Cafeteria 125 Plan Enrollment and Changes
Cafeteria 125 Plan Enrollment and Changes
Monthly Premiums:
Prior Year Monthly Premium - Current Rates 2016-2017 (Effective 10-1-2016 through 09-30-2017) Your Your Your Board Board Board Cost After Cost After Cost After Paid Paid Paid Option 1 Option 2 Option 3
Employee Only Employee/Child(ren) Employee/Spouse Employee/Spouse/Child(ren)
Premium Amount Board Paid Premium Amount Board Paid Premium Amount Board Paid 111 616 505 567 505 62 505 470 35 466 1,071 605 983 605 378 878 605 273 486 1,091 605 1,003 605 398 896 605 291 839 1,544 705 1,418 705 713 1,268 705 563
Monthly Premiums:
Monthly Premium - Renewal Rates 2017-2018 (Effective 10-1-2017 through 09-30-2018) Your Your Your Your Board Board Board Cost After Cost After Cost After Cost After Paid Paid Paid Option 1 Option 2 Option 3 Option 4 Board Paid
Employee Only Employee/Child(ren) Employee/Spouse Employee/Spouse/Child(ren)
Premium Amount Board Paid Premium Amount Board Paid Premium Amount Board Paid Premium 88 653 565 633 565 68 576 565 11 494 472 1,137 665 1,102 665 437 1,006 665 341 869 495 1,160 665 1,126 665 461 1,027 665 362 881 878 1,643 765 1,592 765 827 1,456 765 691 1,258
Amount *494 665 665 765
Board Paid 204 216 493
*$ 71bo ard paid to ward HSA if enro lled
The maximum benefit payment for all covered dental procedures or each Eligible Person in any one contract year is: $1,500. Coverage for diagnostic preventative services is not subject to any deductible amount. For all other covered benefits, the contract year deductible is: $50 x 3. Dependents are covered to age 19 or to age 24 if a full-time student. Employee Employee/Spouse
$33.33 (prior year $32.36) $76.61 (prior year $74.38)
Employee/Child(ren) $79.81 (prior year $77.49) Family $119.87 (prior year $116.38)
Children are covered until age 19 and full-time students are covered until age 26. The Coverage provided by a VSP doctor can be found on the Vision Benefit Summary Form online. This monthly rate is the same for the past two years. Employee Employee/Spouse
$11.99 $21.93
Employee/Child(ren) Family
$20.93 $31.72
Your benefits package is an important part of your employment with USD 250 Pittsburg. If have questions or need additional information please call Julie Menghini or Lita Biggs and we will gladly assist you in finding the answers. Revised 08/01/2017
Monthly Premiums:
Prior Year Monthly Premium - Current Rates 2016-2017 (Effective 10-1-2016 through 09-30-2017) Your Your Your Board Board Board Cost After Cost After Cost After Paid Paid Paid Option 1 Option 2 Option 3
Employee Only Employee/Child(ren) Employee/Spouse Employee/Spouse/Child(ren)
Premium Amount Board Paid Premium Amount Board Paid Premium Amount Board Paid 111 616 505 567 505 62 505 470 35 466 1,071 605 983 605 378 878 605 273 486 1,091 605 1,003 605 398 896 605 291 839 1,544 705 1,418 705 713 1,268 705 563
Monthly Premiums:
Monthly Premium - Renewal Rates 2017-2018 (Effective 10-1-2017 through 09-30-2018) Your Your Your Your Board Board Board Cost After Cost After Cost After Cost After Paid Paid Paid Option 1 Option 2 Option 3 Option 4 Board Paid
Employee Only Employee/Child(ren) Employee/Spouse Employee/Spouse/Child(ren)
Premium Amount Board Paid Premium Amount Board Paid Premium Amount Board Paid Premium 88 653 565 633 565 68 576 565 11 494 472 1,137 665 1,102 665 437 1,006 665 341 869 495 1,160 665 1,126 665 461 1,027 665 362 881 878 1,643 765 1,592 765 827 1,456 765 691 1,258
Amount *494 665 665 765
Board Paid 204 216 493
*$ 71bo ard paid to ward HSA if enro lled
The maximum benefit payment for all covered dental procedures or each Eligible Person in any one contract year is: $1,500. Coverage for diagnostic preventative services is not subject to any deductible amount. For all other covered benefits, the contract year deductible is: $50 x 3. Dependents are covered to age 19 or to age 24 if a full-time student. Employee Employee/Spouse
$33.33 (prior year $32.36) $76.61 (prior year $74.38)
Employee/Child(ren) $79.81 (prior year $77.49) Family $119.87 (prior year $116.38)
Children are covered until age 19 and full-time students are covered until age 26. The Coverage provided by a VSP doctor can be found on the Vision Benefit Summary Form online. This monthly rate is the same for the past two years. Employee Employee/Spouse
$11.99 $21.93
Employee/Child(ren) Family
$20.93 $31.72
Your benefits package is an important part of your employment with USD 250 Pittsburg. If have questions or need additional information please call Julie Menghini or Lita Biggs and we will gladly assist you in finding the answers. Revised 08/01/2017
