HM Medical Clinic

 

Ci.seattle.wa.us

Temporary Benefits-
Eligible Employees
Benefits Guide
for health and living — take charge Benefits Eligibility for Temporary City Employees
Benefits
Interim/Short term/Interim assignment up to assignments. assignment of (assignment does not exceed
Within 1 year up to 1 year not exceed 1,040 1,040 hrs*
has worked
1,040 hrs*, ** effect for 1,040 Assistance Program Flexible Spending Accounts (Health Care and Day Care Group Term Life Disability (Basic) Disability (Supplemental) SCERS Cessation Weight Watchers Interim/Short term/Interim assignment up to assignments. assignment of (assignment does not exceed
Within 1 year up to 1 year not exceed 1,040 1,040 hrs*
has worked
1,040 hrs*, ** effect for 1,040 *Receives premium pay. If conversion for a regular position is requested, then position becomes eligible for **Seefor more information on health care coverage for temporary workers who receive Premium Pay. ***Receives benefits in lieu of premium pay **** A temporary worker may elect to join the Seattle City Employees' Retirement System: 1. Within 6 calendar months of completing 1,044 hours of compensated straight-time service; or 2. Upon appointment to an eligible position if such appointment occurs after the work has completed 1,044 hours of City service but before they have completed 10,440 hours of City service; or 3. Within 6 calendar months of completing 10,440 hours of continuous compensated straight-time service. Exclusions:
 Work study, interns and independent contractors are not eligible for benefits regardless of hours worked
 Benefits do not include health care or day care flexible spending account programs, AD&D insurance,
supplemental Group Term Life, supplemental Long-Term Disability, Long-Term Care insurance, Vision Buy-Up plan, Employee Assistance Program, tobacco cessation program, and Weight Watchers City pricing. Dear City Employee, As a temporarily appointed employee who is eligible for benefits, the City offers you a benefits package that helps provide for your and your family's health care, disability and survivor needs. It is the City's goal to offer a range of choices that can help you address your unique financial needs. This employee benefits guide includes information to guide you in choosing the insurance coverages that best fit your situation*. You will find information on employee benefits, answers to commonly asked questions, and important deadlines for new temporary benefits eligible employees. The booklet also covers other work/life programs that are designed to help you manage your life and promote a satisfying and productive relationship between you and the City. More detailed information is available on th Please contact your department'sif you have questions about your employee benefits. Sincerely, Susan L. Coskey, Acting Personnel Director Personnel Department *This Employee Benefits Guide applies to temporary benefits-eligible City employees: CMEOs, Fire Chiefs, General City Employees, Library employees, and SPMA members. It does not apply to employees covered by union contracts with the International Brotherhood of Electrical Workers Local 77, the Seattle Police Officers Guild, and the International Association of Fire Fighters Local 27. Please note: We've made every attempt to ensure the accuracy of this information. If there is any discrepancy between this booklet and the insurance contracts, other legal documents or the terms of an authorized collective bargaining agreement, the contracts, legal documents and applicable collective bargaining agreements will always govern. The City of Seattle intends to continue these plans indefinitely but reserves the right to amend or terminate them at any time in whole or part, for any reason, according to the amendment and termination procedures described in the legal documents. This booklet does not create a contract of employment with the City of Seattle. If you have difficulty understanding the information in
this Guide
Help is available if you have trouble reading or understanding this Guide. If the problem you have is not addressed below, please call the City Benefits Unit at 206-615-1340 so we can provide assistance.
 English is Your Second Language? If English is not your native
language, translators are available to help you. Many City employees have volunteered to translate for fellow employees. To find someone who "speaks your language" click here Inside the light blue box, click the arrow next to the white box and find the language you speak. Click the GO button. You will find a list of employees who speak that language. If the "Translate" box contains a "Y," that person will translate for you. Call and find a time they are available; make an appointment with the City Benefits Unit (206-615-1340) and bring that person with you. Together we'll help you understand your City benefits. If you do not have access to a computer, ask your department's HR/Benefits representative to help you, or call the Benefits Unit at 206-615-1340.
 Hearing Impaired? If you use a TDD, the City provides translation
services. Call 7-1-1 or 1-800-833-6384 on your TDD. You will be connected with the Washington Relay Service. Give them the number of the party you wish to call. They will call the person for you, then translate information from your TDD to the person you are calling.  Visually Impaired? This Guide is available in a larger font. To request
an electronic copy, contact the Benefits Unit at 206-615-1340.  Would rather hear the information than read it? If your
understanding is improved by having someone read or paraphrase information for you, you are invited to attend a benefits orientation. Orientations cover all City benefits and provide ample time for questions. You can meet with the presenter after the session if you have additional questions or questions you want to ask confidentially. Orientations are held every week - call 206-615-1340 to sign up. If you have further questions or concerns or want to speak to someone confidentially, call the Benefits Unit (206-615-1340). TABLE OF CONTENTS
Employee Responsibilities Temporary Benefits Eligible employees are responsible for making benefits elections or changes by their due dates including Open Enrollment. They must notify their of any family or employment status changes that impact benefits such as marriage, divorce, new or terminated domestic partnership, a birth or adoption, a leave of absence, or a death in the family.
New Temporary Benefits Eligible employee? You are responsible for making
your benefits elections within 31 days of your date of hire. Adding a new family member to your health care coverage? Contact your
departmentwithin 31 days of marriage or new domestic
partnership. You have 60 days to notify your representative of a birth or
adoption.

Dropping a family member from your health care coverage? Contact your
department'swithin 31 days of divorce or legal
separation, domestic partnership termination.

Planning a leave of absence? Contact youabout how
it could affect your City benefits.
Designating or changing your beneficiary?
· Life insurance - · Retirement - contact the· Sick leave or Deferred Compensation - see you
Moving? Update your address in
To change your benefits, go online during fall Open Enrollment to make
benefits elections for the following year.
Access your benefits information from home at click
on "Benefits".
Eligibility and Coverage Information The City of Seattle provides employees and their families a range of benefit options to support individual financial planning.

Medical
The City offers regular employees and their family members a choice among four
 City of Seattle Preventive (Aetna)  City of Seattle Traditional (Aetna)  Group Health Standard  Group Health Deductible Dental
The City offers dental coverage through Delta Dental of Washington and Dental
Health Services.
Vision
The City offers a Basic vision plan through VSP.
Life Insurance & Long-Term Disability (LTD)
The City offers Basic Long-Term Disability insurance and shares the cost of basic Group
Term Life insurance.

Deferred Compensation Plan
The City offers a tax deferred compensation "457" plan which allows employees to invest
current, pre-tax earnings to generate additional retirement income. Eligibility and Coverage Information
Eligibility for If you are a temporary benefits-eligible employee working full- or part-
Temporary
time (scheduled to work at least 80 hours per month), you are eligible to participate in selected benefits programs when you meet the eligibility requirements of your position: Eligible
 Term Limited Assignment – on your date of hire of your 1-3 Employees
 One or More Interim/Short Term Assignments: after your short- term assignment of up to 1 year is in effect for 1,040 hours. This is your "eligibility date". See page 4 for when your coverage
The benefits you are eligible for are: the medical, dental, basic, basic life, basic LTD, and deferred compensation plans (see pages 1-2). Eligible
The following family members are also eligible to participate in the medical, dental, and vision programs: Spouse or domestic partner – an Affidavit of Marriage/Domestic
Partnership or Certificate of State Registered Domestic partnership must be filed with your department's Human Resources Unit to cover your spouse or domestic partner.
Children – your children, and your spouse's or domestic partner's
Eligibility
children. Please check child eligibility requirements below. Medical, Dental, (through age 25) -be dependent on you for support -have access to other Coverage may continue for a handicapped/incapacitated child if the child becomes disabled prior to the limiting age, provided that proof of his or her fully handicapped/incapacitated status has been documented Eligibility and Coverage Information You must submit your benefits enrollment forms within 31 days of your benefits eligibility date (see prior page). When does
Actual coverage in the plans in which you are enrolled will begin on coverage
either your eligibility date, or the first day of the month following your eligibility date:  Your coverage begins on your eligibility date if that date is: o the first calendar day of the month designated as a City business day, or o the first calendar day of the month designated or recognized as the first working day for the shift to which you are assigned, whichever is later.  Your coverage begins on the first day of the following month if your eligibility date begins after the date described immediately Remember, to be covered, you must submit a completed benefits enrollment form to your department's Benefits Representative within 31 days of becoming benefits eligible. You may decline coverage, but will not be eligible for premium pay in lieu of benefits as a result of declining coverage. If you fail to submit your enrollment forms within 31 days, you will not be able to enroll in a medical plan until the next open enrollment enrollment
period (or within 31 days of a change in family status). However, you deadline?
will be enrolled automatically for dental and vision coverage. Your dental coverage will default to the Delta Dental of Washington plan. You will also need to meet additional requirements to be eligible for Life Insurance. You will be required to submit a Medical History Statement and have it approved by the insurance company in order to be eligible for Life Insurance coverage. You have the option to decline medical coverage within 31 days of your Coverage
hire date, during Open Enrollment, or within 31 days of a qualifying event. If you waive coverage, you may not cover dependents under the City's medical plans. You will not be charged premium payments if you decline medical coverage and will still be enrolled in the dental and Basic vision plans because there is no employee premium contribution. Note that in 2014, employees who decline coverage considered affordable and adequate under the Patient Protection and Affordable Care Act (such as the City's plans) will not qualify for government subsidies to purchase individual health insurance. In addition, an employee who refuses employer coverage and doesn't obtain coverage on his or her own will be subject to a penalty. Eligibility and Coverage Information
To enroll in medical, dental and vision coverage, you must complete and submit a health care benefit election form to your department's Group Term Life has a separate enrollment form. Make sure all forms are signed and dated before they are submitted. Forms are available at the end of this booklet, from your department's Human Resources Representative or on the Personnel Department's Benefits website at Continuing
To remain eligible for City paid benefits, you must have at least 80 Eligibility
hours of paid time during the calendar month. If the number of hours worked per month is less than 80 hours, benefits will be terminated, you will be responsible for any charges incurred. Can I enroll
The following family members are eligible for coverage: my family
 Your spouse or domestic partner; members?
 Your birth or adopted children, or children placed for adoption;  Children of your domestic partner who live with you;  Stepchildren who live with you; or  Any child for whom you are legal guardian or for whom coverage is required by a Qualified Medical Child Support Order. Children may be covered on the following plans; see page 3 for detailed eligibility requirements for children.  Group Health Cooperative plans  Preventive Plan (Aetna)  Traditional Plan (Aetna)  Delta Dental of Washington  Dental Health Services Coverage may continue after age 25 for a handicapped/incapacitated child if the child becomes disabled prior to the limiting age, provided that proof of fully handicapped/incapacitated status has been documented by a physician. Visifor more information. Call your department'sor the City's Benefits Unit (206-615-1340) if you have questions. Eligibility and Coverage Information If you need to remove a family member from coverage outside of Open disenroll my Enrollment, submit a completed Benefit Election Form to your
department's benefits representative. members?
If you and your spouse or domestic partner's coverage due to a termination of the marriage/partnership, submit a completed Statement of Termination of Marriage/ Domestic Partnership form or a Notice of Termination of State Registered Domestic Partnership within 31 days of the divorce or domestic partnership termination. You cannot file a new Affidavit until 90 days have elapsed from the termination of the prior marriage/partnership, unless the termination was due to the spouse or domestic partner's death or if the domestic partnership was certified with the State of Washington. Changing
There are two opportunities to change your benefit choices:  Open Enrollment Benefits
 Mid-year, if you have a change in family or job status.
Open Enrollment
Open Enrollment is held once each year in the fall. During this time, you can change your benefits plans, add and drop family members, and add or drop coverages. If you make changes during Open Enrollment, your new coverage is effective on January 1 of the new (next) plan year. Increases in your Life insurance coverage are subject to the approval of your Medical History Statement by the life insurance carrier.
Life Events that Affect Your Benefits
You must enroll a new spouse or domestic partner within 31 days of your marriage or establishment of a domestic partnership. You have 60 days to add a child acquired through birth, adoption, placement for adoption, legal guardianship, marriage or domestic partnership. If you miss the deadline, you can only add family members during the annual fall Open Enrollment period. If you have a change in family status, you may be able to make a related change to your benefits. Here are several examples. Contact your Human Resources representative if any of the following occur.  Your spouse or domestic partner loses coverage due to termination of employment, change in employment status, or beginning an unpaid leave of absence – you may add your spouse or partner to the plan.  Your spouse or domestic partner gains coverage due to start of employment, change in employment status, or ending an unpaid leave of absence–you may drop your spouse or partner from the Eligibility and Coverage Information  You get divorced, separate, or dissolve a domestic partnership – you may drop the spouse or domestic partner from the plan.  Your child no longer meets the age requirements for medical/dental/vision – your child will be dropped from coverage. Your medical/dental/vision, Basic Long-Term Disability, and Group Coverage
Term Life coverages end on the last day of the calendar month in  You are no longer eligible  You resign, retire or are terminated  You stop making any required payment. Your medical, dental and vision coverages will also end on the day the plan terminates, or if you die (your family members' coverage will end on the last day of the calendar month in which you die). Continuing
To help you maintain health coverage, Congress passed the Coverage
Consolidated Omnibus Reconciliation Act (COBRA) in 1986. Under COBRA, you are eligible to purchase continuing medical only, dental/vision only, or medical/dental/vision coverage under certain circumstances when your group health plan coverage with the City If you are a City employee and have City medical, dental and vision coverage, you and your covered family members have the right to elect COBRA continuation coverage for up to 18 months if your coverage is lost because of one of these qualifying events: Your employment ends for a reason other than gross misconduct Your work hours are reduced to the point where you no longer are eligible for benefits. The 18-month COBRA continuation period may be extended to 29 months if you or a family member (who is a qualified beneficiary) is disabled according to Social Security at the time of one of the above qualifying events. This 11-month extension is available to all qualified beneficiaries who lose coverage due to termination of employment or a reduction of hours. Covered family members have the right to choose COBRA continuation coverage for up to 36 months if coverage is lost for any of these qualifying events: Eligibility and Coverage Information  Death of the employee  Divorce or legal separation of the employee and spouse or dissolution of the domestic partnership.  A child loses coverage (turns 26 and/or obtains full-time job with access to health care insurance. The Life and disability plans have conversion options. Coverage
You may choose an individual medical plan through the health insurance exchange. Depending on your income and the number of dependents you cover, you may find a plan on the exchange that fits your coverage needs. More information at Insurance
Exchange
Coverage
When you are eligible to retire, contact the Retirement Office at through a
(206) 386-1293 for information about the City's retiree medical plans. City Retiree
If you want to participate in a retiree medical plan instead of COBRA or a Health Insurance Exchange plan, be aware that you must choose a plan within 31 days of retiring. In some cases, you can delay your enrollment in a City retiree medical plan if you are covered under another employer's plan. Contact the Retirement Office for more Paying for Benefits If you elect medical coverage, the City of Seattle pays most of the premium for you and your eligible, enrolled family members. The amount you pay depends on which plan you select and whether you cover a spouse or domestic partner. Medical premiums are deducted each month on a pre-tax basis. Pre-tax deductions are exempt from Social Security taxes. This may Deductions
slightly reduce your future Social Security benefits, but most people find that ongoing tax savings outweigh a future reduction in Social Security benefits, if any. If this is a concern for you, discuss it with your financial advisor. (Premium amounts paid for a domestic partner cannot be taken on a pre-tax basis if your partner is not a dependent on your IRS tax form.) See page 22 Your share of the cost for your medical premium is taken in equal
for medical
amounts from the first and second paychecks of the month during the premiums
month of coverage on a pre-tax basis. For example, premium deductions taken from your March paychecks provide for March Dental and the Basic Vision plans are fully paid by the City for most Life Insurance
Your basic after-tax premium deductions are taken from your second paycheck of the month for the next month's coverage. Benefits and Financial Planning Because everyone's medical and financial situations are different, the City offers a variety of plans to help protect employees and their families from the financial hardship that unusual medical expenses can bring. The plans are designed to cover much of the cost of medically necessary health care services. However, employees still bear a portion of their medical service costs in the form of premiums, deductibles, copayments and coinsurance. Since health care costs may be unanticipated, it makes sense to plan in advance and save for your out-of-pocket costs. Here are ways to cut costs and save money.  Quit smoking and encourage your family to quit.  Be more active and eat nutrient dense food. Many diseases and conditions are preventable, and healthy behavior reduces your future health care costs and enhances your life now.  Go to check ups and screenings. Have regularly scheduled physical examinations by your doctor, dentist, eye doctor and so on. Take advantage of free medical screenings, flu shots and go to the City's wellness and benefits fairs.  Choose the best health plan for you and your family. There is more to selecting a good health plan than just the payroll deduction. If you are shopping for a health plan, compare the premiums along with what is and is not covered by the various plans.  Stay within the network. Look for doctors and health care providers that are within the plan's network. If you participate in an Aetna plan and require a specialist, make sure you use an Aexcel specialist, which will save you 10%.  Review medical bills carefully. Billing errors can cost you hundreds or even thousands of dollars. Contact the billing office if there is an error or you do not understand your bill. You may be able to negotiate fees and bills that you feel are too high. Medical Plan Options The City offers four different medical plans:  City of Seattle Preventive Plan  City of Seattle Traditional Plan  Group Health Cooperative Standard Plan  Group Health Cooperative Deductible Plan Plan features, coverages and costs vary. The City's self-insured plans offer unlimited choice of doctors; coverage is higher if you use doctors Medical Plan in the Aetna network. The Group Health Cooperative (GHC) plans
require that you use the GHC network of doctors, clinics, hospitals and pharmacies, but offer a higher level of coverage. Plans offering higher coverage (City Preventive and Group Health Standard) have lower copays but higher monthly premiums. Plans with larger annual deductibles have lower or no monthly premiums (City Traditional and Group Health Deductible). When making your decisions, you should consider cost, choice, and coverage. Here are some questions to ask yourself:  Do you want a plan that allows you to choose any doctor, hospital or clinic (City self-insured plans) or are you willing to stay within a network (GHC) and receive a higher level  Would you rather pay higher monthly premiums to have a small annual deductible (City Preventive Plan) or no annual deductible (GHC Standard Plan) and smaller copays?  Would you rather pay lower or no monthly premiums and have higher coinsurance and deductibles (GHC Deductible and City Traditional plans)? The following very brief plan descriptions may help you make
New Temporary Benefits Eligible Employees: Remember - You
have 31 days from your hire date to enroll in the medical, dental, vision and Group Term Life plans. Medical Plan Options
City of Seattle The City has two plans with Aetna — the Preventive Plan and the
Traditional Plan. The plans use the Aetna provider network, and Aetna administers the claims. Preventive
This plan has a $100 annual deductible per person ($300 per family) and a $15 copay for all office visits except preventive care (which is covered at 100%). The deductible applies to most services except where a copay applies. Most other services are covered at 90% after a copay if you use an Aetna network provider. Traditional
This plan has a $400 annual deductible per person ($1,200 per family). Most services are covered at 80% if you use an Aetna network provider. Most preventive care is not covered. Both of the City's plans include the Aetna network of doctors; Don't Use the
however, you choose whether to use a network or non-network provider when you require care. If you choose a doctor who is not in Network?
the network, you will pay a higher percentage of the cost of the visit. Another issue to keep in mind is that prices charged by a non- network provider are often higher than those charged by a network provider. If you use a non-network provider, you will pay 40% of the network cost for a service, and your doctor may charge you an additional amount over the established network price. Aetna has a special sub-network, called the Aexcel network, which Aetna's Aexcel consists of doctors who specialize in the following areas: cardiology,
cardiothoracic surgery, gastroenterology, general surgery, obstetrics/ gynecology, orthopedics, otolaryngology, neurology, neurosurgery, plastic surgery, vascular surgery and urology. Doctors were selected for this special network because they meet screening criteria in the areas of experience, performance, effectiveness and efficiency. If you need care in one of these areas and you do not choose a doctor
from the Aexcel network to provide that care, you will pay 10% higher coinsurance. You do not need a referral to see a specialist. Aetna's member website is called Aetna Navigator. Through the site Navigator
you can locate detailed claim information, review your benefits, request changes, find service providers, and email member services. Simple Steps
Traditional and Preventive plan members have access to a health risk to a Healthier assessment – Simple Steps to a Healthier Life. Following completion
of a questionnaire, you will receive a health report and a personal action plan along with access to healthy living programs. Medical Plan Options Health Care Options Group Health Cooperative (GHC) is a health maintenance organization which provides an integrated system of health care services. All Cooperative services are delivered in GHC clinics, hospitals and pharmacies. You
must use GHC providers and facilities unless a GHC doctor refers you elsewhere. You do not need a physician's referral to see most GHC specialists. The City offers two plans through Group Health Cooperative. This is a managed care plan with no deductible and an office copay of Standard
$15. Most services are covered at 100% after payment of a copay. Preventive care is covered. This is a managed care plan with a $200 annual deductible per person Deductible
($600 per family) and a $15 office copay. The deductible does not apply to ambulance service, prescription drugs, durable medical equipment and preventive visits (preventive visits do have a copay). After the deductible is satisfied, most services are covered at 100% after the copayment. The health care website is My Group Health aMembers can request appointments and exchange emails with their provider, view their online medical record, refill prescriptions online, and view lab and test reports. The provider and facilitator directory, and drug formulary are all accessible online. The plan has a health risk assessment called Health Profile. Members complete the profile online and receive a report and personalized action plan. Free healthy lifestyle coaching is available. 2014 Medical Benefits Highlights - Most City of Seattle Employees
The purpose of this document is to help you make decisions; it is not a contract. Details are provided in your medical plan booklet at seattle.gov/personnel/benefits/health/medical.asp. Group Health Cooperative (GHC)*
City of Seattle Traditional Plan*
City of Seattle Preventive Plan*
Standard Plan
Deductible Plan
Aetna In-Network
Aetna In-Network
Deductible (per calendar year)
No Deductible
$1,000 per person $1,200 per family $3,000 per family $1,350 per family Deductible applies as noted except for Deductible applies to most services, except as Deductible applies to most services, except as prescriptions, preventive noted. Deductible does not apply for noted. Deductible does not apply for visits, ambulance, and prescriptions or when the Inpatient co-pay or prescriptions or when the Inpatient co-pay or emergency room co-pay applies. emergency room co-pay applies. Annual Out of Pocket Maximum (OOP Max) if applicable. Aetna Copays do not apply towards OOP Max.
$2,000 per person
$2,000 per person $1,000 per person $2,000 per person** $2,000 per person $3,000 per person* $4,000 per family $6,000 per family $3,000 per family $6,000 per family* $4,000 per family $6,000 per family* Hospital Copay
$200 per admission Deductible applies Hospital Pre-admission Authorization
Except for maternity or emergency admissions, Except for maternity or emergency admissions, Except for maternity or emergency admissions, must be authorized by GHC physician must contact Aetna prior to your physician must contact Aetna prior to your admission. Member responsible for obtaining admission Member responsible for obtaining precertification of out-of-network care. precertification of out-of-network care. Choice of Providers
Aetna contracted Any licensed, qualified Aetna contracted Any licensed, qualified All care and services must be approved and/or providers. No primary provider of your providers. No primary provider of your care physician selection choice. Expenses care physician selection choice. Expenses paid by GHC or GHC designated providers. or referrals required. or referrals required. based on recognized Members may self-refer to most GHC specialists. Aexcel*** specialists recognized charges*. Aexcel** specialists must charges*. You pay the be used in designated difference between designated specialty difference between specialty areas to recognized and billed areas to receive the recognized and billed receive the maximum maximum benefit. Group Health Cooperative (GHC)*
City of Seattle Traditional Plan*
City of Seattle Preventive Plan*
Standard Plan
Deductible Plan
Aetna In-Network
Aetna In-Network
COVERED EXPENSES
Acupuncture
$15 copay for up to 8
$15 copay for up to 8 Paid at 100% after $15 visits per condition per visits per condition per year self-referred. year self-referred. Additional visits when Additional visits when Maximum of 12 visits per calendar year in- and All acupuncture services are subject to ongoing approved by plan. approved by plan. out-of-network combined. review and approval by Aetna for medical Deductible applies. Alcohol/Drug Abuse Treatment
Inpatient: Paid at 100% Inpatient: Paid at 100% Inpatient: Paid at 80%
Inpatient: Paid at 60% Inpatient: Paid at 90% Inpatient: Paid at 60% after $200 copay per after deductible after $200 copay after $200 copay Outpatient: Paid at Outpatient: Paid at Outpatient: Paid at 80% Outpatient: Paid at Outpatient: Paid at 100% Outpatient: Paid at 100% after $15 copay 100% after $15 co-pay. Deductible applies. Contraceptives
For contraceptive drugs and devices, IUDs and Depo Provera covered as medical IUDs and Depo Provera covered as medical see Prescription Drug benefit See Prescription Drug benefit. See Prescription Drug benefit. Durable Medical Equipment
Breast pump covered at Breast pump covered at 100% through DME 100% through DME Emergency Medical Care
 Urgent Care Clinic
Paid at 100% after $15 $15 copay. Deductible
Paid at 100% after $15 Paid at 60% copay (no fee for preventive care) Emergency Room (copays waived if admitted)
GHC facility: $100 GHC facility: $100 copay Paid at 80% after $150 Paid at 80% after Paid at 90% after $150 Paid at 90% after $150 Non-GHC facility: $150 Non-GHC facility: $150 copay. If non-emergency, If non-emergency, paid Deductible applies paid at 60% after at 60% after copay.  Ambulance
Paid at 80% when medically necessary. Paid at 90% when medically necessary. GHC-initiated non- GHC-initiated non- Non-emergency transportation must be Non-emergency transportation must be approved emergency transfers emergency transfers are approved in advance are paid at 100% Group Health Cooperative (GHC)*
City of Seattle Traditional Plan*
City of Seattle Preventive Plan*
Standard Plan
Deductible Plan
Aetna In-Network
Aetna In-Network
Gender Reassignment Services
Covered as any other Covered as any other Covered as any other Covered as any other Covered as any other Covered as any other copays/coinsurance copays/coinsurance copays/coinsurance copays/coinsurance copays/coinsurance copays/coinsurance depend on type and depend on type and depend on type and depend on type and depend on type and depend on type and location of service location of service location of service location of service location of service location of service Hearing Aids (per ear, every 36 months)
In-network coinsurance applies whether In-network coinsurance applies whether purchased in- or out-of-network. Deductible purchased in- or out-of-network. Deductible does Home Health Care
Paid at 100% when
Paid at 100% when Maximum benefit of 130 visits per calendar year Maximum benefit of 130 visits per calendar year for in- and out-of-network combined for in- and out-of-network combined Hospital Inpatient
Paid at 100% after $200 Paid at 100% after
Paid at 80% after $200 Paid at 60% after Paid at 90% after $200 Paid at 60% after $200 copay per admission copay. Physician copay. Physician services paid at 70% services paid at 80% if Aexcel** specialist not if Aexcel** specialist not used in specialty areas. used in specialty areas. Hospital Outpatient
Paid at 100% after $15 $15 copay. Deductible
Paid at 80% after Paid at 60% after Paid at 90% after Paid at 60% after deductible. Physician deductible. Physician services paid at 70% services paid at 80% if Aexcel** specialist is if Aexcel** specialist is used in specialty areas. used in specialty areas. Hospice
Paid at 100% when
Paid at 100% when Maternity Care (delivery & related hospital)
Paid at 100% after $200 Deductible applies.
Paid at 80% after $200 Paid at 60% after Paid at 90% after $200 Paid at 60% after $200 copay per admission Group Health Cooperative (GHC)*
City of Seattle Traditional Plan*
City of Seattle Preventive Plan*
Standard Plan
Deductible Plan
Aetna In-Network
Aetna In-Network
Maternity Care (prenatal and postpartum)
Paid at 100% after $15 $15 copay. Deductible
Paid 100% after one $15 Paid at 60% Routine care not Routine care not subject subject to outpatient to outpatient services Mental Health Care (inpatient)
Paid at 100% after $200 Paid at 100% after
Paid at 80% after $200 Paid at 60% after Paid at 90% after $200 Paid at 60% after $200 Mental Health Care (outpatient)
Paid at 100% after $15 $15 copay per individual,
Paid at 80% after deductible Paid at 100% after $15 Paid at 60% after family or couple session. per individual, family or Deductible applies. couple session.
Physician Office Visit
Paid at 100% after $15 Paid at 100% after $15
Paid at 100% after $15 copay. Deductible copay per visit (waived for preventive care) Prescription Drugs (retail)
For a 30 day supply:
For a 30-day supply: For a 31-day supply: For a 31-day supply: Generic: $15 copay Generic: $15 copay Generic: 30%
Generic: 30%
Brand: $30 copay
Brand: $30 copay
coinsurance. Brand:
Contraceptive drugs and Contraceptive drugs and 40% coinsurance Brand: 40%
devices are covered devices are covered subject to the pharmacy subject to the pharmacy coinsurance is $10, or actual cost of the drug if coinsurance is $10, or less. Maximum is $100 actual cost of the drug if less. Maximum is $100 per drug. Smoking cessation Smoking cessation Coinsurance applies to the prescription $1,200 out-of-pocket annual maximum per person, $3,600 prescription drugs not prescription drugs not per family. Prescription Allowance on all non-sedating antihistamines (for allergy symptoms) and Proton Pump Inhibitors (for heartburn relief and ulcer treatment). City pays $20 per month, and to pharmacy copay. to pharmacy copay. plan participant pays remaining; some over the counter medications are also included. $5 copay for generic diabetic drugs and supplies, $15 copay for brand. Many contraceptive products are covered. IUDs and Depo Provera covered under the medical plan benefit. Coinsurance for asthma, anti-high cholesterol, and tobacco cessation drugs 10% for generic and 20% for brand pharmacy. Group Health Cooperative (GHC)*
City of Seattle Traditional Plan*
City of Seattle Preventive Plan*
Standard Plan
Deductible Plan
Aetna In-Network
Aetna In-Network
Prescription Drugs (mail order)
For a 90 day supply:
For a 90 day supply: For a 90-day supply: For a 90-day supply: Generic: $45 copay Generic: $30 copay Generic: 30%
Generic: 30%
Brand: $90 copay
Brand: $60 copay
Brand: 40% coinsurance
Brand: 40% coinsurance
Contraceptive drugs and devices are covered Minimum is $20 or Minimum is $20 or subject to the pharmacy copay. double the cost of the double the cost of the drug if less. The drug if less. The maximum is $200 per maximum is $200 per Preventive Care
Paid at 100% after $15 Paid at 100% after $15
Mammograms paid at Mammograms paid at Paid at 100% (copay Paid at 60% for well Covers adult physical Covers adult physical Covers adult physical and well child exams, and well child exams, and well child exams, most immunizations, most immunizations, No other preventive services are covered immunizations, digital No other preventive hearing exams, eye hearing exams, eye rectal exams/prostate- services covered exams, digital rectal exams, digital rectal specific antigen test, exams/prostate-specific exams/prostate-specific colorectal cancer antigen test, colorectal antigen test, colorectal cancer screening, pap cancer screening, pap Hearing exams subject to deductible. Rehabilitation Services (inpatient)
Paid at 100% after $200 Paid at 100% after
Paid at 80% after $200 Paid at 60% after Paid at 90% after $200 Paid at 60% after $200 copay per admission Maximum of 60 days per calendar year Maximum of 120 days per calendar year for (combined with other therapy benefits) skilled nursing and rehab services in- and out-of- network combined Rehabilitation Services (outpatient)
Paid at 100% after $15 $15 copay Deductible
Paid at 100% after $15 Paid at 60% Maximum of 60 visits per calendar year Includes medically necessary Includes medically necessary physical/massage, (combined with other therapy benefits) physical/massage, speech, and occupational speech, occupational and cardiac/pulmonary therapy for non-chronic conditions. Coinsurance therapy for non-chronic conditions. Coverage of does not apply to OOP Max. Coverage of services subject to Aetna's review for medical services subject to Aetna's review for medical necessity at any time necessity at any time Group Health Cooperative (GHC)*
City of Seattle Traditional Plan*
City of Seattle Preventive Plan*
Standard Plan
Deductible Plan
Aetna In-Network
Aetna In-Network
Skilled Nursing Facility
Paid at 100%. 60 day
60 day maximum per Paid at 80% after $200 Paid at 60% after Paid at 90% after $200 Paid at 60% after $200 maximum per calendar calendar year. Paid at 100% after deductible. Maximum of 90 days per calendar year for Maximum of 120 days per calendar year for in- and out-of-network combined rehab services and skilled nursing in- and out-of- network combined Smoking Cessation
Paid at 100% for
Paid at 100% for Lifetime maximum of one Not covered Smoking cessation 90-day supply of aids or prescription drugs or group sessions or group sessions covered subject to 10% Nicotine replacement therapy included in generic, 20% brand drug Prescription Drug benefit generic, 20% brand. See Prescription Drugs. Spinal Manipulations
Paid at 100% after $15 $15 copay.
Paid at 100% after $15 Deductible applies. Self-referral to GHC designated providers. Must Maximum of 10 visits per calendar year Maximum of 20 visits per calendar year meet GHC protocol. Maximum of 10 visits per for in-network and out-of-network combined. for in-network and out-of-network combined. Sterilization Procedures
Inpatient: Paid at 100% Inpatient: Paid at 100% Inpatient: Paid at 80%
Inpatient: Paid at 60% Inpatient: Paid at 90% Inpatient: Paid at 60% after $200 copay after $200 copay after $200 copay after $200 copay Outpatient: Paid at Outpatient: $15 copay. 100% after $15 copay Deductible applies. Outpatient: Paid at 80% Outpatient: Paid at Outpatient: Paid at 90% Outpatient: Paid at Temporomandibular Joint Services
Covered as any other Covered as any other
Covered as any other Covered as any other Covered as any other Covered as any other copays/coinsurance copays/coinsurance copays/coinsurance copays/coinsurance copays/coinsurance copays/coinsurance depend on type and depend on type and depend on type and depend on type and depend on type and depend on type and location of service location of service location of service location of service location of service location of service provided. 5,000 lifetime provided. $5,000 lifetime maximum $5,000 lifetime maximum for non-surgical $5,000 lifetime maximum for non-surgical in- and out-of-network combined. in- and out-of-network combined Group Health Cooperative (GHC)*
City of Seattle Traditional Plan*
City of Seattle Preventive Plan*
Standard Plan
Deductible Plan
Aetna In-Network
Aetna In-Network
Tooth Injury (due to accident)
Not covered
Inpatient: Paid at 80% Inpatient: Paid at 60% Inpatient: Paid at 90% Inpatient: Paid at 60% after $200 copay after $200 copay Outpatient: Paid at Outpatient: Paid at Outpatient: Paid at 80% 60% Outpatient: Paid at 100% 60% after $15 copay for office visit. Other charges paid at 90% Vision Exam/Hardware
Exam: Paid at 100% Exam: Paid at 100% Covered under VSP. Covered under VSP. $15 copay. One exam $15 copay. One exam every Hardware: Not covered. covered.
X-ray and Lab Tests
Paid at 100%
Deductible applies. Provider responsible for Provider responsible for obtaining precertification obtaining precertification of high tech radiology of high tech radiology * Coverage for any service is subject to the carrier's determination of medical necessity and adherence to their clinical policy guidelines.
** Applies to Aetna -- Recognized charges are the lower of the provider's usual charge for performing a service, and the charge Aetna determines to
be the recognized charge percentage in the geographic area where the service is provided.
*** Applies to Aetna – Aexcel network, a specialty network of doctors in 13 specialty areas. The coinsurance level will drop 10% for non-Aexcel
doctors in the 13 specialty areas (coinsurance applies to in-network, out-of-pocket maximum). Call 1-877-292-2480for more information about the
Aexcel network.

Plan details are in your medical plan booklet at seattle.gov/personnel/benefits/health/medical.asp. This document is not a contract.


Group Health Cooperative (GHC)*
City of Seattle Traditional Plan*
City of Seattle Preventive Plan*
Standard Plan
Deductible Plan
Aetna In-Network
Aetna In-Network
Vision Exam/Hardware
Exam: Paid at 100% after Exam: Paid at 100% after Covered under VSP. Covered under VSP. $15 copay. One exam every $15 copay. One exam every 12 months. Hardware: Not covered. Hardware: Not covered. X-ray and Lab Tests
Paid at 100%.
Paid at 100%. Deductible Provider responsible for Provider responsible for obtaining precertification of obtaining precertification of high tech radiology. high tech radiology.
* Coverage for any service is subject to the carrier's determination of medical necessity and adherence to their clinical policy guidelines.
** Applies to Aetna -- Recognized charges are the lower of the provider's usual charge for performing a service, and the charge Aetna determines to be the
recognized charge percentage in the geographic area where the service is provided.
*** Applies to Aetna – Aexcel network, a specialty network of doctors in 13 specialty areas. The coinsurance level will drop 10% for non-Aexcel doctors in the 13
specialty areas (coinsurance applies to in-network, out-of-pocket maximum). Call 1-877-292-2480for more information about the Aexcel network.

Plan details are in your medical plan booklet at seattle.gov/personnel/benefits/health/medical.asp. This document is not a contract.
Paying Out-of-Network Claims
The following is an explanation of how out-of-network claims are paid by Aetna. This wil explain how "Recognized Charges" are used, and how the
amount that you are "balance bil ed" is calculated.
Explanation of Terms
Recognized Charge - The charge determined by Aetna on a semiannual basis to be in the 70th percentile of the charges made for a service or supply
by providers in the geographic area where it is furnished. The 70th percentile is determined by the maximum amount that 70% of providers charge for a
particular service in the geographic area where the service is provided. For example, if 70% of the doctors in a specific area charge $100 or less for an
office visit, the Recognized Charge at the 70th percentile would be $100.

Out-of-network reimbursement level – The percentage of the "Recognized Charge" that Aetna wil reimburse an out-of-network provider. Aetna uses
60% of the "Recognized Charge" for most eligible claims. The member pays the remaining 40% of the "Recognized Charge."
Out-of-network provider – A provider who does not have a contractual reimbursement relationship with Aetna. When Aetna receives a claim from an
out-of-network provider, Aetna determines the "Recognized Charge" and pays 60% of that amount if the out-of-pocket maximum has not been
satisfied, even though the provider may actually charge more that the "Recognized Charge."
Health Care Premiums 2014 Premium Sharing
Effective January 1, 2014, you will pay the monthly premium amount listed below. The table also shows the total premium amount each month for each employee's coverage, and the City's contribution. Employee, with or
Employee with
without children
Spouse/Domestic Partner,
with or without children
City Pays Employee City Pays
Employee
Medical Plan
City of
Seattle Preventive City of Seattle Traditional Group Your premium will be divided into two equal payments and taken from the first two pay checks of the month for the current month's coverage. (For example, deductions taken in January will pay for January coverage.) No premiums are deducted from the third paycheck. Premiums are deducted on a pre-tax basis, reducing your taxable income. *Provided they are IRS tax dependents. Health Care Premiums Enrolling
To cover a spouse or domestic partner (and tax dependents of your Spouse/DP
domestic partner), you must complete a Benefit Election form and an Affidavit of Marriage/ Domestic Partnership. Spouse/DP/
If they are IRS tax dependents, the rate information on the previous Dependents
page applies. If you enroll your domestic partner and your domestic Who are IRS
partner's children, you will be taxed on the value of their medical Tax Dependents coverage if they are not your tax dependents. (The value of the
benefits will be imputed to your gross income.) After Tax Premium Contributions
DP/Dependents If you choose to cover a domestic partner who is not your IRS tax
Who are Not
dependent, the portion of the premium deducted from your
paycheck (your contribution) that pays for his/her coverage must be Dependents
taken "after tax" to comply with IRS regulations. The column headed "Monthly Premium Contributions Taken After Taxes" shows the
portion of your monthly premium contribution that will be deducted from your paycheck after taxes are calculated. Medical Plans
Monthly Premium Contribution
Taken After Taxes for Domestic
City of Seattle Preventive
City of Seattle Traditional
GHC Standard
GHC Deductible

Imputed Income for Value of Health Coverage
In addition, if your domestic partner or your partner's non-IRS tax dependent's children do not qualify as your IRS tax dependents, you will also be taxed on the City-paid value of their medical, dental and
vision coverage as required by IRS regulations. The following amounts will be listed on your paycheck as taxable income each month and are subject to federal income and Social Security tax withholding. These values have been adjusted to reflect the premium amounts taken after-tax (as explained above) so you are not taxed Health Care Premiums DP/Dependents Domestic Partner Coverage Information
Who are Not
If your domestic partner or your partner's non-IRS tax dependent's children do not qualify as your IRS tax dependents, the following Dependents
amounts will be listed on your paycheck as taxable income each (cont'd.)
month and are subject to federal income and Social Security tax withholding. (These values have been adjusted to reflect the premium amounts taken after-tax so you are not taxed twice.) Medical/Dental/Vision Coverage Values with Delta Dental of
Washington Service Coverage
2014 Monthly Taxable Values of City Coverage Provided to:
Your Non-IRS Tax Dependent Domestic Partner or Your Domestic Partner's Non-IRS Tax Dependent's Child Type of Coverage
Domestic Partner
Taxable Amount
Taxable Amount
Per Child
Amount –
(with DDWA)
Traditional Plan Buy-Up Vision Plan Total Taxable Value with DDWA & VSP Basic Plan
Traditional Plan GH Standard Plan GH Deductible Plan Health Care Premiums DP/Dependents Medical/Dental/Vision Coverage Values with Dental Health
Who are Not
Services Coverage
Dependents
2014 Monthly Taxable Values of City Coverage Provided to:
(cont'd.)
Your Non-IRS Tax Dependent Domestic Partner Your Domestic Partner's Non-IRS Tax Dependent's Child Type of Coverage
Domestic Partner
Taxable Amount
Taxable Amount
Per Child
Taxable Benefit
Amount – (with
Traditional Plan Basic Vision Plan Buy-Up Vision Plan Total Taxable Value with DHS & VSP Basic Plan
Traditional Plan GH Standard Plan GH Deductible Plan Prescription Drug Coverage Prescription Drug Retail Program
Aetna classifies medications into three tiers:  Preferred brand-name  Non-preferred brand-name Group Health Cooperative uses two classifications: Preferred brand-name (no coverage for non-preferred brands) Preventive
With the Aetna plans, you pay 30% of the actual cost for generic drugs, and 40% for preferred and non-preferred brand-name drugs, up to a Traditional
maximum of $100 per drug per month. There is a $1,200 annual out- of-pocket maximum per member for retail and mail order drugs. Present your medical plan ID card at any Aetna network retail pharmacy. Prescriptions filled at a non-network pharmacy will not be covered. You may contact the toll-free Member Services number on the back of your ID card to find a participating pharmacy, or check the GHC Plans
You are responsible for a $15 copay for generic drugs and a $30 copay for brand name drugs. All prescriptions must be filled at a GHC pharmacy. Prescriptions filled at any non-GHC pharmacy will not be covered. See next page for more detailed information about prescription drug Prescription Drug Coverage Comparison Features
Standard
Deductible
Preventive
Traditional
Annual out-
of-pocket
 Coinsurance You pay $15
You pay 30% of You pay 30% of 40% of cost for cost for brand  Minimum Not applicable
Coinsurance
 Monthly
 Days Supply 30-day
 Out-of-
Mail Order
 Coinsurance Generic:$45
You pay 30% of You pay 30% of 40% of cost for cost for brand  Minimum Not applicable
Coinsurance
 Monthly
 Days Supply 90-day supply
*Coinsurance exceptions:  City pays $20 towards cost of proton pump inhibitors and non-sedating antihistamines and you pay the remaining amount, whether medication is purchased over-the-counter or is a brand name drug.  You pay 10% of cost for generic and 20% for brand drugs for anti-high cholesterol, asthma, and tobacco cessation drugs.  Diabetic drugs and supplies have special copays: $5 copay for generic, $15 copay Dental Plan Options There are two dental plans: Delta Dental of Washington (DDWA) and Dental Health Services (DHS). Delta Dental of Washington
If you select DDWA, you can receive services from any dentist, but your out-of-pocket expenses may be lower if you choose a dentist who belongs to the DDWA network. Selecting a DDWA dentist means:  The portion of the dentist bill you pay is smaller than if you use a non-network dentist.  You do not need to submit a claim - the dentist's office will submit  After you pay your portion of the bill, the dentist will not bill you more for a covered service. (A non-DDWA dentist may bill you for the portion of the bill that DDWA does not cover.) Payment of The DDWA Incentive program is designed to promote regular dental care
Routine by increasing from one incentive period to the next, the amount paid for
preventive care and regular visits. During the first incentive period, the Care payment level for covered and allowable Preventive and Diagnostic
Benefits (routine care) benefits will be 70 percent even if you had DDWA coverage
through a previous employer. This payment level increases by 10 percent — up to a maximum of 100 percent — each successive incentive period in which routine care benefits are used at least once by the eligible person(s). If the once-a-year visit is missed, the payment level will be decreased by 10 percent for each period during which routine care benefits are not used. In no event will the payment level be less than 70 Orthodontia DDWA offers orthodontia benefits for children. Pre-treatment estimates
are recommended. The orthodontia benefit is paid at a 50% level to a lifetime maximum of $1,500 for each eligible child. There is no adult orthodontia coverage. Dental Plan Options
Dental Health Services
The Dental Health Services Plan provides greater benefits for services received in network than if you enroll in DDWA, but the DHS network of participating dentists is smaller and you must see a network participating dentist. Selecting a Dental Health Services dentist means:  There are no deductibles or annual maximums. Coverage does not decrease if you do not visit your dentist Payment of This plan has an office visit copay of $10 for all employees. There are
Basic also copays for selected services. The plan comparison on the next
Services page lists services and copay requirements.
Orthodontia DHS offers both child and adult (age 25 and over) orthodontia.
Orthodontia charges include: a copayment of $1,800 per adult or $1,000 per child for orthodontic treatment; a $150 charge for the initial exam, study models and X-rays; and a $10 copay for each visit during the course of treatment. Dental Plan Comparison Plan Features
Delta Dental of
Dental Health Services
Washington (DDWA)
Calendar Year
$50 per person, $150 per family Deductible
(No deductible for preventive services) Annual Maximum
$2,000 per person per year No Annual Maximum. Benefit
Diagnostic and
$10 office visit copay Preventive (routine and
Incentive payments levels Two additional cleanings for emergency exams, x-rays, 1st Year – 70% pregnant women, up to four cleaning, fluoride 2nd Year – 80% treatment, sealants) 3rd Year – 90% 4th Year – 100% Inlays (Fillings)
Class II: Constant 70% $10 office visit copay Covers composite fillings in all teeth (posterior composite fillings additional $15) Crowns, Onlays
Class II: Constant 70% $145 noble, $175 high noble or titanium, $200 upgraded, specialized porcelain if applicable per unit. (Non-specialized porcelain is $75.) Prosthodonic Services
Class III: Constant 50% $125 plus $10 office visit copay (Dentures, Bridges) $75 plus $10 office visit copay (bridges) Orthodontia
Available for Child & Adult Plan pays 50% up to lifetime Adult (age 25 and over) $1,800 plus maximum of $1,500; deductible $150 for initial exam, study models and x-rays covers full course of treatment plus $10 copay for each visit (new cases) Orthodontia cases (less than age 25) $1,000 copay $150 for initial exam, study models and x-rays covers full course of treatment plus $10 copay for each visit (new cases) Choice of Providers
In-Network: Any contracted In-Network: Any contracted provider in the DHS network. Out-of-Network: Expenses paid will be based on actual charges or Out-of-Network: No out-of-network Delta Dental of Washington's maximum allowable fees for nonparticipating dentists, whichever is less. You will be responsible for any balance remaining. Dental Plan Comparison (continued) Plan Features
Delta Dental of
Dental Health Services
Washington (DDWA)
Periodontics (surgical
Class II: Paid according to Paid at 100% after $25 copay for incentive payment levels shown periodontal scaling and procedures for treatment maintenance at general dentist. If of the tissues supporting referred to periodontist, member Endodontics (procedures Class II: Paid according to
Paid at 100% after applicable copay for pulpal and root canal incentive payment levels shown ($50 for anterior, $75 for bicuspid, or above, Root canal treatment of $100 for molar root canal) If referred same tooth covered only once in a to endodontist, member pays 20%. 2-year period. Oral Surgery (routine and Class II: Paid according to
Paid at 100% after $10 office visit surgical extractions) incentive payment levels shown copay for general dentist. If referred to an oral surgeon, member pays 20% $1,000 annual maximum Joint (TMJ) Disorders
$5,000 lifetime maximum Dental Implants
Call DHS Office for details – fees apply Class III: Occlusal (night guard) Occlusal (night guard) with $350 covered at 50% if patient has advanced gum disease 2014 Monthly Dental Premiums for Most City Employees
Employee's Monthly Premium Contribution
Coverage for Employee with or
Coverage for Employee with
without children
Spouse/Domestic Partner with or
without children
Dental of Washington
New Temporary Benefits Eligible Employees: Remember - You have 31 days from
your hire date to enroll in the medical, dental, vision and Group Term Life plans.
The Basic vision plan is fully paid by the City. Service Plan
If you use a VSP provider, you will receive the benefits listed in the following table. If you use a non-VSP provider, the Plan will reimburse you for expenses in the amounts shown. Lens options such as scratch coating, anti-reflective coating, and high density plastic are not covered. Vision Benefits – Basic Plan
Plan Feature
Coverage by Provider
VSP Provider
Non-VSP Provider
Eye exam:
$10 copay. Exam covered in Covered up to $50. Covered each calendar year
Lenses and Frames:
Lenses covered up to $50 - Covered every other Frames covered in full up to $100 depending on type of contract allowance of $150. Frames covered up to $70. Single vision, lined bifocal, lined trifocal lenses are Single vision, lined bifocal, covered in full; progressive lined trifocal lenses are lenses not covered** covered as shown above; progressive lenses not Contact Lenses:
Contact lens fitting and Elective contact lenses Covered every other evaluation exam & contact covered up to $105; includes lenses covered up to elective contact lens evaluation exam, contact lens allowance of fitting and materials.* Lens options such as scratch coating, anti-reflective coating, or high density plastic not covered. *Medically necessary contacts are covered in full (up to $210 at a Non-VSP Provider) when patient meets specific requirements as determined by VSP doctor at the time of service. 2014 Monthly Vision Premiums for Most City Employees
Vision Plan
Employee's Monthly Premium Contribution
Coverage for Employee
Coverage for Employee
with or without children
with Spouse/Domestic
Partner with or without
children

New Temporary Benefits Eligible Employees: Remember - You have 31 days from
your hire date to enroll in the medical, dental, vision and Group Term Life plans.
Basic Long-Term Disability Basic Long-
The basic benefits package provided by the City includes a Long-Term Disability (LTD) policy that will pay you a portion of your monthly pay if Disability
you are sick or injured and cannot work. If you are disabled according to the plan definition, the benefit will combine with other income sources, if any, to pay you up to $400 per month after a 90-day waiting period while you are unable to work. You do not need to enroll in this coverage, you are automatically enrolled as a temporary employee with benefits. Group Term
The City benefits program includes optional Basic Term Life Insurance. Life (GTL)
The City and you pay for Basic Life Insurance. You can sign up for Group Term Life Insurance within 31 days of your hire date, during an Insurance
Open Enrollment period, or within 31 days of a qualifying change in Basic Life
This optional coverage provides you with a Term Life Insurance benefit Insurance
amount equal to one-and-a-half times your annual salary. The City contributes 40% of the cost and you pay the remaining 60% of the cost. A table with information regarding the monthly cost of Basic Term Life Insurance follows. If you sign up for Basic Term Life Insurance as a new temporary benefits eligible employee, you are guaranteed coverage. However, if you sign up for it later, you will be required to complete a Medical History Statement, which must be approved by the insurance company before your life insurance takes effect. If you have certain health conditions, you could be denied coverage. This policy includes a conversion privilege which allows you to continue some level of coverage if you leave City employment. Conversion is guaranteed, which means you can continue the policy regardless of any existing medical condition. It is more costly because of this provision, but could allow you to maintain coverage when you otherwise might not qualify for new life insurance coverage.
Limited Basic IRS rules state that the value of Basic Life Insurance over $50,000,
Life
which is paid for by the City, is taxable. Because the City pays 40% of Insurance
the cost for your Basic Term Life Insurance, you may have some taxable value. If you do, the amount on which you pay taxes will be shown on your second paycheck each month. You may limit your Basic Term Life Insurance coverage amount to $50,000 to avoid the additional taxes by signing a notarized Waiver form available from Basic Group Life Insurance Costs Costs for
Employee's Annual
Amount of Employee
Basic Life
Earnings
Insurance
Insurance
$29,000.01 – $30,000 (based on
$30,000.01 – $31,000 employee's
$31,000.01 – $32,000 $32,000.01 – $33,000 earnings)
GTL Limited
$33,000.01 – $34,000 $34,000.01 – $35,000 $35,000.01 – $36,000 $36,000.01 – $37,000 $37,000.01 – $38,000 $38,000.01 – $39,000 $39,000.01 – $40,000 $40,000.01 – $41,000 $41,000.01 – $42,000 $42,000.01 – $43,000 $43,000.01 - $44,000 $44,000.01 - $45,000 $45,000.01 - $46,000 $46,000.01 - $47,000 $47,000.01 - $48,000 $48,000.01 - $49,000 $49,000.01 – $50,000 $50,000.01 – $51,000 $51,000.01 – $52,000 $52,000.01 – $53,000 $53,000.01 – $54,000 $54,000.01 – $55,000 $55,000.01 – $56,000 $56,000.01 – $57,000 $57,000.01 – $58,000 $58,000.01 – $59,000 $59,000.01 – $60,000 $60,000.01 – $61,000 $61,000.01 – $62,000 $62,000.01 – $63,000 $63,000.01 – $64,000 $64,000.01 – $65,000 $65,000.01 – $66,000 $66,000.01 – $67,000 $67,000.01 – $68,000 Basic Group Life Insurance Costs - Continued Employee's Annual
Amount of Employee
Earnings
Insurance
$68,000.01 – $69,000 $69,000.01 – $70,000 $70,000.01 – $71,000 $71,000.01 – $72,000 $72,000.01 - $73,000 $73,000.01 - $74,000 $74,000.01 - $75,000 $75,000.01 - $76,000 $76,000.01 - $77,000 $77,000.01 - $78,000 $78,000.01 - $79,000 $79,000.01 - $80,000 $80,000.01 - $81,000 $81,000.01 - $82,000 $82,000.01 - $83,000 $83,000.01 - $84,000 $84,000.01 - $85,000 $85,000.01 - $86,000 $86,000.01 - $87,000 $87,000.01 - $88,000 $88,000.01 - $89,000 $89,000.01 - $90,000 $90,000.01 - $91,000 $91,000.01 - $92,000 $92,000.01 - $93,000 $93,000.01 - $94,000 $94,000.01 - $95,000 $95,000.01 - $96,000 $96,000.01 - $97,000 $97,000.01 - $98,000 Your coverage amount is equal to your annual salary, rounded up to the next $1,000 increment, multiplied by 1.5. Your monthly premium equals $0.066 times each $1,000 of coverage. For example, if your salary is $78,600 per year, round it up to $79,000. Your coverage amount is $118,500 (Calculation: $79,000 x 1.5 = $118,500). Your premium is $7.78 per month (Calculation: $0.066 x 118). Work Life Programs Temporary Benefits Eligible employees who work a minimum of 40 hours per month, are eligible for Mytrips benefits. The City of Seattle encourages employees to use alternatives to driving alone to work. City of Seattle employees are eligible to receive an ORCA Passport which pays full fare for all land based transit. Employees who use the ferry may instead choose to receive up to $90 per month towards a WA State ferry pass. City employees that use the transit system, carpool, and/or bike to work are also eligible for a guaranteed ride home and may also receive discounted membership in ZipCar and Car2Go. The Internal Revenue Code allows up to $125 per month (less City Transit Pass
subsidy) for transit passes to be deducted from paychecks on a Subsidy and Tax pre-tax basis. Once the deduction has been withheld from your
paycheck, the IRS will not allow you to revoke the deduction or receive a refund. Any amount over the allowable maximum will be deducted from post-tax dollars. Actual savings will vary depending on your federal tax filing status and the amount of the transit pass. Employees who purchase a payroll-deducted transit pass are automatically enrolled in the pre-tax plan. City employees can get a discounted membership in Zipcar. The City will pay the application fee, and your first year membership fee. Your monthly costs as a member will vary depending on how much you use the Zipcar vehicles. Subsequent year membership fee will be charged absent rental activity. Use a rideshare mode to get to work. Then use Zipcar to go to doctor appointments, do special errands during the day, or drive home after working an extended day. Zipcar vehicles are located throughout Seattle and in Bellevue. You'll have access to the entire Zipcar fleet on evenings and weekends. For more information and to apply online, go Vacation
You earn vacation based on the number of hours you work regular (non-overtime) hours. You accumulate vacation based on a maximum of 80 hours per pay period. (See the vacation accrual chart below.) Approximately 2,088 hours of regular pay status equal one year of full-time employment. Your vacation accrual rate is 12 days per year for your first four years of service. The accrual rate gradually increases to 20 days per year after 20 years of service with an additional day per year of service thereafter to a maximum of 30 You can accumulate two times your annual vacation without penalty. The amount of vacation you have earned and not used is shown on your biweekly paycheck. You may also view this information on You must wait six months after your initial hire date (or your most recent temporary appointment if you provided temporary service and were regularly appointed without a break in service) to take vacation. Follow your department's protocol for requesting and taking vacation. Your unused vacation balance will be cashed out when you leave City provisions regarding employment, unless your collective bargaining agreement provides Hours of Regular Vacation Days Hours information differs per Hour Year Year bargaining agreement prevails. Sick Leave
Sick leave is a short-term disability program that pays your wages if you must be absent from work because of your own personal illness, injury or disability which makes you temporarily unable to perform your job. You may also request sick leave compensation when you are absent because of illness, injury or disability of your spouse or domestic partner, parent, grandparent, sibling, or dependent child. Finally, you may request sick leave compensation to cover time missed for your medical or dental appointments or to accompany your eligible family member(s) to medical or dental appointments. You are eligible to use available sick leave hours after 30 days of employment. Temporary Benefits Eligible, full-time employees accumulate 12 days or 96 hours of sick leave per calendar year, at the rate of .046 hours per hour on regular pay status. If you are absent more than four consecutive work days, you must submit a medical certification stating why you needed sick leave and confirming your ability to return to work. In addition, your supervisor may, with justification, require a medical certification every time you request sick leave regardless of the length of your absence. When you retire through the City of Seattle Retirement System you are eligible to receive a cash equivalent of 25 percent of unused sick leave hours, unless your union has elected to participate in VEBA or you are eligible to defer your sick leave into Deferred Compensation. Check with your HR representative. Holidays
Temporary Benefits Eligible employees are eligible for 10 official paid holidays and two personal paid holidays per year. To qualify for a paid holiday, you must be on regular pay status either the day before or the day after the observed holiday. However, if you returned the day after a holiday, but had been on unpaid leave for more than four days immediately preceding the holiday, you would not be eligible for holiday pay. For more information regarding holiday leave policies, consult Personnel Rule 7.6 at and any applicable union Here is the 2014 holiday schedule. New Year's Day
Wednesday, 1/1/2014 Martin Luther King Jr. Day
Monday, 1/20/2014 President's Day
Monday, 2/17/2014 Memorial Day
Monday, 5/26/2014 Independence Day
Friday, 7/04/2014 Labor Day
Monday, 9/01/2014 Veterans' Day
Tuesday, 11/11/2014 Thanksgiving Day
Thursday, 11/27/2014 Day following Thanksgiving
Friday, 11/28/2014 Christmas Day
Thursday, 12/25/2014 New Years Day 2015
Thursday, 1/1/2015 Funeral Leave You are permitted time off without loss of pay or paid leave balances
to attend the funeral of a close relative. With supervisory approval, you may use up to five days of accumulated sick leave to attend the funeral or a relative other than a close relative. Jury Duty
If you serve on jury duty during normal work hours, you will be paid your regular straight-time pay upon surrendering to the City any compensation you receive from the Court, less transportation Family and
You are eligible for Family and Medical leave after six calendar Medical Leave months of employment.
The City offers two programs to help you prepare financially for Deferred
You may participate in an IRS Section 457 Deferred Compensation Compensation Plan administered by Prudential Retirement. You may enroll any time
Savings Plan
throughout the year. This plan allows you to save a portion of your annual income to supplement retirement funds. Contributions are made through payroll deductions from your pre-tax gross pay. You have the choice of several investment options to diversify your savings. For more information regarding the Deferred Compensation Plan contact Prudential at 1-800-833-5761.  You may enroll, as well as start and stop your contributions to this program, at any time.  You many contribute as little as $20 per month and as much as 50% of your annual taxable income up to the annual limit  You do not pay federal income tax on your money until it is  You can apply for a loan, not to exceed the lesser of $50,000 or half your account balance.  You are eligible to withdraw your money only when you leave City service, regardless of age. Limit for
employees over
There are three opportunities when a temporary employee may elect Retirement
membership in the Seattle City Employees' Retirement System 1. At the completion of 1,044 hours of City employment, the equivalent of 6 months full-time work 2. After completing 10,440 hours of City employment, the equivalent of 5 years full-time work 3. When appointed to a regular position of City employment, you may join the Retirement System and purchase prior credit, provided this occurs before completion of 10,440 hours of City Contact the Retirement Office (206-386-1292) for more information. Retirement
Temporary employees who participate in the Retirement System are automatic members of the Death Benefit Program. The intended System Death purpose of this policy is to be an adjunct to your burial insurance. The
benefit is $2,000 and payable only to the beneficiary. The premium is $12.00 per year, deducted from the first paycheck of the year. The policy has no cash value for the retiree. Balance billing
The amount over and above your co-insurance amount that you may be required to pay if you use a non-network provider. See the
explanation for Paying out-of-network claims that bills more
than Aetna's allowable amount on page 18. Coinsurance
The arrangement by which both the Plan and the employee share a specified ratio of the covered expenses under the policy. For example, the Aetna Open Choice Traditional Plan pays 80% of most covered expenses while the employee pays the remaining 20% of covered expenses once the deductible has been met. A fee paid at the time a medical or dental service is provided. A copay may be a percentage of charges, but is usually a flat fee. In general, copayments may not be applied toward the coinsurance or out-of-pocket deductibles. Deductible
The amount of covered expenses that must be incurred before benefits are paid by the Plan. The deductible is set on an annual basis and there are individual and family deductibles. Eligible Expenses Expenses as defined in the health plan as being eligible for
coverage. This could involve specified health services fees or "reasonable and customary charges." A list of preferred brand-name and generic drugs. Drugs are Formulary
selected for inclusion based on evaluation criteria developed by each Plan. Formularies are different depending on the Plan, and may change to include new drugs or to drop brand-name drugs as generic equivalents become available. Generic Drug
A drug which contains the same active ingredients in the same amounts as the brand-name product, although it may differ in color, shape or size from the brand-name product. It is produced after the brand name drug's patent has expired. It is also called a "generic equivalent."
Network Provider A medical provider, such as a physician, who has a signed contract
to participate in a health plan. Also known as a preferred provider. Non-network
A provider who has not signed a contract with a health plan. Also Provider
known as a non-preferred provider. The amount not covered by the plan that the plan member pays. This includes such things as coinsurance, deductibles, etc. The amount of copays and/or coinsurance an individual will be required to pay within a calendar year before most covered Pocket Maximum) expenses are covered in full.
A physical condition that existed prior to the effective date of a condition
policy. In many health policies these are not covered until after a stated period of time has elapsed. The City's medical plans cover all pre-existing conditions. Preferred
A medical provider, such as a physician, who has a signed contract Provider
to participate in a health plan. Also known as a network provider. Preventive Care
Care that consists of routine physical examinations and immunizations. The emphasis is on preventing illnesses before Recognized
The charge determined by Aetna on a semiannual basis to be in the 70th percentile of the charges made for a service or supply by providers in the geographic area where it is furnished. Who to Contact if You Have Questions If you have questions, contact the following organizations by phone or obtain information through their web sites. The Personnel Department's Central Benefits Unit can be reached at 206-615-1340. Custom Doc Find: Click on "Members and Consumers" Washington (DDWA) Dental Health Services Prudential Retirement Local Representative Alternative Dispute 206-615-1692 206-684-7888 TTY City's Central Benefits Employee Self-Service Health Care Benefits Election Form
Temporary Benefits Eligible Employees – Most Plans
Last Name (Please Print) Home Address - Street Birth Date (M/D/Y) Social Security Number Decline coverage (skip to Page 2) Effective Date of Coverage Reason for re-enrolling:
Loss of other coverage (Attach proof of other coverage) Birth/adoption of child Marriage/new domestic partnership (Attach affidavit of marriage/domestic partnership)
Medical Plan Selection
Employee Premium Share
(Please choose ONE Medical Plan below) City of Seattle Preventive Plan
Employee Only (with or without Children) Employee & Spouse/Domestic Partner (with or without Children) 
 City of Seattle Traditional Plan
Employee Only (with or without Children) Employee & Spouse/Domestic Partner (with or without Children) 
 Group Health Standard Plan

Employee Only (with or without Children) Employee & Spouse/Domestic Partner (with or without Children)
 Group Health Deductible Plan

Employee Only (with or without Children) Employee & Spouse/Domestic Partner (with or without Children) Vision Plan
Vision Service Plan Dental Plan Selection (Please choose ONE Dental Plan)
 
Dental Health Services OR
Delta Dental of Washiongton Add Dependent Coverage Information: List all eligible dependents to be included. Attach list for any additional dependents.
Spouse/Domestic Partner
Birth Date
Enroll In
Relationship Domestic Partner
Partner claimed as IRS tax dependent 1. Dependent Child
Birth Date
Enroll In
Relationship Employee's Dependent
Partner's Dependent
Other (Step-child or Legal
Guardian)
THIS ENROLLMENT FORM IS NOT VALID UNLESS IT IS SIGNED AND DATED ON THE REVERSE SIDE
2. Dependent Child
Birth Date
Enroll In
Relationship Employee's Dependent
Partner's Dependent
Other (Step-child or Legal
Guardian)
3. Dependent Child
Birth Date
Enroll In
Relationship Employee's Dependent
Partner's Dependent
Other (Step-child or Legal
Guardian)
Dependent Eligibility Information: If you have listed a dependent child over the age of 18 years, please answer
the questions below about your dependent:
1. Incapacitated or Disabled?
No 2. Working full time and have access to health insurance? It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the insurance company. Penalties include imprisonment, fines and denial of insurance benefits. Coverage Options

I ACCEPT COVERAGE
Previously submitted enrollment information for a specific insurance plan is superseded by changes indicated on this form. I certify that my family members and I are eligible for the coverage requested. I authorize the City to deduct from my earnings any premium I am required to pay for the coverage I selected above. By signing below, I declare that the information on this form is true, correct and complete to the best of my knowledge; that I have read and understand the election form and descriptive material covering the options provided under the City of Seattle's benefit plans. I authorize the insurance carriers to obtain, examine or release information needed to coordinate benefits or process claims fo r myself or my family. I understand I may be subject to disciplinary action and/or repayment of any claims paid by my health plan or premiums paid by my employer if I have provided false, incomplete, or misleading information, or fail to update this information in accordance with eligibility guidelines. Employee's signature I DECLINE COVERAGE
If you have medical coverage elsewhere and lose your other coverage, you may enroll within 30 days of the loss of the other coverage upon providing proof of continuous medical coverage. If you have a qualifying change in family status, you may enroll within 31 days (or 60 days for a new child) of that change. If you leave City employment or go on a leave of absence, you will not be eligible to obtain your medical coverage under the federal COBRA law through the City. However, if you retire you will be eligible to enroll in a City retiree medical plan. If you decline coverage and have no medical insurance elsewhere, you will NOT be eligible to enroll in a medical plan until the next annual Open Enrollment unless you have a qualifying change in family status. If you leave City employment or go on a lea ve of absence, you will not be eligible to obtain your medical coverage under the federal COBRA law or enroll in a City retiree medical plan. I understand that by declining City of Seattle medical insurance, my medical coverage through the City will end, but my vision and dental insurance will continue. I decline medical coverage for myself and family members. Employee's signature Department Representative's signature Date Entered into HRIS _ CITY OF SEATTLE
Marriage/Domestic Partnership Affidavit
SECTION I

(print name of employee) Complete either A for marriage or B for domestic partnership were legally married on (print name of spouse) (date of marriage) have formed a domestic partnership and we:
(print name of domestic partner) 1. Share the same regular and permanent residence and
2. Have a close personal relationship and
3. Are jointly responsible for basic living expenses as defined below and
4. Are not married to anyone and
5. Are each eighteen (18) years of age or older and
6. Are not related by blood closer than would bar marriage in the state of Washington and
7. Were mentally competent to consent to contract when our domestic partnership began and
8. Are each other's sole domestic partners and are responsible for each other's common
"Basic living expenses" means the cost of basic food, shelter, and any other expenses of a Domestic partner, which are paid at least in part by a program or benefit for which the partner qualified because of the Domestic Partnership. The individuals need not contribute equally or jointly to the cost of these expenses as long as they agree that both are responsible for the cost. SECTION II

A. I understand that this affidavit shall be terminated upon the death of my spouse/domestic partner or by a change of circumstance attested to in this affidavit. I agree to notify my payroll/personnel representative if there is any change of circumstances attested to in this affidavit within thirty-one (31) days of change by filing a Statement of Termination of Marriage/Domestic Partnership. B. After such termination, I understand that another Affidavit of Marriage/Domestic Partnership cannot be filed until ninety (90) days after a Statement of Termination of Marriage/Domestic Partnership has been filed with my payroll/personnel representative, unless such termination is due to the death of my spouse/domestic partner or the dissolution of my marriage. AFFIDAVIT OF MARRIAGE/ DOMESTIC PARTNERSHIP
I understand that if I have indicated on my Medical Benefit Election Form that my domestic partner is my IRS tax dependent, he/she meets the IRS Section 152 definition of a dependent. I understand that if my domestic partner is not an IRS tax dependent that any employee health premiums attributed to my domestic partner will be paid with after tax dollars.

SECTION III
We understand that this information will be held confidential and will be subject to disclosure only upon our express written authorization or if otherwise required by law. We understand that this declaration of responsibility for our common welfare may have legal implications under Washington law. We understand that a civil action may be brought against us for any losses, including reasonable attorney's fees, because of a false statement contained in this Affidavit of Marriage/Domestic Partnership. We also certify under penalty of perjury, under the laws of the State of Washington, that the foregoing is true and correct. I, the undersigned City of Seattle Employee, understand that willful falsification of information on this affidavit may lead to disciplinary action, up to and including discharge from employment. Signature of Employee Signature of Spouse/Domestic Partner Employing Department Employing Department (if applicable) Send completed form to your HR Department City of Seattle
Group Term Life Election Form
Last Name (Please Print) Home Address - Street Social Security Number BASIC GROUP TERM LIFE INSURANCE
Effective date of coverage/change for: Canceling coverage YES, I am applying for group term life insurance according to the terms of the group policy issued to the City of Seattle,
with coverage equaling 1½ times my annual salary. I authorize deductions from my salary for any contribution I am required to make toward the cost of this insurance. NO, I do not care to participate in the City of Seattle's group term life insurance plan. I understand that a Medical History
Statement will be required if I desire to apply for coverage later during an annual open enrollment period and coverage will be provided at the discretion of the insurance carrier. BASIC GROUP TERM LIFE INSURANCE -- LIMITED COVERAGE
Effective date of coverage/change for: Canceling coverage My gross salary is greater than $33,000, and I am applying for Basic GTL coverage limited to $50,000 (instead of the above Basic GTL coverage equal to 1½ times my salary) according to the terms of the group policy issued to the City of Seattle. I authorize premiums to be deducted from my salary. Previously submitted enrollment information for Basic GTL insurance, excluding current beneficiary information, is superseded by this election. I understand if I later want to increase my GTL coverage amount, I will be required to provide a Medical History Statement. My signed and notarized Waiver Agreement accompanies this application. BENEFICIARY INFORMATION
Effective date of beneficiary change List the beneficiary(ies) for your Basic Group Term Life Insurance. (You are the designated beneficiary for any spouse or partner, or dependent child loss.) Please specify the percentage of benefit for each beneficiary and if any beneficiary is contingent. Contingent means the person listed only receives the benefit if your named beneficiary is deceased. You are not required to list a contingent beneficiary. If more space is required, use a separate list, sign, date and attach to this form. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Beneficiaries for Basic Group Term Life
Last Name (Please Print) First Name By signing below, I declare that the information on this form is true, correct and complete to the best of my knowledge, that I have read and understand the election form and descriptive material covering the options provided under this plan. I authorize the insurance carrier to obtain, examine or release information needed to process claims for myself or my family. Employee's signature _ I have completed and mailed the required Medical History Statement to the insurance company because: I am not a new employee and I am applying during open enrollment. I am a new employee and the combined total of my Basic coverage exceeds $500,000. Department Representative's signature _ Date Entered into HRIS _
*Temporary benefits eligible employees (TBE) are not eligible for Supplemental, Spouse/DP, and Child GTL Coverage.
INITIAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS **CONTINUATION COVERAGE RIGHTS UNDER COBRA **
Introduction
It is important that all covered individuals (employee, spouse/domestic partner, and eligible dependent children, if
able) take the time to read this notice carefully and be familiar with its contents. If there is a covered dependent not
living at your address, please provide written notification to your department's Benefits Representative so a notice
can be sent to that dependent as well.
You are receiving this notice because you may have recently become covered under one or more of the following
group health plans: City of Seattle Preventive Plan, City of Seattle Traditional Plan, Group Health Cooperative, Delta
Dental of Washington, Dental Health Services, Vision Service Plan, United HealthCare, and the Health Flexible
Spending Account (Health FSA). This notice contains important information about your right to COBRA continuation
coverage, which is a temporary extension of group health coverage under a plan under certain circumstances when
coverage would otherwise end due to a qualifying event. This notice generally explains COBRA coverage, when it
may become available to you and your family, and what you need to do to protect the right to receive it. COBRA
(and the description of COBRA coverage contained in this notice) applies only to the group health plans listed above
(medical, dental, vision, and the Health FSA) and not to any other benefits offered by the City of Seattle (such as life
insurance, long term disability, or accidental death and dismemberment insurance). Should an actual qualifying
event occur in the future, the City of Seattle will send you additional information and an election notice at
that time.
The right to COBRA coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of
1985 (COBRA). COBRA coverage can become available to you when you would otherwise lose your group health
coverage under a plan. It can also become available to your spouse/domestic partner and dependent children, if
they are covered under a plan, when they would otherwise lose their group health coverage under the plan. This
notice does not fully describe COBRA coverage or other rights under a plan. For additional information about your
rights and obligations under a plan and under federal law, you should review the plan booklet or contact the City of
Seattle Personnel Department Benefits Unit, which is the COBRA Plan Administrator. A plan provides no greater
COBRA rights than what COBRA requires – nothing in this notice is intended to expand your rights beyond COBRA's
requirements.
What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of plan coverage when coverage would otherwise end because of a
life event known as a "qualifying event." Specific qualifying events are listed in this notice. After a qualifying event
occurs and any required notice of that event is properly provided to your department's Benefits Representative,
COBRA coverage must be offered to each person losing plan coverage who is a "qualified beneficiary." You, your
spouse/domestic partner, and your dependent children could become qualified beneficiaries and would be entitled to
elect COBRA if coverage under a plan is lost because of the qualifying event. Under a plan, qualified beneficiaries
who elect COBRA coverage must pay for COBRA coverage.
Who is entitled to elect COBRA Continuation Coverage?
If you are an employee, you will be entitled to elect COBRA coverage if you lose your group health coverage under a
plan because either one of the following qualifying events happens:
 your hours of employment are reduced, or  your employment ends for any reason. If you are the spouse/domestic partner, you will be entitled to elect COBRA coverage if you lose your group health coverage under a plan because any of the following qualifying events happens:  your spouse/domestic partner dies;  your spouse's/domestic partner's hours of employment are reduced;  your spouse's/domestic partner's employment ends for any reason other than his or her gross misconduct; or  you become divorced or legally separated from your spouse, or you terminate your domestic partnership. Also, if your spouse (the employee) reduces or eliminates your group health coverage in anticipation of a divorce or legal separation, and a divorce or legal separation occurs within three months of the reduction or elimination of coverage, then the divorce or legal separation will be considered a qualifying event for you even though your coverage was reduced or eliminated before the divorce or legal separation. A person enrolled as the employee's dependent child wil be entitled to elect COBRA if he or she loses group health coverage under a plan because any of the following qualifying events happen:  The parent-employee dies;  The parent-employee's hours of employment are reduced;  The parent-employee's employment ends for any reason other than his or her gross misconduct;  The child stops being eligible for coverage under a plan as a "dependent child."
When is COBRA Continuation Coverage Available?
When the qualifying event is the end of employment, reduction of hours of employment, or death of the employee, a
COBRA election notice will be made available to qualified beneficiaries. You do not need to notify the Benefits
Representative in your department of the occurrence of any of these three qualifying events. However, notice must
be provided to your department's Benefits Representative for other qualifying events, as explained below in the
section entitled "You Must Give Notice of Some Qualifying Events."
You Must Give Notice of Some Qualifying Events
For the other qualifying events (divorce or legal separation of the employee and spouse, termination of domestic
partnership, or a dependent child's loss of eligibility for coverage as a dependent child), a COBRA election notice will
be available to you only if you complete and submit a Health Care Benefits Change Form to the Benefits
Representative for your department within 60 days after the date on which the qualified beneficiary loses or would
lose coverage under the terms of the plan as a result of the qualifying event. If this procedure is not followed during
the 60-day notice period, YOU WILL LOSE YOUR RIGHT TO ELECT COBRA COVERAGE. (A Health Care
Benefits Change Form is available from your department's Benefits Representative.)
Electing COBRA Coverage
Each qualified beneficiary will have an independent right to elect COBRA coverage. Covered employees and
spouses/domestic partners (if the spouse/domestic partner is a qualified beneficiary) may elect COBRA coverage on
behalf of all of the qualified beneficiaries and parents may elect COBRA coverage on behalf of their children. Any
qualified beneficiary for whom COBRA coverage is not elected within the 60-day election period specified in the
COBRA election notice WILL LOSE HIS OR HER RIGHT TO ELECT COBRA COVERAGE.
Qualified beneficiaries who are entitled to elect COBRA may do so even if they have other group health plan
coverage or are entitled to Medicare benefits on or before the date on which COBRA is elected. However, a
qualified beneficiary's COBRA coverage wil terminate automatical y if, after electing COBRA, he or she becomes
entitled to Medicare benefits or becomes covered under other group health plan coverage (but only after any
applicable preexisting condition exclusions of that other plan have been exhausted or satisfied.
How Long Does COBRA Coverage Last?
COBRA coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee,
the covered employee's divorce, legal separation or termination of domestic partnership; or a dependent child's
losing eligibility as a dependent child, COBRA coverage can last for up to a total of 36 months. However, COBRA
coverage under the Health FSA component can last only until the end of the year in which the qualifying event
occurred. (See the paragraph below entitled "Health FSA Component.")
When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the
employee became entitled to Medicare benefits less than 18 months BEFORE the qualifying event, COBRA
coverage for qualified beneficiaries (other than the employee) who lose coverage as a result of the qualifying event
can last up to 36 months after the date of Medicare entitlement. For example, if a covered employee becomes
entitled to Medicare 8 months before the date on which his employment terminates, COBRA coverage for his
spouse/domestic partner and children who lost coverage as a result of his termination can last up to 36 months after
the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus
8 months). However, COBRA coverage under the Health FSA component can last only until the end of the year in
which the qualifying event occurred. (See the paragraph below entitled "Health FSA Component.")
Otherwise, when the qualifying event is the end of employment or reduction of the employee's hours of employment,
COBRA coverage generally can last for only up to a total of 18 months. However, COBRA coverage under the
Health FSA component can last only until the end of the year in which the qualifying event occurred. (See the
paragraph below entitled "Health FSA Component."

Extension of Maximum Coverage Period
If the qualifying event that resulted in your COBRA election was the covered employee's termination of employment
or reduction of hours, an extension of the maximum period of coverage may be available if a qualified beneficiary is
disabled or a second qualifying event occurs. You must notify the COBRA Plan Administrator of a disability or a
second qualifying event in order to extend the period of COBRA coverage. Failure to provide notice of a disability or
second qualifying event will eliminate the right to extend the period of COBRA coverage. (The period of COBRA
coverage under the Health FSA cannot be extended under any circumstances.)
Disability extension of 18-month period of continuation coverage
If a qualified beneficiary is determined by the Social Security Administration to be disabled and you notify the
COBRA Plan Administrator in a timely fashion, all of the qualified beneficiaries in your family may be entitled
to receive up to an additional 11 months of COBRA coverage, for a total maximum of 29 months. This
extension is available only for qualified beneficiaries who are receiving COBRA coverage because of a
qualifying event that was the covered employee's termination of employment or reduction of hours. The
disability must have started at some time before the 61st day after the covered employee's termination of
employment or reduction of hours and must last at least until the end of the period of COBRA coverage that
would be available without the disability extension (generally 18 months, as described above.)
The disability extension is available only if you complete and submit a Notice of Disability and a copy of the
Social Security Administration's determination of disability to the COBRA Plan Administrator: (a) during the
18 months after the covered employee's termination of employment or reduction of hours, and (b) within 60
days after the latest of:
 the date of the Social Security Administration's disability determination;  the date on which the qualified beneficiary loses (or would lose) coverage under the terms of a plan as a result of the covered employee's termination of employment or reduction of hours. If these procedures are not followed or if the notice is not provided to the COBRA Plan Administrator during
the 60-day notice period and within 18 months after the covered employee's termination of employment or
reduction of hours, THEN THERE WILL BE NO DISABILITY EXTENSION OF COBRA COVERAGE. You
can obtain a copy of a Notice of Disability from the COBRA Plan Administrator.
Second qualifying event extension of COBRA coverage
If your family experiences another qualifying event while receiving COBRA coverage because of the covered
employee's termination of employment or reduction of hours (including COBRA coverage during a disability
extension period as described above), the spouse/domestic partner and dependent children receiving
COBRA coverage can get up to 18 additional months of COBRA coverage, for a maximum of 36 months, if
notice of the second qualifying event is properly given to the COBRA Plan Administrator. This extension may
be available to the spouse/domestic partner and any dependent children receiving COBRA coverage if the
employee or former employee dies; gets divorced or legally separated, or terminates a domestic partnership;
or if the dependent child stops being eligible under a plan as a dependent child, but only if the event would
have caused the spouse/domestic partner or dependent child to lose coverage under a plan had the first
qualifying event not occurred. (This extension is not available to the spouse/domestic partner and any
dependent children under a plan when a covered employee becomes entitled to Medicare after electing
COBRA coverage .)
This extension due to a second qualifying event is available only if you notify the COBRA Plan Administrator
by completing and submitting a Notice of Second Qualifying Event within 60 days after the date of the second
qualifying event. You can obtain a copy of a Notice of Second Qualifying Event from the COBRA Plan
Administrator. If these procedures are not followed or if the notice is not provided in writing to the COBRA
Plan Administrator during the 60-day notice period, THEN THERE WILL BE NO EXTENSION OF COBRA
COVERAGE DUE TO A SECOND QUALIFYING EVENT.

Health Care FSA Component
COBRA coverage under the Health Care FSA will be offered to qualified beneficiaries. Health Care FSA COBRA
coverage will consist of the Health Care FSA COBRA coverage that will be charged for the remainder of the plan
year. Health Care FSA COBRA coverage will consist of the Health FSA coverage in force at the time of the
qualifying event (i.e., the elected annual limit reduced by expenses reimbursed up to the time of the qualifying event).
The use-it-or-lose-it rule will continue to apply, so any unused amounts will be forfeited at the end of the plan year,
and Health Care FSA COBRA coverage will terminate at the end of the plan year.
More Information About Individuals Who May Be Qualified Beneficiaries
 Children born to or placed for adoption with the covered employee during COBRA coverage period
A child born to, adopted by, or placed for adoption with a covered employee during a period of COBRA coverage is
considered to be a qualified beneficiary provided that, if the covered employee is a qualified beneficiary, the covered
employee has elected COBRA coverage for himself or herself. The child's COBRA coverage begins when the child
is enrolled in a plan, whether through special enrollment or open enrollment, and it lasts for as long as COBRA
coverage lasts for other family members of the employee. To be enrolled in a plan, the child must satisfy the
otherwise applicable plan eligibility requirements (for example, regarding age).
 Alternate recipients under QMCSOs
A child of the covered employee who is receiving benefits under a plan pursuant to a qualified medical child support
order (QMSCO) received by the COBRA Plan Administrator during the covered employee's period of employment
with the City of Seattle is entitled to the same rights to elect COBRA as an eligible dependent child of the covered
employee.
Keep Your Plan Informed of Address Changes
In order to protect your family's rights, you should keep your department's Benefits Representative informed of any
changes in the addresses of family members. You should also keep a copy, for your records, of any notices you
send to your department's Benefits Representative or COBRA Plan Administrator.
If You Have Questions
Questions concerning your Plan or COBRA coverage should be addressed to the:
COBRA Plan Administrator
City of Seattle Personnel Department
Benefits Unit
700 5th Ave., Suite 5500
PO Box 34028
Seattle, WA 98124-4028 Phone: 206-684-7928

Source: http://www.ci.seattle.wa.us/personnel/benefits/pubs/tempempbenguide.pdf