service orprescription medication. DeductibleThe amount you’re responsible forpaying in care expenses before themedical or dental plan starts payingdeductible-eligible expenses.In-networkIn-network care is always yourlowest-cost option. Networks aregroups of medical, dental, andvision providers, pharmacies, andfacilities that agree to discount thecost of their care or service.Out-of-pocket maximumThe most you’ll pay for covered in-network medical care in a year. Thisincludes your deductible, anycoinsurance or copays, andprescription drugs. The out-of-pocket maximum doesnot include your premium (theamount you pay for coverage), non-covered expenses, or out-of-network care that’s been balancebilled.Primary care physicianA primary care physician (PCP) isyour main medical doctor – usuallya general practitioner (GP), familydoctor, internist, OB/GYN, orpediatrician (for children).Referral/pre-authorizationSome specialty medical providersand services require a referral froma primary doctor. These may include- but are not limited to -cardiology, psychiatry, orthopedicsurgeons, rheumatology, surgery,and imaging (CT or MRI).Have questions? Your advocate is here to help youwith all things benefits. See theircontact information on the nextpage.How to handle medicalbills (4:46)Annual NoticesWe’re required to tell you about certainrights and responsibilities you have as anemployee of South Bronx Charter School. Download nowHelpful terms & resourcesGetting startedWe've removed as much jargon as possible.But you’ll probably still encounter some terms as you enroll in and use your benefits, and wewant you to be prepared!

Medical insuranceAnthem1-800-331-1476www.anthem.comFlexible Spending Accounts (FSAs)Gente1-973-995-1000www.gente.solutionsEmployee Assistance Program (EAP)Sunlife1-800-786-5433www.sunlife.comDental insuranceDelta Dental NYPPO Group: 20654-08013DHMO Group: 79315-000011-212-946-2835www.deltadentalins.comVision insuranceSunlifeGroup: 9446761-800-786-5433www.sunlife.comLife and AD&D insuranceSunlifeGroup: 9446761-800-786-2835www.sunlife.comDisability insuranceSunlifeGroup: 944676 1-800-786-2835www.sunlife.comCommuter BenefitsGente1-973-995-1000www.gente.solutionsJacqueline GoinsDirector of Human Resourcesjgoins@sbcsica.orgContact informationGetting startedHR DEPARTMENT CONTACT:

In-network careGold EPO planGold Blue Access planAnnual Deductible (DED)Out-of-pocket maximum$1000 per person $2,000 family max$7,000 per person $14,000 family maxn/a n/a$8,700 per person $17,400 family maxPreventive carePrimary care visitSpecialist visit100% covered$50 copay$55 copay100% covered$25 copay$50 copayUrgent careEmergency roomInpatient hospital care$60 copay$500 copay$500 admission$50 copay$750/visit$500 admissionPrescription drugsGeneric Preferred brand Non-preferred brand(30 days | 90 days)$10 copay | $25 copay$40 copay | $100 copay$80 copay | $200 copay(30 days | 90 days)$10 copay | $25 copay$65 copay | $163 copay$90 copay | $225 copayOut-of-network careAnnual deductible Out-of-pocket maximum Balance billing appliesn/an/aBalance billing appliesn/an/aSee plan detailsMedical insuranceSee plan detailsThe information shown in this presentation is an illustrative summary only. The underlying plan contract or document governs all aspects of the plan. Finalrates are dependent on actual enrollment, insurance carrier or plan rules, plan selection, and eligibility criteria. Please refer to the plan document, contract,and other notices contained in this document, applications, and other corresponding communications for additional information.See your plan documents for out-of-network benefits.what you pay for the plan, what you pay when you get care, how out-of-network care is covered, andyour annual maximum cost for care (out-of-pocket maximum).Both plans cover in-network preventive care at 100%, prescription drugs, andinclude an annual limit on your expenses. The differences are: Select from two medical options through Anthem.*CONTACT HR FOR COSTOF COVERAGE

Eligible expenses2024 maximum contribution$3,200Annual rollover amount$02024 maximum contribution$5,000Married filing separately: contribute up to $2,500 per person.Monthly maximum contribution$300See plan detailsFlexible Spending Accounts (FSAs)Pay for eligible child or disabled adult care while youwork or attend school.Dependent care FSAOnly the amount you’ve actually contributed isavailable for use at any one time.Estimate carefully! Unused funds will be forfeited at theend of the year per IRS regulations.Pay for eligible transit and parking expenses related towork.Commuter BenefitsEnrollment and contribution elections are made on amonthly basis, not annual.Enrolled in an HDHP plan and eligible for HSA contributions? You’re not eligiblefor a health care FSA; you can contribute to a limited purpose FSA instead.The information shown in this presentation is an illustrative summary only. The underlying plan contract or document governs all aspects of the plan. Finalrates are dependent on actual enrollment, insurance carrier or plan rules, plan selection, and eligibility criteria. Please refer to the plan document, contract,and other notices contained in this document, applications, and other corresponding communications for additional information.Pay for eligible medical, prescription, dental, andvision expenses.Health careHealth care FSAHealth and dependent care expenses can add up. Paying with tax-free fundscan help. Enroll in one or more flexible spending accounts (FSAs) dependingon your needs.Pay for qualifying expenses with tax-free money using yourFlexible Spending Account through Gente.

Employee AssistanceProgram (EAP)Confidential. No one at South Bronx Charter School will ever know youcalled or what was discussed.Available 24/7/365. Life doesn't happen during office hours. The EAP ishere when you need them.Family care is included. Anyone living in your home is eligible for EAPservices at no cost.EAP features:.Web ID: EAPEssential: 24/7/365 access to care. 1-800-460-4374Online: guidanceresources.comApp: GuidanceNowThe benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlyingplan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlyinginsurance documents will govern in all cases.mental health concerns (including substance abuse or addiction),adoption, parenting, or caregiving needs,financial or legal support,familial relationships and friendships,coping with day-to-day challenges, andso much more.Our Employee Assistance Plan (EAP) is a confidential service with access toguidance and resources at no cost for: Essentially, if it's part of your life, our EAP is here for you.Access support online, through live chat, or over the phone. 24/7/365.Everyone needs support sometimes (even superheroes)Care for your mind – and your life – with support throughSunlife.Confidential care designed for all that life brings.See plan details

Stay in-network to avoid balance billing (the difference between what an out-of-network provider charges and the amount your insurance pays). Learn about dental care categoriesIn-network carePPO Plus Premier planDeltaCare USA planNetwork name:National PPONational PPOAnnual Deductible (DED)$50 per person $150 family maxn/an/aAnnual maximum benefit$2,000 per person UnlimitedPreventive care100% coveredSee attached schedule of benefits Applicable copays applyBasic care90% coveredSee attached schedule of benefits Applicable copays applyMajor care60% coveredSee attached schedule of benefits Applicable copays applyOrthodontic careCoverageLifetime maximum benefit50% Child only$1,500See attached schedule of benefitsApplicable copays applySee plan detailsSee plan detailsDental insuranceThe information shown in this presentation is an illustrative summary only. The underlying plan contract or document governs all aspects of the plan. Finalrates are dependent on actual enrollment, insurance carrier or plan rules, plan selection, and eligibility criteria. Please refer to the plan document, contract,and other notices contained in this document, applications, and other corresponding communications for additional information.what you pay for the plan, what you pay when you get care, the maximum amount carrier will pay each year for dental care (annualmaximum benefit), andwhether orthodontic care is covered.Both plans cover in-network preventive care at 100%. The differences are: Select from two dental options through Delta Dental NY.

Vision insuranceThe information shown in this presentation is an illustrative summary only. The underlying plan contract or document governs all aspects of the plan. Finalrates are dependent on actual enrollment, insurance carrier or plan rules, plan selection, and eligibility criteria. Please refer to the plan document, contract,and other notices contained in this document, applications, and other corresponding communications for additional information.Your vision plan covers either glasses (lenses and frames) or contact lenses each year. If you receive contact lenses, they will be instead of your glasses benefit.You'll get an annual exam with coverage for lenses and frames, or contacts inlieu of glasses.Your vision coverage is through Sunlife.Vision planNetwork name:National PPOIn-networkNon-network(reimbursement)Annual eye exam (every 12 months)$0 copayUp to $45Lenses (every 12 months)Combined with Exams copay(lenses and frame)Up to $30 / $50 / $100 Frames(every 12 months)$150 allowance plus 20% off balanceUp to $70Contact lenses(every 12 months)Elective: $150 allowanceMed. nec: 100% coveredElective: Up to $105Med. nec: Up to $200See plan details

Basic Life and AD&D1x basic earnings to a max of $400,000See plan detailsFor youFor your spouseFor your child(ren)Coverageincrements$100,000$30,000$10,000CoveragemaximumIncr$10,000 to lesserof 5x your annualearnings or $500,000maxIncrements if $5,000to $100,000 not toexceed 50% of(employee) coverageamount $10,000You may also purchase additional coverage for you, your spouse, and youreligible child(ren). Additional life and AD&D insuranceSee plan detailsLife insurance pays a benefit if you pass away while you're covered. AccidentalDeath and Dismemberment (AD&D) insurance offers additional support if youpass away or are seriously injured due to an accident.Financial peace of mind through Sunlife.Life and AD&D insuranceyour beneficiary if you passaway due to an accidentyou a partial benefit if youlose specified bodily functions(sight, limbs, etc.)What's AD&D?Accidental death anddismemberment (AD&D)insurance may pay:Make sure to designate a beneficiary for your life insurance coverage to ensureyour family is cared for according to your wishes.Medical question limitWhen you’re first eligible (a newhire), you can purchaseadditional life insurance up tothis limit without any medicalquestions required. Medical questions and approvalwill be required for all futureincrease and purchase requests.The benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlyingplan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlyinginsurance documents will govern in all cases.Basic life and AD&D insuranceSouth Bronx Charter School provides life and AD&D insurance at no cost to you.

Benefits beginAccident: On the first day you're unable to workIllness: After 7 days of inability to work Coverage amount60% of your income up to $1,500 per weekPayments may continueUp to 25 weeks if you’re unable to return to workElimination PeriodIllness: 8 daysAccident: 8 daysSee plan detailsSee plan detailsIf you make a disability claimwithin the first year of beingcovered, check your plan detailsto see how pre-existingcondition limitations mightimpact your coverage.Pre-existing conditionlimitations Benefits beginAfter 180 days of inability to work (once short-termdisability ends)Coverage amount60% of your income up to $7,500 per monthPayments may continueUntil your Social Security Normal Retirement Age if youremain unable to work.Disability insuranceThe benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlyingplan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlyinginsurance documents will govern in all cases.Protect your paycheck with disability insurance throughSunlife.Disability coverage insures your paycheck, replacing a portion of your income ifyou’re unable to work due to a covered illness or injury.Short-term disability coverage can replace part of your paycheck if you’re unableto work for a shorter period of time. This coverage is available for purchase.Short-term disabilityLong-term disability coverage can provide lasting income protection if youremain unable to work. This coverage is available for purchase.Long-term disability

2024 benefitsENROLLMENT FORMSMEDICAL DENTALVISION & LIFEFSA/TRANSIT