6-5.0-2025-26 Tarpon Springs EBH Booklet FINAL.pdf

E M P L O Y E E B E N E F I T

H I G H L I G H T S

2025 2026

City of Tarpon Springs | Employee Benefit Highlights | 2025-2026

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

This booklet is merely a summary of employee benefits. For a full description, refer to the plan document. Where conflict exists between this summary and the plan document, the plan document controls.

City of Tarpon Springs reserves the right to amend, modify or terminate the plan at any time. This booklet should not be construed as a guarantee of employment.

Table of Contents

Introduction� 1

Summary of Benefits and Coverage� 1

Online Benefit Enrollment� 1

Group Insurance Eligibility� 2-3

Qualifying Events and Section 125� 3

Medical Insurance� 4-5

Medical Plan Resources� 4

UnitedHealthcare Choice Plus Plan 15 Plan At-A-Glance� 5

Dental Insurance� 6-7

MetLife Dental PDP Plan At-A-Glance� 7

Vision Insurance� 8-9

EyeMed Insight Vision Plan At-A-Glance� 9

Flexible Spending Accounts� 10-11

Employee Assistance Program� 12

Basic Life and AD&D Insurance� 12

Voluntary Life and AD&D Insurance� 13

Voluntary Short Term Disability� 13

Long Term Disability� 13

Supplemental Benefits� 14

Notes� 14-15

Contact Information

Human Resources Department Tabatha Adkins Director of Human Resources

Phone: (727) 938-3711 Email: hr2@ctsfl.us

Online Benefit Enrollment Bentek Support

(888) 5-Bentek (523-6835) app.mybentek.com/ctsfl

Medical Insurance UnitedHealthcare Customer Service: (800) 357-0978 www.myuhc.com

Prescription Drug Coverage & Mail-Order Program

Optum Rx Customer Service: (800) 356-3477 www.optumrx.com

Telehealth Virtual Visits through UnitedHealthcare

Customer Service: (800) 357-0978 www.uhc.com/virtualvisits

Dental Insurance MetLife Customer Service: (800) 275-4638 www.metlife.com

Vision Insurance EyeMed Customer Service: (866) 804-0982 www.eyemed.com

Flexible Spending Accounts UpSwing Customer Service: (888) 537-3539 Fax: (904) 880-2830 upswing.wealthcareportal.com

Employee Assistance Program Employee Assistance Program through UnitedHealthcare

Customer Service: (888) 887-4114 www.myuhc.com

Basic Life and AD&D Insurance The Hartford Customer Service: (800) 523-2233 www.thehartford.com

Voluntary Life and AD&D Insurance The Hartford Customer Service: (800) 523-2233 www.thehartford.com

Voluntary Short Term Disability Insurance The Hartford Customer Service: (800) 523-2233 www.thehartford.com

Long Term Disability Insurance The Hartford Customer Service: (800) 523-2233 www.thehartford.com

Supplemental Benefits The Standard Customer Service: (866) 851-5505 Agent: Eric Gonzalez | Phone: (971) 321-1660 ext. 1660 www.standard.com http://upswing.wealthcareportal.com

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

Introduction The City of Tarpon Springs provides group insurance benefits to eligible employees. The Employee Benefit Highlights Booklet provides a general summary of the benefit options as a convenient reference. Please refer to the City Personnel Policies and/or Certificates of Coverage for detailed descriptions of all available employee benefit programs and stipulations therein. If employee requires further explanation or needs assistance regarding claims processing, please refer to the customer service phone numbers under each benefit description heading or contact Human Resources.

Summary of Benefits and Coverage A Summary of Benefits & Coverage (SBC) for the Medical Plan is provided as a supplement to this booklet being distributed to new hires and existing employees during the Open Enrollment period. The summary is an important item in understanding employee's benefit options. A free paper copy of the SBC document may be requested or is also available as follows:

From: Human Resources

Phone: (727) 938-3711

Website URL: app.mybentek.com/ctsfl

The SBC is only a summary of the plan’s coverage. A copy of the plan document, policy, or certificate of coverage should be consulted to determine the governing contractual provisions of the coverage. A copy of the group certificate of coverage can be reviewed and obtained by contacting Human Resources.

If there are any questions about the plan offerings or coverage options, please contact Human Resources at (727) 938-3711.

Online Benefit Enrollment The City provides employees with an online benefits enrollment platform through Bentek’s Employee Benefits Center (EBC). The EBC provides benefit-eligible employees the ability to select or change insurance benefits online during the annual Open Enrollment Period, New Hire Orientation, or for Qualifying Life Events.

Accessible 24 hours a day, throughout the year, employee may log in and review comprehensive information regarding benefit plans, and view and print an outline of benefit elections for employee and dependent(s). Employee also has access to important forms and carrier links, can report qualifying life events and review and make changes to Life insurance beneficiary designations.

To Access the Employee Benefits Center:

9 Log on to app.mybentek.com/ctsfl

Please Note: Link must be addressed exactly as written.

9 Sign in using a previously created username and password or click "Create an Account" to set up a username and password.

9 If employee has forgotten username and/or password, click on the link “Forgot Username/Password” and follow the instructions.

9 Once logged on, navigate using the Launchpad to review current enrollment, learn about benefit options, and make any benefit changes or update beneficiary designations.

For technical issues directly related to using the EBC, please call (888) 5-Bentek (523-6835) or email Bentek Support at support@mybentek.com, Monday through Friday during regular business hours 8:30am - 5:00pm.

To access Bentek using a mobile device, scan code.

http://app.mybentek.com/ctsfl http://app.mybentek.com/ctsfl

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

Group Insurance Eligibility The City's group insurance plan year is October 1 through September 30.

Employee Eligibility Employees are eligible to participate in the City's medical, dental and vision insurance plans if they are full-time employees. Coverage will be effective 90 days following date of hire. For example, if employee is hired on April 1, then the effective date of coverage will be June 29.

Employees are eligible to participate in the City's FSA, Basic and Voluntary Life, Disability and Supplemental insurance plans if they are full-time employees.

Coverage will be effective the first of the month following 90 days of employment. For example, if employee is hired on May 11, then the effective date of coverage will be September 1.

Separation of Employment If employee separates employment from the City, insurance will continue through the end of month in which separation occurred. COBRA continuation of coverage may be available as applicable by law.

Dependent Eligibility A dependent is defined as the legal spouse/domestic partner and/or dependent child(ren) of the participant or spouse/domestic partner. The term “child” includes any of the following:

dependent (Florida State Statute)

• A child for whom legal guardianship has been awarded to the participant or the participant’s spouse/domestic partner

Dependent Age Requirements Medical and Vision Coverage: A dependent child may be covered through the end of the calendar year in which the child turns age

26. An over-age dependent (taxable dependent) may continue to be covered on the medical or vision plan to the end of the calendar year in which the child reaches age 30, if the dependent meets the following requirements:

Social Security Act, unless the child is disabled.

Dental Coverage: A dependent child may be covered through the end of the calendar year in which the child turns age 26.

Please see Taxable Dependents if covering eligible over-age dependents.

Disabled Dependents Coverage for a dependent child may be continued beyond age 26 if:

• The dependent is physically or mentally disabled and incapable of self-sustaining employment (prior to age 26); and

insurance plans; and

• The dependent has been continuously insured.

Proof of disability will be required upon request. Please contact Human Resources if further clarification is needed.

Taxable Dependents Employee covering adult child(ren) under employee's medical and vision insurance plans may continue to have the related coverage premiums payroll deducted on a pre-tax basis through the end of the calendar year in which dependent child reaches age 26. Beginning January 1 of the calendar year in which dependent child reaches age 27 through the end of the calendar year in which the dependent child reaches age 30, imputed income must be reported on the employee’s W-2 for that entire tax year and will be subject to all applicable Federal, Social Security and Medicare taxes. Imputed income is the dollar value of insurance coverage attributable to covering each adult dependent child. Contact Human Resources for further details if covering an adult dependent child who will turn age 27 any time during the upcoming calendar year or for more information.

Please Note: There is no imputed income if adult dependent child is eligible to be claimed as a dependent for Federal income tax purposes on the employee’s tax return.

OCTOBER

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

Group Insurance Eligibility (Continued)

Domestic Partner Coverage Domestic partners may be eligible to participate in the City's group insurance plans if the partner is officially registered as a domestic partner in the County in which they reside or work. The IRS guidelines state that employee may not receive a tax advantage on any portion of premiums paid related to domestic partner coverage. Employees insuring domestic partners and/or child dependent(s) of a domestic partner are required to pay imputed income tax on subsidy amounts and should consult a tax advisor. Please contact Human Resources for more information.

Qualifying Events and Section 125 Section 125 of the Internal Revenue Code Premiums for medical, dental, vision insurance, contributions to Flexible Spending Accounts (FSA), and/or certain supplemental policies are deducted through a Cafeteria Plan established under Section 125 of the Internal Revenue Code and are pre-taxed to the extent permitted. Under Section 125, changes to employee's pre-tax benefits can be made ONLY during the Open Enrollment Period unless the employee or qualified dependent(s) experience(s) a Qualifying Event and the request to make a change is made within 30 days of the Qualifying Event.

Under certain circumstances, employee may be allowed to make changes to benefit elections during the plan year if the event affects the employee, spouse or dependent’s coverage eligibility. An “eligible” Qualifying Event is determined by Section 125 of the Internal Revenue Code. Any requested changes must be consistent with and due to the Qualifying Event.

Examples of Qualifying Events:

dependent(s) termination or start of employment

• An increase or decrease in employee's work hours causes eligibility or ineligibility

or CHIP (including Florida Kid Care) program (60 day notification period)

IMPORTANT NOTES

If employee experiences a Qualifying Event, Human Resources must be contacted within 30 days of the Qualifying Event to make the appropriate changes to employee's coverage. Beyond 30 days, Employee may be required to furnish valid documentation supporting a change in status or “Qualifying Event”. If approved, changes may be effective the date of the Qualifying Event or the first of the month following the Qualifying Event. Newborns are effective on the date of birth. Qualifying Events will be processed in accordance with employer and carrier eligibility policy. Beyond 30 days, requests will be denied and employee may be responsible, both legally and financially, for any claim and/or expense incurred as a result of employee or dependent who continues to be enrolled but no longer meets eligibility requirements.

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

Medical Insurance The City offers medical insurance through UnitedHealthcare to benefit-eligible employees. The costs per pay period for coverage are listed in the premium table below and a brief summary of benefits is provided on the following page. For more detailed information about the medical plan, please refer to the carrier's Summary of Benefits and Coverage (SBC) document or contact UnitedHealthcare customer service.

Medical Insurance – UnitedHealthcare Choice Plus Plan 15 48 Payroll Deductions - Per Pay Period Cost

Tier of Coverage Employee Cost

Employee Only $0.00

Employee + Spouse/Domestic Partner $88.36

Employee + Child(ren) $76.91

Employee + Family $161.27

Please Note: Any premium rounding will occur in the final pay period of the month.

UnitedHealthcare Customer Service: (800) 357-0978 | www.myuhc.com

Medical Plan Resources UnitedHealthcare offers all enrolled employees and dependents additional services and discounts through value added programs. For more details regarding other medical plan resources, please contact UnitedHealthcare's customer service at (800) 357-0978, or visit www.myuhc.com.

Mobile App Mobile app provides on-the-go access to the medical benefit account.

Download the UnitedHealthcare mobile app from the iPhone or Android app store. Using the mobile app, members are able to:

Virta UnitedHealthcare members have access to Virta, a virtual clinic with support from providers and coaches that may help members lose weight, lower blood sugar, and reduce unwanted medications. At no cost, members with qualified health conditions will receive a digital weight scale and blood meter that syncs with member's phone, one-on-one health coach for support and accountability, and a medical provider to oversee medication changes and health improvements. Schedule a free consultation to learn more www.virtahealth.com/join/uhc.

HTH Advantage UnitedHealthcare medical plan offers all enrolled employees and dependents a support team with their "nurse in the family" approach, and various health services and resources when needed. Members can call anytime to speak with a dedicated nurse for questions about a new diagnosis, medical claims, prescription benefits, finding a primary care provider, help managing a chronic or complex health condition such as cancer, diabetes, coronary artery disease or asthma, and much more. For more information please call (844) 518-8079 or visit the Health & Wellness tab on www.myuhc.com.

Virtual Visits UnitedHealthcare provides access to 24/7 Virtual Visits services as part of the medical plan. 24/7 Virtual Visits provides access by smartphone, tablet, and computer to immediate medical assistance for many conditions.

The benefit is provided to all enrolled members. Registration is required and should be completed ahead of time. This program allows members 24 hours a day, seven (7) days a week on-demand access to affordable medical care via smartphone, tablet, and computer to online video consultations when needing immediate care for non-emergency medical issues. 24/7 Virtual Visits, through UnitedHealthcare, should be considered when employee's primary care doctor is unavailable, after-hours or on holidays for non-emergency needs. Many urgent care ailments can be treated via 24/7 Virtual Visits , such as:

24/7 Virtual Visits doctors do not replace employee's primary care physician but may be a convenient alternative for urgent care and ER visits. For further information please contact UnitedHealthcare.

24/7 Virtual Visits through UnitedHealthcare

Services Cost Per Visit

Virtual Visit No Charge

UnitedHealthcare Customer Service: (800) 357-0978 | www.uhc.com/virtualvisits

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

UnitedHealthcare Choice Plus Plan 15 Plan At-A-Glance Network Choice Plus

Calendar Year Deductible (CYD) In-Network Out-of-Network*

Single $250 $500

Family $500 $1,000

Coinsurance

Member Responsibility 10% 30%

Calendar Year Out-of-Pocket Limit

Single $2,500 $5,000

Family $5,000 $10,000

What Applies to the Out-of-Pocket Limit? Coinsurance, Deductible, Copays and Rx

Physician Services

Primary Care Physician (PCP) Office Visit $20 Copay 30% After CYD

Specialist Office Visit $40 Copay 30% After CYD

Non-Hospital Services; Freestanding Facility

Clinical Lab (Bloodwork)** No Charge 30% After CYD

X-rays No Charge 30% After CYD

Advanced Imaging (MRI, PET, CT) $100 Copay 30% After CYD

Outpatient Surgery in Surgical Center $100 Copay 30% After CYD

Physician Services at Surgical Center 10% After CYD 30% After CYD

Urgent Care (Per Visit) $50 Copay 30% After CYD

Hospital Services

Inpatient Hospital (Per Admission) 10% After CYD 30% After CYD

Outpatient Hospital (Per Visit) $100 Copay 30% After CYD

Physician Services at Hospital 10% After CYD 30% After CYD

Emergency Room (Per Visit; Waived if Admitted) $150 Copay $150 Copay

Mental Health/Alcohol & Substance Abuse

Inpatient Hospital Services (Per Admission) 10% After CYD 30% After CYD

Outpatient Services (Per Visit) $20 Copay 30% After CYD

Outpatient Office Visit $20 Copay 30% After CYD

Prescription Drugs (Rx)

Tier 1 $10 Copay $10 Copay

Tier 2 $35 Copay $35 Copay

Tier 3 $60 Copay $60 Copay

Mail Order Drug (90-Day Supply) $25/$87.50/$150 Copay Not Covered

Locate a Provider To search for a participating provider, contact UnitedHealthcare's customer service or visit www.myuhc.com.

When completing the necessary search criteria, select Choice Plus network.

Plan References *Out-Of-Network Balance Billing:

For information regarding out-of-network balance billing that may be charged by out-of-network providers, please refer to the Summary of Benefits and Coverage (SBC) document.

**LabCorp or Quest Diagnostics are the preferred labs for bloodwork through UnitedHealthcare . When using a lab other than LabCorp or Quest, please confirm they are contracted with UnitedHealthcare's Choice Plus network prior to receiving services.

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

Dental Insurance MetLife Dental PDP Plan The City offers dental insurance through MetLife to benefit-eligible employees.

The costs per pay period for coverage are listed in the premium table below and a brief summary of benefits is provided on the following page. For more detailed information about the dental plan, please refer to the carrier's summary plan document or contact MetLife's customer service.

Dental Insurance – MetLife Dental PDP Plan 48 Payroll Deductions - Per Pay Period Cost

Tier of Coverage Employee Cost

Employee Only $0.00

Employee + Spouse/Domestic Partner $4.22

Employee + Child(ren) $5.02

Employee + Family $12.73

Please Note: Any premium rounding will occur in the final pay period of the month.

In-Network Benefits The Dental PDP plan provides benefits for services received from in-network and out-of-network providers. It is also an open-access plan which allows for services to be received from any dental provider without having to select a Primary Dental Provider (PDP) or obtain a referral to a specialist. The network of participating dental providers the plan utilizes is the MetLife PDP Plus. These participating dental providers have contractually agreed to accept MetLife's contracted fee or “allowed amount.” This fee is the maximum amount a MetLife dental provider can charge a member for a service. The member is responsible for a Plan Year Deductible (PYD) and then coinsurance based on the plan’s charge limitations.

Out-of-Network Benefits Out-of-network benefits are used when member receives services by a non-participating MetLife PDP Plus provider. MetLife reimburses out-of-network services based on what it determines as the Maximum Allowable Charge (MAC). The MAC is defined as the most common charge for a particular dental procedure performed in a specific geographic area. If services are received from an out-of-network dentist, the member may be responsible for balance billing.

Balance billing is the difference between MetLife's MAC and the amount charged by the out-of-network dental provider. Balance billing is in addition to any applicable plan deductible or coinsurance responsibility.

Plan Year Deductible The Dental PDP plan requires a $50 individual or a $150 family deductible to be met for in-network or out-of-network services before most benefits will begin.

The deductible is waived for preventive services.

Plan Year Benefit Maximum The maximum benefit (coinsurance) the Dental PDP plan will pay for each covered member is $1,500 for in-network and out-of-network services combined. All services, including preventive, accumulate towards the benefit maximum. Once the plan's benefit maximum is met, the member will be responsible for future charges until next plan year.

Mobile App Mobile app provides on-the-go access to the medical benefit account.

Download the UnitedHealthcare mobile app from the iPhone or Android app store. Using the mobile app, members are able to:

MetLife Customer Service: (800) 275-4638 | www.metlife.com

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

MetLife Dental PDP Plan At-A-Glance Network PDP Plus

Plan Year Deductible (PYD) In-Network Out-of-Network*

Per Member $50 $50

Per Family $150 $150

Waived for Class I Services? Yes

Plan Year Benefit Maximum

Per Member $1,500

Class I Services: Diagnostic & Preventive Care

Routine Oral Exam (2 Per 12 Months )

Plan Pays: 100% Deductible Waived

Plan Pays: 100% Deductible Waived

(Subject to Balance Billing)

Routine Cleanings (2 Per 12 Months)

Complete X-rays (1 Every 5 Years)

Bitewing X-rays(Adults: 1 Per 12 Months; Children (up to age 14): 2 Per 12 Months )

Class II Services: Basic Restorative Care

Fillings (Amalgam & Composite)

Plan Pays: 80% After PYD Plan Pays: 80% After PYD

(Subject to Balance Billing)

Simple Extractions

Oral Surgery

Periodontal Services

General Anesthesia

Endodontics (Root Canal Therapy)

Class III Services: Major Restorative Care

Implants

Plan Pays: 50% After PYD Plan Pays: 50% After PYD

(Subject to Balance Billing)

Crowns

Bridges

Dentures

Class IV Services: Orthodontia

Lifetime Maximum $1,000

Benefit (Dependent Children Up To Age 19) Plan Pays: 50% Plan Pays: 50%

(Subject to Balance Billing)

Locate a Provider To search for a participating provider, contact MetLife customer service or visit www.metlife.com/dental. When completing the necessary search criteria, select PDP Plus network.

Plan References *Out-Of-Network Balance Billing:

For information regarding out-of-network balance billing that may be charged by an out-of-network provider, please refer to the Out-of-Network Benefits section on the previous page.

Important Notes

• Each covered family member may receive up to two (2) routine cleanings per 12 months covered under the preventive benefit.

• For any dental work expected to cost $300 or more, the plan will provide a “Pre-Determination of Benefits” upon the request of the dental provider.

This will assist with determining approximate out-of-pocket costs should employee have the dental work performed.

• Waiting periods and age limitations may apply.

• Benefit frequency limitations may apply to certain services.

• Orthodontic benefits end at cancellation of coverage.

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

Vision Insurance EyeMed Insight Vision Plan The City offers vision insurance through EyeMed to benefit-eligible employees.

The costs per pay period for coverage are listed in the premium table below and a brief summary of benefits is provided on the following page. For more detailed information about the vision plan, please refer to the carrier's summary plan document or contact EyeMed's customer service.

Vision Insurance - EyeMed Insight Vision Plan 48 Payroll Deductions - Per Pay Period Cost

Tier of Coverage Employee Cost

Employee Only $1.58

Employee + Spouse $3.00

Employee + Child(ren) $3.16

Employee + Family $4.64

Please Note: Any premium rounding will occur in the final pay period of the month.

In-Network Benefits The vision plan offers employee and covered dependent(s) coverage for routine eye care, including eye exams, eyeglasses (lenses and frames) or contact lenses. To schedule an appointment, employee and covered dependent(s) may select any network provider who participates in the EyeMed Insight network.

At the time of service, routine vision examinations and basic optical needs will be covered as shown on the plan’s schedule of benefits. Cosmetic services and upgrades will be additional if chosen at the time of the appointment.

Out-of-Network Benefits Employee and covered dependent(s) may choose to receive services from vision providers who do not participate in the EyeMed Insight network.

When going out of network, the provider will require payment at the time of appointment. EyeMed will then reimburse based on the plan’s out-of-network reimbursement schedule upon receipt of proof of services rendered.

Calendar Year Deductible There is no calendar year deductible.

Calendar Year Out-of-Pocket Maximum There is no out-of-pocket maximum. However, there are benefit reimbursement maximums for certain services.

Mobile App Mobile app provides on-the-go access to the medical benefit account.

Download the UnitedHealthcare mobile app from the iPhone or Android app store. Using the mobile app, members are able to:

EyeMed Customer Service: (866) 804-0982 | www.eyemed.com

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

EyeMed Insight Vision Plan At-A-Glance Network Insight

Services In-Network Out-of-Network

Eye Exam $10 copay Up to $40 Reimbursement

Retinal Imaging Up to $39 Copay Not Covered

Contact Lens Exam (Includes Fitting & Follow Up) Standard Up to $40 Allowance Not Covered

Premium 10% Off Retail Price Not Covered

Frequency of Services

Examination 12 Months

Lenses 12 Months

Frames 24 Months

Contact Lenses 12 Months

Lenses

Single $20 Copay Up to $30 Reimbursement

Bifocal $20 Copay Up to $50 Reimbursement

Trifocal $20 Copay Up to $70 Reimbursement

Frames

Allowance Up to$150 Retail Allowance; then

20% Off Balance Over $150 Up to $91 Reimbursement

Contact Lenses*

Non-Elective (Medically Necessary) No Charge Up to $210 Reimbursement

Elective Conventional

$150 Allowance; then 15% Off Balance Over $150

Up to $130 Reimbursement

Disposable Up to$150 Allowance Up to $130 Reimbursement

Locate a Provider To search for a participating provider, contact EyeMed's customer service or visit www.eyemed.com. When completing the necessary search criteria, select Insight network.

Plan References *Contact lenses are in lieu of spectacle lenses.

Important Notes Member options, such as LASIK, UV coating, progressive lenses, etc. are not covered in full, but may be available at a discount.

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

Flexible Spending Accounts The City offers Flexible Spending Accounts (FSA) administered through UpSwing. The FSA plan year is from October 1 to September 30.

If employee or family member(s) has predictable health care or work-related day care expenses, then employee may benefit from participating in an FSA. An FSA allows employee to set aside money from employee's paycheck for reimbursement of health care and day care expenses they regularly pay. The amount set aside is not taxed and is automatically deducted from employee’s paycheck and deposited into the FSA. During the year, employee has access to this account for reimbursement of some expenses not covered by insurance. Participation in an FSA allows for substantial tax savings and an increase in spending power. Participating employee must re-elect the dollar amount to be deducted each plan year. There are two (2) types of FSAs:

Health Care FSA Dependent Care FSA

This account allows participant to set aside up to an annual maximum of $3,300. This money will not be taxable income to the participant and can be used to offset the cost of a wide variety of eligible medical expenses that generate out-of-pocket costs. Participating employee can also receive reimbursement for expenses related to dental and vision care (that are not classified as cosmetic).

Examples of common expenses that qualify for reimbursement are listed below.

This account allows participant to set aside up to an annual maximum of $5,000 if single or married and file a joint tax return ($2,500 if married and file a separate tax return) for work-related day care expenses. Qualified expenses include day care centers, preschool, and before/after school care for eligible children and dependent adults.

Please note, if family income is over $20,000, this reimbursement option will likely save participants more money than the dependent day care tax credit taken on a tax return. To qualify, dependents must be:

incapable of self-care and spends at least eight (8) hours a day in the participant’s household.

Please Note: The entire Health Care FSA election is available for use on the first day coverage is effective.

Please Note: Unlike the Health Care FSA, reimbursement is only up to the amount that has been deducted from participant’s paycheck for the Dependent Care FSA.

A sample list of qualified Health Care expenses eligible for reimbursement include, but not limited to, the following:

9 Prescription/Over-the-Counter Medications 9 Physician Fees and Office Visits 9 LASIK Surgery

9 Menstrual Products 9 Drug Addiction/Alcoholism Treatment 9 Mental Health Care

9 Ambulance Service 9 Experimental Medical Treatment 9 Nursing Services

9 Chiropractic Care 9 Corrective Eyeglasses and Contact Lenses 9 Optometrist Fees

9 Dental and Orthodontic Fees 9 Hearing Aids and Exams 9 Sunscreen SPF 15 or Greater

9 Diagnostic Tests/Health Screenings 9 Injections and Vaccinations 9 Wheelchairs

Log on to http://www.irs.gov/publications/p502/index.html for additional details regarding qualified and non-qualified expenses.

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

Flexible Spending Accounts (Continued)

FSA Guidelines

• Employee may carry over up to $660 of unused Health Care FSA funds into the next plan year after a plan year ends and all claims have been filed (only if the employee re-enrolls the next year).

Dependent Care funds cannot be carried over.

• The Health Care FSA has a run out period at the end of the plan year (90 days) to submit reimbursement on eligible expenses incurred during the period of coverage within the plan year.

• When a plan year ends and all claims have been filed, all unused funds with the exception of the $660 rollover for the Health Care FSA will be forfeited and not returned.

• Employee can enroll in an FSA only during the Open Enrollment Period, a Qualifying Event, or New Hire Eligibility period.

received.

• Employee and dependent(s) cannot receive insurance benefits or any other compensation for expenses reimbursed through an FSA.

• Domestic Partners healthcare expenses are not eligible for reimbursement in the employee FSA as Federal law does not recognize them as a qualified dependent.

Filing a Claim Claim Form A completed claim form along with a copy of the receipt as proof of the expense can be submitted by mail, fax, or online. The IRS requires FSA participants to maintain complete documentation, including copies of receipts for reimbursed expenses, for a minimum of one (1) year.

Debit Card

FSA participants will automatically receive a debit card for payment of eligible expenses. With the card, most qualified services and products can be paid at the point of sale versus paying out-of-pocket and requesting reimbursement.

The debit card is accepted at a number of medical providers and facilities, and most pharmacy retail outlets. BenefitsWorkshop may request supporting documentation for expenses paid with a debit card. Failure to provide supporting documentation when requested, may result in suspension of the card and account until funds are substantiated or refunded back to the City.

Please keep the issued card for use next year. Additional or replacement cards may be requested, however, a small fee may apply.

HERE’S HOW IT WORKS!

An employee earning $50,000 elects to place $1,000 into a Health Care FSA. The payroll deduction is $20.83 based on a 48 pay period schedule. As a result, health care expenses are paid with tax-free dollars, giving the employee a tax savings of $197.

With a Health Care FSA

Without a Health Care FSA

Salary $50,000 $50,000

FSA Contribution - $1,000 - $0

Taxable Pay $49,000 $50,000

Estimated Tax

19.65% = 12% + 7.65% FICA

-$9,628 -$9,825

After Tax Expenses - $0 - $1,000

Spendable Income $39,372 $39,175

Tax Savings $197

Please Note: Be conservative when estimating health care and/or dependent care expenses. IRS regulations state that any unused funds remaining in an FSA, after a plan year ends and after all claims have been filed, cannot be returned or carried forward to the next plan year with the exception of the $660 carry over that may be allowed for the Health Care FSA. This rule is known as “use-it or lose-it.”

Claims Submission Mailing Address: UpSwing Compliance & Technology Solutions

PO Box 56828, Jacksonville, FL 32241 Fax: (321) 445-9605

Mobile App Mobile app provides on-the-go access to the FSA benefit account. Download the UpHealthEase mobile app from the iPhone or Android app store. Using the mobile app, members are able to:

UpSwing Customer Service: (866) 676-3665 | upswing.wealthcareportal.com http://upswing.wealthcareportal.com

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

Employee Assistance Program The City cares about the well-being of all employees on and off the job and provides, at no cost, a comprehensive Employee Assistance Program (EAP) through UnitedHealthcare. EAP offers employee and each family member access to licensed mental health professionals through a confidential program protected by State and Federal laws. EAP is available to help employee gain a better understanding of problems that affect them, locate the best professional help for a particular problem, and decide upon a plan of action. EAP counselors are professionally trained and certified in their fields and available 24 hours a day, seven (7) days a week.

What is an Employee Assistance Program (EAP)?

An Employee Assistance Program offers covered employees and family members/domestic partners free and convenient access to a range of confidential and professional services to help address a variety of problems that may negatively affect employee or family member’s well-being.

Coverage includes three (3) visits with a specialist, per person, per issue, per year, telephonic consultation, online material/tools and webinars. EAP offers counseling services on issues such as:

9 Child Care Resources

9 Legal Resources

9 Grief and Bereavement

9 Stress Management

9 Depression and Anxiety

9 Work Related Issues

9 Adult & Elder Care Assistance

9 Financial Resources

9 Family and/or Marriage Issues

9 Substance Abuse

Are Services Confidential?

Yes. Receipt of EAP services are completely confidential. If, however, participation in the EAP is the direct result of a Management Referral (a referral initiated by a supervisor or Human Resources), we will ask permission to communicate certain aspects of the employee’s care (attendance at sessions, adherence to treatment plans, etc.) to the referring supervisor or department. The referring supervisor or department will not receive specific information regarding the referred employee’s case. The supervisor/department will only receive reports on whether the referred employee is complying with the prescribed treatment plan.

Employee Assistance Program through UnitedHealthcare Customer Service: (888) 887-4114 | www.myuhc.com

Basic Life and AD&D Insurance Basic Term Life Insurance The City provides Basic Term Life insurance at no cost to all eligible employees, through The Hartford. Eligible employees will receive a benefit amount of $50,000.

Accidental Death & Dismemberment Insurance Also, at no cost to employee, the City provides Accidental Death & Dismemberment (AD&D) insurance, which pays in addition to the Basic Term Life benefit when death occurs as a result of an accident. The AD&D benefit amount equals $100,000, partial benefits may also be payable.

Age Reduction Schedule Benefit amounts are subject to the following age reduction schedule:

• Reduces by 50% of the benefit amount at age 70

Dependent Group Life Insurance Employee also has the option to elect group life insurance for spouse and dependent child(ren). A spouse may be insured for $5,000, not to exceed 50% of employee's Basic Life coverage amount. Eligible dependent child(ren), from 15 days up to age 26, may be insured for $2,500.

Always remember to keep beneficiary information updated. Beneficiary information may be updated at anytime through Bentek or Human Resources .

The Hartford Customer Service: (800) 523-2233 | www.thehartford.com

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

Voluntary Life and AD&D Insurance Voluntary Employee Life and AD&D Insurance Eligible employee may elect to purchase additional Life and AD&D insurance on a voluntary basis through The Hartford. This coverage may be purchased in addition to the Basic Term Life and AD&D coverage. Voluntary Life insurance offers coverage for employee at different benefit levels.

New Hires may purchase Voluntary Employee Life and AD&D insurance without being subject to Medical Underwriting, also known as Evidence of Insurability (EOI), up to the Guaranteed Issue amount of $50,000.

• Units can be purchased in increments of $5,000 to the maximum of $300,000 or 3x annual earnings.

Voluntary Life and AD&D Insurance Rate Table Premium

Age Bracket (Based on Employee Age)

Employee (Rate Per $1,000 of Benefit)

< 30 $0.13

30-34 $0.13

35-39 $0.18

40-44 $0.26

45-49 $0.40

50-54 $0.58

55-59 $0.85

60-64 $1.38

65-69 $2.45

70-74 $3.45

75+ $7.41

Always remember to keep beneficiary information updated. Beneficiary information may be updated at anytime through Bentek or Human Resources.

The Hartford Customer Service: (800) 523-2233 | www.thehartford .com

Voluntary Short Term Disability The City offers Voluntary Short Term Disability (STD) insurance to all eligible employees through The Hartford. The STD benefit pays employee a percentage of the weekly earnings if employee becomes disabled due to an illness or non-work related injury.

Voluntary Short Term Disability (STD) Benefits

• STD provides a benefit of 60% of employee's weekly earnings up to a benefit maximum of $1000 per week.

• Employee must be disabled for 7 consecutive days prior to becoming eligible for benefits (known as the elimination period).

• Benefits will begin on the 8 day after the employee is disabled due to non-work related injury or illness.

maximum period is exhausted, may be transitioned to Long Term Disability (LTD).

• Benefits may be reduced by other income.

The Hartford Customer Service: (800) 523-2233

File a Claim: (877) 778-1383 | www.thehartford.com

Long Term Disability The City provides Long Term Disability (LTD) insurance at no cost to all eligible employees through The Hartford. The LTD benefit pays a percentage of monthly earnings if employee becomes disabled due to an illness or injury.

Long Term Disability (LTD) Benefits

• LTD provides a benefit of 60% of employee's monthly earnings up to a benefit maximum of $4,000 per month.

• Employee must be disabled for 90 consecutive days prior to becoming eligible for benefits (known as the elimination period).

employee returns to work on a part-time basis.

• The maximum benefit period is determined based on age at the time of disability.

• Benefits may be reduced by other income.

The Hartford Customer Service: (800) 523-2233

File a Claim: (877) 778-1383 | www.thehartford.com

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved

Supplemental Benefits The Standard offers a variety of voluntary supplemental plans that may be purchased separately on a voluntary basis and premiums paid by payroll deduction. The Standard pays money directly to the employee, regardless of other insurance plans. To learn more about The Standard plans and/or to schedule a personal appointment, contact your local The Standard agent. Details regarding available The Standard plans and services are also available online at www.standard.com.

Available plans include:

Please Note: Limitations, exclusions and waiting periods may apply.

The Standard Agent: Eric Gonzalez | Phone: (971) 321-1660 ext. 1660

Email: eric.gonzalez@standard.com Customer Service: (866) 851-5505 | www.standard.com

Notes Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctors' names and addresses or prescription medications.

Notes Use this section to make notes regarding personal benefit plans or to keep track of important information such as doctors' names and addresses or prescription medications.

3500 Kyoto Gardens Drive, Palm Beach Gardens, Florida 33410 Toll Free: (800) 244-3696 | Fax: (561) 626-6970 | www.gehringgroup.com

© 2016 RSC Insurance Brokerage, Inc., All Rights Reserved FINAL Last Modified: August 19, 2025 12:54 PM