WHAT IS A PRETAX BENEFIT PLAN?

IRS Code Section 125 plan permits employees to elect benefits from a broad selection of choices according to their individual needs and the needs of their families on a pretax basis. The County’s Section 125 Benefit Plan includes:

• Health insurance (including self-funded pharmacy and Health Reimbursement Account)
• Dental insurance
• Vision insurance
• Flexible Spending Accounts 
• Medical Expense Account (maximum annual deferral reduced to $2,500 for 2013)
• Dependent Day Care Account (maximum annual deferral $5,000 for 2013)

IRREVOCABLE ELECTION

Once you enroll in a pretax benefit plan your election is irrevocable until the next annual open enrollment unless you experience a relevant Qualifying Event.  See Relevant Qualifying Events/Change in Status on page 17.

HOW DO I BENEFIT FROM A PRE-TAX PLAN?

Payroll taxes are reduced when premiums and/or FSA contributions are deducted on a pre-tax basis. In addition, any employer subsidy is not taxable income to you under most circumstances. Under current tax law, the portion of the premiums and the County subsidy that applies to coverage for the following dependents cannot be deducted on a pretax basis and becomes imputed income to you:

 • Domestic Partner
 • Domestic Partner children to age 30
 • Non-Domestic Partner children age 26-30 (Over Age Dependents)

COVERAGE EFFECTIVE DATES FOR PRETAX BENEFIT PLANS

COVERAGE END DATES FOR PRETAX BENEFIT PLANS

PRIOR AUTHORIZATION

Certain medical tests and procedures require Prior Authorization by the insurer’s Medical Management Department prior to receiving the service.  Your physician will submit the request and medical necessity to the carrier for Prior Authorization when it is required; however, it is recommended that the member verify the Prior Authorization is in place before receiving the service as benefits that may have otherwise been covered will be denied. The following treatment or services are examples of some services that must be preauthorized:

1. Hospital confinements and Skilled Nursing Facility confinements
2. Nonemergency transportation; air ambulance
3. All nonemergency outpatient hospital services, including but not limited to, surgical, laboratory and diagnostic, except mammograms;
4. Nonemergency wound care procedures
5. Inpatient rehabilitative services
6. Outpatient rehabilitative services at a hospital
7. Durable Medical Equipment;
8. Prosthetics, Braces, Hospice
9. Pain Management
10. CPAP machine (see Sleep Studies benefit).

For a current list of all services requiring Prior Authorization visit the health carrier’s website or contact Customer Service at the number printed on the back of your health ID card.

EXCLUSIONS AND LIMITATIONS

All health plans have specific Exclusions and Limitations. It is recommended that prior to enrollment you review the list of Exclusions and Limitations for the plan you are choosing. Services that are excluded from coverage will not be covered even if there is medical necessity for the service.

SURVIVOR BENEFITS

All of the health insurance plans offer a 12-month survivor benefit for dependents enrolled in a County health plan. Under this benefit, dependents who are not eligible for Medicare continue to be covered, at no charge, under the same insurance plan they were enrolled in at the time of the employee’s death for a period up to 12 months. During this 12-month period, a dependent must continue to meet eligibility requirements per the conditions set forth for this benefit. This 12-month Survivor Benefit is counted towards the period of COBRA or Domestic Partner Continuation Coverage for which the Survivor and/or dependents would be eligible.

If a plan is no longer offered, or if the survivor changes plans during open enrollment or due to a qualifying event, the survivor benefit will end and coverage may be continued under another plan at the full COBRA rate in effect at that time.