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Employee Benefits

Open Enrollment 2015

Benefit - Forms, Brochures, Guides, and Websites

Accidental Death & Dismemberment Insurance

Placer County provides employees with $10,000 Accidental Death and Dismemberment (AD&D) insurance at no cost. Additional coverage is available for the employee and spouse or registered domestic partner, up to age 70, for an additional premium.

Accidental Death and Dismemberment Form

Accidental Death and Dismemberment Insurance Plan Brochure

Beneficiary Update

Cafeteria Plans

PPEO

Placer County PPEO represented employees receive the following for use in a cafeteria plan:

  • CalPERS Miscellaneous Members

Bi-weekly contribution of 6% of the employee’s base salary plus any longevity

  • CalPERS Safety Members

Bi-weekly contribution of 5% of the employee’s base salary plus any longevity

PPEO participants may elect to receive the cafeteria plan amount as cash, a 401(k) contribution, dependent care reimbursement, or any combination of the three options.

Management

Placer County Management employees receive $2,100 per year for use in a cafeteria plan. Participants may elect to receive the cafeteria plan amount as cash, a 401(k) contribution, dependent care reimbursement, medical co-insurance, or any combination of the four options.

Confidential

Placer County Confidential employees receive $2,798.12 per year for use in a cafeteria plan. Participants may elect to receive the cafeteria plan amount as cash, a 401(k) contribution, dependent care reimbursement, medical co-insurance, or any combination of the four options.

CalPERS Health Forms and Guides

CalPERS Long Term Health Care

CalPERS Service Credit

Deferred Compensation

Placer County offers two voluntary deferred compensation programs under IRS Code 457 and 401(k) through MassMutual and CalPERS/VOYA. These plans allow you to set aside additional money for retirement on a pre-tax basis with a minimum contribution of $10 per pay period.

CalPERS/VOYA https://calpers.voyaplans.com
Richard Berg richard.berg@voya.com

MassMutualwww.massmutual.com/serve
Jason Hughes jasonhughes@massmutual.com

                         Forms

CalPERS 401k and 457 Plan Comparison Sheet
MassMutual 457 and 401k Comparison Sheet

CalPERS Forms

Enrollment/Changes

CalPERS 401(k) Account Transfer - Contact Personnel
CalPERS 401(k) Contribution Change Form
CalPERS 401k Enrollment Form
CalPERS 457 Account Transfer - Contact Personnel
CalPERS 457 Contribution Change Form
CalPERS 457 New Enrollment

Beneficiary changes
CalPERS 401(k) Beneficiary Designation
CalPERS 457 Beneficiary Designation

Hardships/Withdrawals
CalPERS 401(k) Loan Application/Spousal Consent
CalPERS 401(k) Loan Justification Form – No Spousal Consent
CalPERS 401(k) Distribution - Contact Personnel
CalPERS 457 Emergency Withdrawal Request - Contact Personnel
CalPERS 457 In-Service Withdrawal Request - Contact Personnel
CalPERS Hardship Distribution Request - Contact Personnel

MassMutual Forms

Enrollment/Changes
MassMutual 401(k) Contribution Change Form
MassMutual 401k New Enrollment with Beneficiary Form
MassMutual 401(k) Installment Payment Change Request Form - Contact Personnel
MassMutual 401(k) Death Benefit Request - Contact Personnel
MassMutual 401(k) and 457 Spousal Consent Form
MassMutual 457 Contribution Change Form
MassMutual 457 New Enrollment with Beneficiary Form
MassMutual 457 Pre-Retirement Catch-Up Form - Contact Personnel
MassMutual Rollover Submission Form - Contact Personnel

Beneficiary changes
MassMutual 401(k) Beneficiary Form
MassMutual 457 Beneficiary Form
MassMutual 401k and 457 Spousal Consent Form

Hardships/Withdrawals
MassMutual 401(k) Loan - Contact Personnel
MassMutual Benefit payment request - Contact Personnel
MassMutual In Service Withdrawal Request - Contact Personnel
MassMutual Installment Payment Request - Contact Personnel
MassMutual Withdrawal Form - Contact Personnel

 : Websites

CalPERS Deferred Compensation website -Then select: CalPERS Investments (457 only)

MassMutual - Deferred Compensation website

Placer County Deferred Compensation Committee website

Dental Insurance

Dental benefits are provided by Delta Dental. Coverage is provided to employees at no cost and dependents can be added at the employee’s expense. Major treatments are excluded in the first year of coverage. Added dependents must be treatment-free ninety days prior to coverage. Visit the Delta Dental website at www.deltadentalins.com for provider information.

Delta Dental
User ID/Password required

Dental Evidence Of Coverage

DSA Dental Plan

Management and Confidential Dental Plan

PPEO Dental Plan

Employee Assistance Program

Managed Health Network (MHN) is the administrator of the Placer County Employee Assistance Program. Offered to Placer County employees as well as their eligible dependents, MHN provides a variety of confidential services to navigate life’s more challenging moments. Help is available for relationship issues, workplace problems, stress, anxiety and sadness. Counseling services can be found for grief, loss, or responses to traumatic events, and concerns about use of alcohol or drugs. Financial and legal service providers can be located, as can referrals for childcare or eldercare assistance. Identity theft recovery services are available through consumer debt counselors and there are a number of health and wellness tools to help you take charge of your well-being.

Phone 24 hrs/7 days: 800-242-6220 or www.members.mhn.com Registration Code: placercounty

Your Employee Assistance Program

Employee Assistance Program - Benefit Summary

Financial Services

Legal Services

Members Website Information Sheet

FSA (Flex Spending Accounts) - WageWorks Dependent Care Forms Medical Reimbursement and Tahoe Rural Health Subsidy

The Dependent Care Flexible Spending Account is a plan to pay for eligible child or elder day care expenses. This plan does not cover any health-related expenses. As little as $5 a pay period may be set aside for use with this pre-tax fund and there is an annual $5000 maximum ($2,500 if married and filing separately). Employees are reimbursed for actual expenses only, and any unused funds are forfeit per IRS rules. The FSA is administered by WageWorks. For plan information visit www.wageworks.com.

Tahoe HRA Form

Health Insurance

Placer County provides group health insurance through HMOs (Health Maintenance Organizations) and PPOs (Preferred Provider Organizations).

HMOs generally pay 100% of the cost of care after a co-payment, but require you to use in-network providers and have your care coordinated through a designated Primary Care Physician.

Anthem (Select & Traditional) (855) 839-4524 www.anthem.com/ca/calpers/HMO

Blue Shield (NetValue & Access+) (800) 334-5847 www.blueshieldca.com/calpers

Kaiser (800) 464-4000 www.kp.org/calpers

United Health Care (877) 359-3714 www.uhc.com/calpers

PPOs generally pay a percentage of the cost of care after co-pay and deductible requirements are met. The services of in-network providers are paid at a higher percentage than out-of-network providers.

PERS Choice (877) 737-7776 www.anthem.com/ca/calpers

PERS Select

PERSCare & PERSCare DSA

PORAC (DSA/Safety Mgmt Only) (800) 937-6722 www.porac.org

In Lieu of Health(ILH Plan

If you have other health insurance coverage, you may waive the Placer County health insurance and take advantage of an employer contribution to a 401(k) savings plan.

Long Term disability (LTD) Insurance

LTD insurance provides income of 60% of your monthly earnings, up to $6,500 per month, after you have been unable to work for one year due to illness or injury. The policy may continue to pay up to age 65 as long as you are disabled. Coverage begins automatically when employees working at least 20 hours per week reach 10,400 hours of active service (five years). Employees, at hire and working a minimum of 25 hours per week, may purchase LTD Insurance until they reach the required five years of service. Premiums are based upon earnings and age. Lincoln Financial Group is the plan provider www.lfg.com.

Supplemental Life Insurance

Placer County provides, at no cost, a life insurance policy in the amount of $10,000 for PPEO and DSA employees, and a policy in the amount of $50,000 to those employees who are Management and Confidential. Additional coverage in amounts up to $100,000 is available for purchase by employees. Coverage of up to $50,000 may be purchased for a spouse or registered domestic partner and in amounts up to $10,000 for unmarried dependent children less than 23 years.

ING ReliaStar Life Beneficiary Designation

ING ReliaStar Life Change Form

ING ReliaStar Life Insurance Application

Vision

Vision benefits are provided by Vision Service Plan (VSP). Coverage is provided to employees at no cost and dependents can be added at the employee’s expense. If requesting dependent coverage, all eligible dependents must be enrolled, and must remain on the plan for one year. Dropped dependents must remain off the plan for one year. Visit the VSP website at www.vsp.com for provider information.

Vision Out of Network Reimbursement Form

VSP Evidence of Coverage and Disclosure Form

VSP Summary Brochure

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