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Health Insurance Information New employees, who are full-time, will have the opportunity of enrolling in insurance after the New Teacher Orientation on August 3, 2015. YOU MUST SIGN UP WITHIN 30 DAYS OF EMPLOYMENT
TO BE CONSIDERED A NEW ENROLLMENT. If you will be adding dependents, you will need to bring the following documents: Birth certificates to add children Marriage license to add spouse
Coverage becomes effective on the 1st day of the month following a minimum 30 day waiting period. (Example: If hired August 3, insurance is effective October 1.)
Health Insurance Information
(Offered through OGB)
Medical Benefits Comparison Sheet Official Schedule of Rates Enrollment Instructions Life Insurance Information Life Insurance Schedule Enrollment/Change Form OGB Requirements for Vesting at Retirement
If you have questions regarding Life Insurance, please contact Amanda Glascock at [email protected] or (225) 686-4230.
First Financial Benefits Information Representatives from First Financial Group of America will also be available if you want to enroll in the following plans: Annuity Critical Illness Insurance Dental Insurance Disability Income Protection (short and long term) Flexible Spending Accounts Heart/Stroke Insurance Life Insurance Long Term Care Vision Insurance Medical Reimbursement Dependent/Child Care Reimbursement
If you have questions regarding First Financial’s Benefits, please contact them at (866) 541-5096.
1 2
Active Employee Benefits Comparison: Pelican HRA1000, Pelican HSA775,
Magnolia Local, Magnolia Local Plus,Magnolia Open Access, Vantage Medical Home
Blue Cross Blue Shield benefits effective March 1, 2015 - December 31, 2015
Vantage Medical Home benefits effective January 1, 2015 - December 31, 2015
Pelican HRA 1000 Pelican HSA775 Magnolia Local
NetworkBlue Cross Blue Shield of Louisiana
Preferred Care Providers & BCBS National Providers
Blue Cross Blue Shield of Louisiana Preferred Care Providers & BCBS
National Providers
Blue Cross Blue Shield of Louisiana Community
Blue & Blue Connect
Eligible OGB Members Active Employees Active Employees Active Employees
Network Non-Network Network Non-
Network Network Non-Network
You Pay You Pay You Pay
Deductible
You $2,000 $4,000 $2,000 $4,000 $400 No Coverage
You + 1 (Spouse or child) $4,000 $8,000 $4,000 $8,000 $800 No Coverage
You + Children $4,000 $8,000 $4,000 $8,000 $1,200 No Coverage
You + Family $4,000 $8,000 $4,000 $8,000 $1,200 No Coverage
HRA dollars will reduce this amount HSA dollars will reduce this amount
Out of Pocket Maximum
You $5,000 $10,000 $5,000 $10,000 $2,500 No Coverage
$10,000 $20,000 $10,000 $20,000 $5,000 No Coverage
You + Children $10,000 $20,000 $10,000 $20,000 $7,500 No Coverage
You + Family $10,000 $20,000 $10,000 $20,000 $7,500 No Coverage
State Funding The Plan Pays The Plan Pays The Plan Pays
You $1,000 $775*
Not Available
$2,000 $775*
You + Children $2,000 $775*
You + Family $2,000 $775*
Funding not applicable to Pharmacy Expenses.
$200, plus up to $575 more dollar for dollar match of employee contributions*
Physicians’ Services The Plan Pays The Plan Pays The Plan Pays
Primary Care Physician or Specialist Office
Treatment of illness or injury
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage;subject todeductible
100% coverage after a $25 PCP
or $50 SPC co-payment
per visit
No Coverage
Active Employee Benefits Comparison: Pelican HRA1000, Pelican HSA775,
Magnolia Local, Magnolia Local Plus,Magnolia Open Access, Vantage Medical Home
Blue Cross Blue Shield benefits effective March 1, 2015 - December 31, 2015
Vantage Medical Home benefits effective January 1, 2015 - December 31, 2015
Magnolia Local Plus Magnolia Open Access Vantage Medical Home
Blue Cross Blue Shield of Louisiana Preferred Care Providers & BCBS National Providers
Blue Cross Blue Shield of Louisiana Preferred Care Provider & BCBS National Providers
Statewide HMO plan offered in all regions of Louisiana
Active Employees Active Employees Active Employees
Network Non-Network Network Non-Network Network Non-Network
You Pay You Pay You Pay
Deductible
$400 No Coverage $900 $500 $1,500
$800 No Coverage $1,800 $1,500 $3,000
$1,200 No Coverage $2,700 $1,500 $3,000
$1,200 No Coverage $2,700 $1,500 $3,000
Out of Pocket Maximum
$2,500 No Coverage $2,500 $3,700 $3,000 Unlimited
$5,000 No Coverage $5,000 $7,500 $9,000 Unlimited
$7,500 No Coverage $7,500 $11,250 $9,000 Unlimited
$7,500 No Coverage $7,500 $11,250 $9,000 Unlimited
The Plan Pays The Plan Pays The Plan Pays
Not Available Not Available Not Available
The Plan Pays The Plan Pays The Plan Pays
100% coverage after a $25 PCP or $50 SPC co-payment per visit
No Coverage90% coverage;
subject to deductible 70% coverage; subject
to deductible
100% coverage after a $0*/$10 PCP or $35*/$45 SPC co-payment per visit
50% coverage; subject to deductible
You + 1 (Spouse or child)
You + 1 (Spouse or child)
$900
$1,800
$2,700
$2,700
3 4
Active Employee Benefits Comparison: Pelican HRA1000, Pelican HSA775,
Magnolia Local, Magnolia Local Plus,Magnolia Open Access, Vantage Medical Home
Blue Cross Blue Shield benefits effective March 1, 2015 - December 31, 2015
Vantage Medical Home benefits effective January 1, 2015 - December 31, 2015
Pelican HRA 1000 Pelican HSA775 Magnolia Local
Network Non-Network Network Non-Network Network Non-Network
Physicians’ Services The Plan Pays The Plan Pays The Plan Pays
Maternity Care
(prenatal, deliver and postpartum)
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage after a $90 co-payment per pregnancy
No Coverage
Physician Services Furnished in a Hospital
Visits; surgery in general, including charges by surgeon, anesthesiologist, pathologist and radiologist.
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; subject to deductible
No Coverage
Preventative Care Primary Care Physician or Specialist Office or Clinic
For a complete list of benefits, refer to the Preventive and Wellness/Routine Care in the Benefit Plan
100% coverage; not subject to
deductible
100% of fee schedule
amount. Plan participant
pays the difference
between the billed amount
and the fee schedule amount
100% coverage; not subject to
deductible
100% of fee schedule
amount. Plan participant
pays the difference
between the billed amount
and the fee schedule amount
100% coverage; not subject to
deductibleNo Coverage
Physician Services for Emergency Room Care
80% coverage; subject to deductible
80% coverage; subject to deductible
80% coverage; subject to deductible
80% coverage; subject to deductible
100% coverage; subject to deductible
100% coverage; subject to deductible
Allergy Shots and Serum
Co-payment per visit is applicable only to office visit
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage after a $25
PCP or $50 SPC per office visit co-payment
per visit; shots and serum 100% after deductible
No Coverage
Outpatient Surgery/Services
When billed as office visits
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; after a $25
PCP or $50 SPC per office visit co-payment
per visit
No Coverage
Outpatient Surgery/Services
When billed as outpatient surgery at a facility
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; subject to deductible
No Coverage
Hospital Services The Plan Pays The Plan Pays The Plan Pays
Inpatient Services
Inpatient care, delivery and inpatient short-term acute rehabilitation services
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; after a $100 co-
payment per day max $300 per admission
No Coverage
Active Employee Benefits Comparison: Pelican HRA1000, Pelican HSA775,
Magnolia Local, Magnolia Local Plus,Magnolia Open Access, Vantage Medical Home
Blue Cross Blue Shield benefits effective March 1, 2015 - December 31, 2015
Vantage Medical Home benefits effective January 1, 2015 - December 31, 2015
Magnolia Local Plus Magnolia Open Access Vantage Medical Home
Network Non-Network Network Non-Network Network Non-Network
The Plan Pays The Plan Pays The Plan Pays
100% coverage; after a $90
co-payment per pregnancy
No Coverage90% coverage;
subject to deductible
70% coverage; subject to deductible
100% coverage after a $0*/$10 co-payment per
pregnancy
50% coverage; subject to deductible
100% coverage; subject to deductible
No Coverage90% coverage;
subject to deductible
70% coverage; subject to deductible
100% coverage; subject to deductible
50% coverage; subject to deductible
100% coverage; not subject to
deductibleNo Coverage
100% coverage; not subject to
deductible
70% coverage; subject to deductible
100% coverage; not subject to
deductible
50% coverage; subject to deductible
100% coverage; subject to deductible
100% coverage; subject to deductible
90% coverage; subject to deductible
90% coverage; subject to deductible
100% coverage; subject to deductible
50% coverage; subject to deductible
100% coverage after a $25 PCP or $50 SPC per office visit co-payment
per visit; shots and serum 100% after
deductible
No Coverage90% coverage;
subject to deductible
70% coverage; subject to deductible
80% coverage; subject to deductible
50% coverage; subject to deductible
100% coverage after a $25 PCP or $50 SPC
per office visit co-payment per visit
No Coverage90% coverage;
subject to deductible
70% coverage; subject to deductible
100% coverage; subject to deductible
50% coverage; subject to deductible
100% coverage; subject to deductible
No Coverage90% coverage;
subject to deductible
70% coverage; subject to deductible
100% coverage; subject to deductible
50% coverage; subject to deductible
The Plan Pays The Plan Pays The Plan Pays
100% coverage; after a $100
co-payment per day max $300 per
admission
No Coverage90% coverage;
subject to deductible
70% coverage; subject to
deductible + $50 co-payment per day
(days 1 - 5)
100% coverage after a $100*/$300 co-payment per day
max $300*/$900 per admission;
subject to deductible
50% coverage; subject to deductible
5 6
Active Employee Benefits Comparison: Pelican HRA1000, Pelican HSA775,
Magnolia Local, Magnolia Local Plus,Magnolia Open Access, Vantage Medical Home
Blue Cross Blue Shield benefits effective March 1, 2015 - December 31, 2015
Vantage Medical Home benefits effective January 1, 2015 - December 31, 2015
Pelican HRA 1000 Pelican HSA775 Magnolia Local
Network Non-Network Network Non-Network Network Non-Network
Hospital Services The Plan Pays The Plan Pays The Plan Pays
Outpatient Surgery/Services
Hospital / Facility
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; after a $100 facility co-
payment per visit
No Coverage
Emergency Room Care - Hospital
Treatment of an emergency medical condition or injury
80% coverage; subject to deductible
80% coverage; subject to deductible
80% coverage; subject to deductible
80% coverage; subject to deductible
100% coverage after $150 co-payment per
visit; waived if admitted
100% coverage after $150 co-payment per
visit; waived if admitted
Behavioral Health The Plan Pays The Plan Pays The Plan Pays
Mental Health and Substance Abuse Inpatient Facility
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; after a $100 co-
payment per day max $300 per admission
No Coverage
Mental Health and Substance Abuse Outpatient Visits - Professional
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; after a $25
co-payment per visit
No Coverage
Other Coverage The Plan Pays The Plan Pays The Plan Pays
Outpatient Acute Short-Term Rehabilitation ServicesPhysical Therapy, Speech Therapy, Occupational Therapy, Other short term rehabilitative services
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; after a $25
co-payment per visit
No Coverage
Chiropractic Care80% coverage;
subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; after a $25
co-payment per visit
No Coverage
Hearing AidNot covered for individuals age eighteen (18) and older
80% coverage; subject to deductible
No Coverage80% coverage;
subject to deductible
No Coverage80% coverage;
subject to deductible
No Coverage
Vision Exam (routine) No Coverage
Urgent Care Center80% coverage;
subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; after a $50
co-payment per visit
No Coverage
Home Health Care Services80% coverage;
subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; subject to deductible
No Coverage
Active Employee Benefits Comparison: Pelican HRA1000, Pelican HSA775,
Magnolia Local, Magnolia Local Plus,Magnolia Open Access, Vantage Medical Home
Blue Cross Blue Shield benefits effective March 1, 2015 - December 31, 2015
Vantage Medical Home benefits effective January 1, 2015 - December 31, 2015
Magnolia Local Plus Magnolia Open Access Vantage Medical Home
Network Non-Network Network Non-Network Network Non-Network
The Plan Pays The Plan Pays The Plan Pays
100% coverage; after a $100 facility
co-payment per visit
No Coverage90% coverage;
subject to deductible
70% coverage; subject to deductible
100% coverage after a $100*/$300
co-payment per visit; subject to
deductible
50% coverage; subject to deductible
100% coverage after $150 co-payment
per visit; waived if admitted
100% coverage after $150 co-payment
per visit; waived if admitted
$150 co-payment per visit; waived if admitted 100% coverage after a $200 co-payment per visit; subject to
deductible
100% coverage after a $200 co-payment per visit; subject to
deductible
90% coverage; subject to deductible
90% coverage; subject to deductible
The Plan Pays The Plan Pays The Plan Pays
100% coverage after $100 co-payment per day max $300
per admission
No Coverage90% coverage;
subject to deductible
70% coverage; subject to
deductible + $50 co-payment per day
(days 1-5)
100% coverage; after a $300
co-payment per day max $900 per admission; subject
to deductible
50% coverage; subject to deductible
100% coverage; after a $25 co-
payment per visitNo Coverage
90% coverage; subject to deductible
70% coverage; subject to deductible
100% coverage; after a $10 PCP or
$45 SPC per co-payment per visit
50% coverage; subject to deductible
The Plan Pays The Plan Pays The Plan Pays
100% coverage; after a $25 co-
payment per visitNo Coverage
90% coverage; subject to deductible
70% coverage; subject to deductible
80% coverage; subject to deductible
50% coverage; subject to deductible
100% coverage; after a $25 co-
payment per visitNo Coverage
90% coverage; subject to deductible
70% coverage; subject to deductible
100% coverage; after a $10 co-
payment per visit
50% coverage; subject to deductible
80% coverage; subject to deductible
No Coverage90% coverage;
subject to deductible
70% coverage; subject to deductible
80% coverage; subject to deductible
50% coverage; subject to deductible
No Coverage100% coverage; after a $45 co-
payment per visit
50% coverage; subject to deductible
100% coverage after a $50 co-payment
per visitNo Coverage
90% coverage; subject to deductible
70% coverage; subject to deductible
100% coverage after a $45 co-payment
per visit
50% coverage; subject to deductible
100% coverage subject to deductible
No Coverage90% coverage;
subject to deductible
70% coverage; subject to deductible
80% coverage; subject to deductible
50% coverage; subject to deductible
7 8
NOTE: Prior Authorizations and Visit Limits may apply to some benefits - refer to your Plan Document for details
This comparison chart is a summary of plan features and is presented for general information only. It is not a guarantee of coverage. For full details of the plan, refer to the official plan document. Benefits outlined in the Vantage Medical Home column were provided by Vantage Health Plan. OGB is not responsible for the accuracy of this information.1 Prescription drug benefit - 31 day fill; 2 Member who chooses brand-name drug for which approved generic version is available pays cost difference between brand-name drug & generic drug, plus co-pay for brand-name drug; cost difference does not apply to $1,500 out of pocket max; 3 Prescription drug benefit - 30 day fill
* Benefits available for Affinity Health Network Providers
Active Employee Benefits Comparison: Pelican HRA1000, Pelican HSA775,
Magnolia Local, Magnolia Local Plus,Magnolia Open Access, Vantage Medical Home
Blue Cross Blue Shield benefits effective March 1, 2015 - December 31, 2015
Vantage Medical Home benefits effective January 1, 2015 - December 31, 2015
Pelican HRA 1000 Pelican HSA775 Magnolia Local
Network Non-Network Network Non-Network Network Non-Network
Hospital Services The Plan Pays The Plan Pays The Plan Pays
Skilled Nursing Facility Services
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; after a $100 co-
payment per day max $300 per admission
No Coverage
Hospice Care80% coverage;
subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
100% coverage; subject to deductible
No Coverage
Durable Medical Equipment (DME) - Rental or Purchase
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage; subject to deductible
60% coverage; subject to deductible
80% coverage of the first
$5,000 allowable; 100%
in excess of $5,000 per plan year; subject to
deductible
No Coverage
Transplant Services80% coverage;
subject to deductible
No Coverage80% coverage;
subject to deductible
No Coverage100% coverage;
subject to deductible
No Coverage
Pharmacy You Pay You Pay You Pay
Tier 1 - Generic 50% up to $30 1 $10; subject to deductible 1 50% up to $30 1
Tier 2 - Preferred 50% up to $55 1,2 $25; subject to deductible 1 50% up to $55 1,2
Tier 3 - Non-Preferred 65% up to $80 1,2 $50; subject to deductible 1 65% up to $80 1,2
Tier 4 - Specialty 50% up to $80 1,2 $50; subject to deductible 1 50% up to $80 1,2
90 day supplies for maintenance drugs from mail order OR at participating 90-day retail network pharmacies
Two and a half times the cost of your applicable co-payment
Applicable co-payment; Maintenance drugs not subject
to deductible
Two and a half times the cost of your applicable co-payment
After the out-of-pocket amount of $1,500 is met:
Tier 1 - Generic $0 co-payment 1 – $0 co-payment 1
Tier 2 - Preferred $20 co-payment 1,2 – $20 co-payment 1,2
Tier 3 - Non-Preferred $40 co-payment 1,2 – $40 co-payment 1,2
Tier 4 - Specialty $40 co-payment 1,2 – $40 co-payment 1,2
Active Employee Benefits Comparison: Pelican HRA1000, Pelican HSA775,
Magnolia Local, Magnolia Local Plus,Magnolia Open Access, Vantage Medical Home
Blue Cross Blue Shield benefits effective March 1, 2015 - December 31, 2015
Vantage Medical Home benefits effective January 1, 2015 - December 31, 2015
Magnolia Local Plus Magnolia Open Access Vantage Medical Home
Network Non-Network Network Non-Network Network Non-Network
The Plan Pays The Plan Pays The Plan Pays
100% coverage; after $100 co-
payment per day max $300 per admission
No Coverage90% coverage;
subject to deductible70% coverage;
subject to deductible
100% coverage after a $50 co-payment
per day
50% coverage; subject to deductible
100% coverage; subject to deductible
No Coverage80% coverage;
subject to deductible70% coverage;
subject to deductible 80% coverage;
subject to deductible50% coverage;
subject to deductible
80% coverage of the first $5,000
allowable; 100% in excess of $5,000 per
plan year; subject to deductible
No Coverage90% coverage;
subject to deductible70% coverage;
subject to deductible 80% coverage;
subject to deductible50% coverage;
subject to deductible
100% coverage; subject to deductible
No Coverage90% coverage;
subject to deductible70% coverage;
subject to deductible80% coverage;
subject to deductibleNo Coverage
You Pay You Pay You Pay
50% up to $30 1 50% up to $30 1 Low Cost Generics - $3 co-payment 3 Non Preferred Generics - $10 co-payment 3
50% up to $55 1,2 50% up to $55 1,2 $45 co-payment 3
65% up to $80 1,2 65% up to $80 1,2 $95 co-payment 3
50% up to $80 1,2 50% up to $80 1,2 33% up to $150 3
Two and a half times the cost of your applicable co-payment
Two and a half times the cost of your applicable co-payment
30-day supply for 1 co-pay; 60-day supply for 2 co-pays; 90-day supply for 3 co-pays – All
tiers but Tier 5
After the out-of-pocket amount of $1,500 is met:
$0 co-payment 1 $0 co-payment 1 –
$20 co-payment 1,2 $20 co-payment 1,2 –
$40 co-payment 1,2 $40 co-payment 1,2 –
$40 co-payment 1,2 $40 co-payment 1,2 –
STATE OF LOUISIANA - OFFICE OF GROUP BENEFITS - ENROLLMENT/CHANGE FORMAGENCY NUMBER AGENCY NAME DATE OF HIRE ANNUAL SALARY EMPLOYEE NAME CHANGED TO
PURPOSE Waiver of Coverage Agency Transfer New Enrollment Reinstate Coverage Re-enrollment - Previous Employment Rehired Retiree
Annual Enrollment Add/Delete Dependent(s)_________________________ Reason for Addition/Deletion_____________________________________________
Surviving Spouse/Dependent Special Enrollment Late Applicant Retired ______________________________
Employment Terminated ______________________________ Deceased ______________________________
Cancel all coverage (health and life) ________________________________________ Other _________________________________________
PERSONAL INFORMATION (Please print or type)NAME (LAST, FIRST, MIDDLE INITIAL) SOCIAL SECURITY NUMBER DATE OF BIRTH
ADDRESS CITY STATE ZIP CODE
PHONE NUMBER
( )EMAIL ADDRESS SEX
M F
MARITAL STATUS
SINGLE MARRIED
DATE OF MARRIAGE DATE OF DIVORCE
HEALTH PLAN SELECTED (Write in health plan selection) No coverage Employee Only Employee + Children/Child Employee + Spouse FamilyLEVEL OF MEDICAL COVERAGE
NAME(LAST, FIRST, MIDDLE INITIAL)
RELATIONSHIP SEX BIRTH DATE(MM/DD/YYYY)
ADD/ DELETE
SOCIAL SECURITY NUMBER HEALTH DEP. LIFE
SPOUSE M
F
ADD
DELETE YES YES
DEPENDENT M
F
ADD
DELETE YES YES
DEPENDENT M
F
ADD
DELETE YES YES
DEPENDENT M
F
ADD
DELETE YES YES
DEPENDENT M
F
ADD
DELETE YES YES
C.O.B.R.A. Prior F/T Terminated Divorced Spouse Dependent
MEDICAREEMPLOYEE SPOUSE
No Coverage Hospital (Part A) Medical (Part B) Drugs (Part D)
No Coverage Hospital (Part A) Medical (Part B) Drugs (Part D)
A COPY OF MEDICARE CARD MUST BE ATTACHED
RETIREE 100 Employee Only Dependent Only Employee + 1 Dependent
LIFE INSURANCE (check one only)
No Coverage
BASIC BASIC PLUS SUPPLEMENTAL
Employee/No Dependent Coverage Employee/Dependent Coverage Eligible Spouse $1000 Eligible Child $500 Employee/Dependent Coverage Eligible Spouse $2000 Eligible Child $1000
Employee/No Dependent Coverage Employee/Dependent Coverage Eligible Spouse $2000 Eligible Child $1000 Employee/Dependent Coverage Eligible Spouse $4000 Eligible Child $2000
Annual Salary _____________ Date of Last Salary Increase ______________ Face Life _______________ WAIVER OF COVERAGEI waive all coverage offered through the Office of Group Benefits. I understand that if I enroll for OGB offered life insurance at a future date, the cover-age I receive will be subject to evidence of insurability.
NOTE TO AGENCY REPRESENTATIVE: If the employee waives his/her right to all coverage, he/she must sign an enrollment document. A copy of this document is to be retained by the agency as evidence the employee was offered coverage within 30 days of eligibility and the employee declined. The original of this document is to be transmitted to the Office of Group Benefits.
ACKNOWLEDGEMENT OF COVERAGE LIMITATIONS » I understand that I must provide appropriate documents to OGB to verify eligibility of all covered dependents. I acknowledge that my application
for dependent coverage will not be approved until all required documents are received. » I acknowledge that I have reviewed the descriptive literature about OGB health plans available to me. I apply for participation or a change in my
participation in the named health plan and agree to be bound by its terms and conditions. » I authorize deductions from my earnings or retirement check to pay for insurance for myself and my dependents, if applicable. » I certify that the information provided on this form is true and correct. I understand that if I provide false information on this form, it may result in
denial or recision of coverage retroactive to the initial day of coverage. A copy of my signature is as valid as the original. » I accept that this declaration will become a part of my application for coverage.
_____________________________________________________________________________________________________________________________
Date
Date
Date Date
Reason for Cancellation
Employee Signature Date Agency Representative Signature Date
GB-01REV 1-14
IMPORTANT INFORMATION ABOUT THE STATE'S CONTRIBUTION
TOWARD RETIREE HEALTH PLAN PREMIUMS
(including surviving spouse and/or dependents of retiree)
In 2001, the Louisiana Legislature enacted a law that established a schedule for the amount
that the state, school boards and other participating agencies (collectively, "the state") shall
contribute toward the premium for retiree coverage based upon years of participation in an
OGB health plan before retirement.Here are some important things you should know about the
"participation schedule" established in that law.
1. Your state contribution is not affected by the participation schedule if you retired before
January 1, 2002, and continued your health coverage through OGB. Under the law, you will
continue to receive the state contribution toward the premiums that is currently set at 75
percent.
2. Your state contribution is not affected by the participation schedule if you were covered by an
OGB health plan before January 1, 2002, and you maintain continuous coverage through
retirement. Under the law, you will receive the state contribution toward the premiums for
retiree coverage that is currently set at 75 percent.
3. Your state contribution is affected by the participation schedule if:
a. your coverage in an OGB health plan began on or after January 1, 2002; or
b. you previously had coverage in an OGB health plan, dropped coverage, and rejoined on
or after January 1, 2002; or
c. you have a break in coverage after January 1, 2002.
4. If it applies to you, the participation schedule sets the state's contribution toward the premium
for retiree coverage as follows:
Retiree Participation Schedule
Years of OGB Plan
Participation
State’s Share of Total
Monthly Premium
20 years or more 75 percent
15 years but less than 20
years 56 percent
10 years but less than 15
years 38 percent
less than 10 years 19 percent
5. This schedule also applies to the state's contribution toward the premium for coverage of
retirees' surviving spouses and dependents whose coverage in an OGB health plan began on
or after July 1, 2002, or who had previous coverage, dropped that coverage and rejoined on or
after July 1, 2002, or who experienced a break in coverage after July 1, 2002.
6. Participation in an OGB health plan includes all participation in health plans available to
employees of OGB participant employers, for which the state contributes a share of the
premium, including self-insured plans such as the PPO and HMO plans, fully-insured
plans such as the MCO plan the Medical Home HMO plan, consumer driven plan such
as the CD-HSA, and other health plan options such as the LSU System health plan.
Participation also includes COBRA continuation coverage in an OGB health plan.
7. If the participation schedule does apply to you, then at the time of retirement, your years of
participation in OGB health plans must be certified by the employer from which you will retire.
. The certification must be based on business records maintained by your employer or provided
by you.
a. The business records must be available to OGB, the Division of Administration and the
Legislative Auditor upon request.
b. Not more than 120 days before your scheduled date of retirement, and upon request,
OGB will provide to your employer all information in its possession relating to your
participation.
c. At the time of application for surviving spouse and/or surviving dependent coverage,
OGB will, upon request, provide all information in its possession relating to participation
of such surviving spouse and/or surviving dependent.
8. When applicable, the participation schedule sets the state's contribution toward the premium
for retiree coverage. It does not establish eligibility for retiree coverage. To be eligible for
retiree coverage, you must:
. be a covered employee in an OGB health plan immediately prior to retirement;
a. elect to continue your coverage at the time of retirement; and
b. immediately receive retirement benefits from an approved state or governmental
defined benefit plan.
Life Insurance Information (Offered through OGB by Prudential)
New employees, who are full-time, will have the opportunity of enrolling in insurance after the New Teacher Orientation on August 3, 2015. You must sign up within 30 days of employment; otherwise you’ll be subject to a medical evaluation. If you wish to enroll in our life insurance policy, you’ll need to complete an enrollment form. These are available upon request. Please refer to the following page for plans & rates.
If you have questions regarding Life Insurance, please contact Amanda Glascock at [email protected] or (225) 686-4230.
BASIC AND SUPPLEMENTAL LIFE SCHEDULE 1INSURANCE SCHEDULE FOR Effective January 1, 2013
ACTIVE AND RETIRED EMPLOYEESUNDER AGE 65
Includes Accidental Death & Dismemberment (AD&D)*
ANNUAL EARNINGS** MAXIMUM TOTAL PREM. EMPLOYEESINSURANCE WITH AD&D*** SHARE
BASIC LIFE: $ 5,000 $5.40 $2.70
BASIC ANDSUPPLEMENTALLIFE: 2,000.01 - 2,666.66 6,000 6.48 3.24
2,666.67 - 3,333.33 7,000 7.56 3.783,333.34 - 4,000.00 8,000 8.64 4.324,000.01 - 4,666.66 9,000 9.72 4.864,666.67 - 5,333.33 10,000 10.80 5.405,333.34 - 6,000.00 11,000 11.88 5.946,000.01 - 6,666.66 12,000 12.96 6.486,666.67 - 7,333.33 13,000 14.04 7.027,333.34 - 8,000.00 14,000 15.12 7.568,000.01 - 8,666.66 15,000 16.20 8.108,666.67 - 9,333.33 16,000 17.28 8.649,333.34 - 10,000.00 17,000 18.36 9.18
10,000.01 - 10,666.66 18,000 19.44 9.7210,666.67 - 11,333.33 19,000 20.52 10.2611,333.34 - 13,333.33 20,000 21.60 10.8013,333.34 - 14,000.00 21,000 22.68 11.3414,000.01 - 14,666.66 22,000 23.76 11.8814,666.67 - 15,333.33 23,000 24.84 12.4215,333.34 - 16,000.00 24,000 25.92 12.9616,000.01 - 16,666.66 25,000 27.00 13.5016,666.67 - 17,333.33 26,000 28.08 14.0417,333.34 - 18,000.00 27,000 29.16 14.5818,000.01 - 18,666.66 28,000 30.24 15.1218,666.67 - 19,333.33 29,000 31.32 15.6619,333.34 - 20,000.00 30,000 32.40 16.2020,000.01 - 20,666.66 31,000 33.48 16.7420,666.67 - 21,333.33 32,000 34.56 17.2821,333.34 - 22,000.00 33,000 35.64 17.8222,000.01 - 22,666.66 34,000 36.72 18.3622,666.67 - 23,333.33 35,000 37.80 18.9023,333.34 - 24,000.00 36,000 38.88 19.4424,000.01 - 24,666.66 37,000 39.96 19.9824,666.67 - 25,333.33 38,000 41.04 20.5225,333.34 - 26,000.00 39,000 42.12 21.0626,000.01 - 26,666.00 40,000 43.20 21.6026,666.01 - 27,333.33 41,000 44.28 22.1427,333.34 - 28,000.00 42,000 45.36 22.6828,000.01 - 28,666.66 43,000 46.44 23.2228,666.67 - 29,333.33 44,000 47.52 23.7629,333.34 - 30,000.00 45,000 48.60 24.3030,000.01 - 30,666.66 46,000 49.68 24.8430,666.67 - 31,333.33 47,000 50.76 25.3831,333.34 - 32,000.00 48,000 51.84 25.9232,000.01 - 32,666.66 49,000 52.92 26.4632,666.67 - And Over 50,000 54.00 27.00
*Accidental Death & Dismemberment benefits are included for all active and retired employees who are under the age of sixty-five (65).
**Annual Earnings for those academic employees who work less than twelve months of the calendar year shall be the salary for that period of time required by their regular job duties as defined at the beginning of the academic year. For retired employees "annual earnings" means that salary level for which benefits were provided as an active employee on the last day of the month immediately preceeding the actual last day of work.
***Total includes both state and employee share of the premium.