TABLE OF CONTENTS - Dayton, Ohiogo.cityofdayton.org/enews/ENEWSNOV11final/2012 FOP.pdfOpen Enrollment Material 2012 Summary of Health Insurance Benefits TABLE OF CONTENTS Welcome letter

2012 Summary of Health Insurance

Benefits

FOP

Open Enro l lment Ma ter ia l

2012 Summary o f Hea l th Insurance Benef i ts

TABLE OF CONTENTS Welcome letter

Informat ion For A l l employees

Dependent e l ig ib i l i ty

High Deduct ib le Heal th P lan

Heal th Sav ings Account

Heal th reimbursement Account

Anthem.com

Premium only P lan

Benef i ts Based on employee class i f icat ion

medica l

Addi t ional Benef i ts

medicare And Prescr ipt ion Drug

Waiver of Insurance Form

Payrol l Deduct ion Form

Back cover

enrol lment meet ings

contacts



1

Welcome to your 2012 City of Dayton Benefits GuideThis year Open Enrollment takes place November 14, 2011 through November 28, 2011

We want to help you understand which benefit choices could be the best for you and your family. The benefit choices you make are effective January 1, through December 31, 2012.

It’s Your Choice

This is an informational packet to explain your benefit options for 2012.

•AnthemBlueCross&BlueShieldHighDeductibleHealthPlan(HDHP) •HealthSavingsAccount(HSA)orHealthReimbursementAccount(HRA),providedthatyouenrollin

health insurance coverage

Health Insurance

The Summary of Benefits provides a good review of the medical benefits available through the Lumenos High DeductibleHealthPlan(HDHP).PleasereviewtoseethefewchangesthatwillbeeffectiveonJanuary1st.

All employees who enroll should choose either a health savings account or a health reimbursement account.

If you waive the City of Dayton’s health insurance coverage and obtain coverage from another source, full-time employees may be eligible to receive an incentive paid bi-weekly. To receive the incentive, you must complete a Waiver of Health Insurance Form contained with this packet and also attach proof of other coverage.

How to Learn More

To assist you and your family in making these important decisions regarding your health insurance and other insurance benefits, we urge you to review the enclosed material and attend one of the scheduled informational meetingsconductedbyrepresentativesofAnthemandtheHumanResourcesDepartment.Ifyouaremarried,pleasefeelfreetobringyourspousetoanyofthemeetings(exceptthemeetingheldintheAirportterminal).

Enrollment Steps

Carefully read all of the materials in your enrollment packet. If you do not want to make any changes to your election (i.e. same plan option and same dependents covered), you do not need to do anything. If how-ever, you want to make any changes to your plan selection or add/delete a dependent from the plan, forms will beavailableattheopenenrollmentmeetingsorintheHumanResourcesDepartment.

All completed enrollment forms must be received by the Human Resources Department in City Hall Room 330 no later than November 28, 2011 at 5:00 p.m.

Changes will not be accepted after the deadline unless there has been a special enrollment event according to theHIPAAguidelines(i.e.birth,death,marriage,adoption,etc.).Alsoanyplanelectionchanges(i.e.HSAtoHRA)will not be accepted after the deadline. Applications will not be accepted after the deadline because they require changestothepre-taxcontributionsandmustbeacceptableundertheIRSguidelinesthatgovernourSection125 plan.

If you have any questions on any of the information contained in this packet, please come to an enrollment meetingorcontacttheHumanResourcesDepartmentat(937)333-4064.

Sincerely,

Brent L. McKenzie ActingDirectorofHumanResources

2

2012 OPEN ENROLLMENT BASICS DEADLINE IS 5:00 P.M. NOvEMBER 28 2011

Open Enrollment is Monday, November 14 through Monday, November 28, 2011

This guide provides benefit highlights. For more detailed information such as a medical summary plan description or benefit certificates of coverage, please see Human Resources.

Forms are available in Human Resourcesandduringopenenrollment meetings.

Be sure to complete the appropriateform(s)forthebenefit choices you make and return it to your Human ResourcesDepartmentno later than 5:00 pm on Monday, November 28, 2011. We cannot accept forms after this time and date.

The plan selections you make will be in effect from January 1, 2012 through December 31, 2012.

You’re making

important benefit decisions

for you and your family.

Healthcare Reform

High Deductible

Health Plan (HDHP)

Health Savings Account

Health Reimbursement

Account

Anthem.com

Premium Only Plan

Health Enrollment Meetings

We are available to answer questions and will review important details during informational meetings conducted by Human ResourcesandanAnthemRepresentative.Pleasejoinus. The meeting schedule is on the back cover.

Be sure you have benefit coverage for 2012

3

Only employees who want to make a change to your 2012 health insurance benefits need to fill out an enrollment form.

To Enroll in the Lumenos High Deductible Health Plan:

•CompletetheAnthemMedical Enrollment Form

To Enroll in an HSA or make a change with your HSA vendor:

•Completeanapplication for a new HSA account with Fifth Third Bank, CODE Credit Union, or Dayton Firefighters Federal Credit Union.

To make a change in your HSA Payroll Deduction:

•Completeanewpayrolldeduction form.

•Onlyemployeesthatneed to change their amount or those who terminated their deductions need to complete a new form. All other current deductions will continue.

•Pleasecallpayrollifyouhave questions about your current deductions at 333-3551.

To Enroll in the Lumenos High Deductible Health Plan with the HRA:

•CompletetheAnthemMedical enrollment form andselectLumenosHRA on the application.

Open Enrollment “To-Do’s” for Health Plans for all City of Dayton Employees:



4

HSA vs. HRA ComparisonHealth Savings Account (HSA) Health Reimbursement Account (HRA)

1. Account belongs to the employee. 1. Account belongs to the City.

2. Employee keeps account balance when he/she terminates employment. 2.EmployeehasaccesstotheaccountuntiltheHDHPcoverage is terminated.

3. Employee can move the account to a different financial institution. 3. n/a

4.CitydepositsmoneyinJanuary: - Single coverage: $1,500 - Family coverage: $3,000

4.CityauthorizesmoneyinJanuary: - Single coverage: $1,500; - Family coverage: $3,000.

5. Employee can contribute additional money on a pre-tax basis up to the maximum 2012 contribution. The maximum 2012 contributions are: $3,100forsinglecoverageand$6,250forfamilycoverage.Themaximumyou can contribute after the City contribution is: -Singlecoverage:upto$1,600; - Family coverage: up to $3,2150; -Age55andover:Additional$1,000(2012limit).

5. No employee contribution.

6.Employeecanearninterestonfundsintheaccount. 6.Nointerestearningsfortheemployee.

7.Allunusedfundscanberolledoverfromyeartoyear.Thereisnolimit on the account balance.

7.Unusedfundscanberolledover;however,theaccountbalancecannotexceedtheamountoftheHDHPdeductible.

8.FundscanbeusedforHDHPdeductibleexpensesandotherIRSqualifiedmedical expense such as over-the-counter drugs, dental expenses, Lasik surgery, and long-term care premiums. Starting January 1, 2012, over-the-counter drugs and medicines will need a prescription to qualify for reimbursement.

8.FundscanonlybeusedforHDHPdeductibleexpenses.

9.Beforeage65,fundsusedfornon-medicalpurposesaretaxableandthereisa20%penalty.Employeesage65andoldercanusefundsfornon-medical purposes. The funds are taxable; however, there is not a 20% penalty.

9.FundscanonlybeusedforHDHPdeductibleexpenses.

10. Debit cards can be used for all eligible expenses. 10. No debit card

11. Banking fees are paid by the employee from the account. 11. City pays all administration fees for the account.

12. Employee eligibility: -MusthaveCityHDHP; - Must enroll at the beginning of the plan year; - Must have completed initial City probationary period prior to the begin-

ning of the plan year; - Cannot be claimed as a dependent for tax purposes; - Cannot be enrolled in Medicare benefits; -Cannothaveothernon-HDHPhealthcoverage.

12. Employee eligibility: MusthavecityHDHP

13. Dependent eligibility: -IRSdependentattimeofexpenditure. -MustbeadependentontheCity’sHDHP.

13. Dependent eligibility: Mustbeadependentonthecity’sHDHP

14.EmployeeisresponsibleforcompliancewithIRSregulationsandmustmaintaincopiesofallHSAtransactionsforIRSauditpurposes.

14.NoIRSliability.

5

MyAnthem Arm yourself with the information you need to make informed health care decisions about all of your health plan benefits and services on line. With MyAnthem®, you have access to online tools that are designed to help you maximize your benefits. For example, you can check your benefits, claims status, view referrals and authorizations quickly and easily. Download claim forms, email customer service, find a doctor, view deductibles and benefits used and more using this secure website!

MyHealth@Anthem is a website specially designed to help you and your family make healthier choices to improve wellness. With a host of health-related articles and interactive tools, it can be a prime resource for information you can trust. You can find tools to:

•Bettermanagechronicandacuteconditionslike asthma, diabetes and more

•Checkyourhealthrisklevelthroughahealthassessment. It will help you understand your risks and identify ways to lower them.

•Keepallofyourmedicalinformationinacentral location you can access anytime with YourPersonalHealthRecord.Itisaprivate,secure service.

•Findhealthinformationandtoolsspecifictomen and women.

•Identifywhattypeofailmentsmightbecausing a particular pain or discomfort through The Symptom Checker.

Over the Counter Drugs & Medicines Impacted for HSA & HRA Accounts

Just a reminder, effective January 1, 2011 certain over-the-counter (OTC) drugs and medicines require a prescription to be considered an “eligible expense”.

SpecialOffers@AnthemSaving money is good. Saving money on things that are good for you — that’s even better. With SpecialOffers@Anthem, you can receive discounts on products and services that help promote better health and well-being. And, there’s no extra cost to you. Here’s a small sampling:

Barnes & Noble.com — Browse an online library of selected health and wellness titles, and save 5% on your order along with free standard shipping on all orders over $25. See website for details.

Jenny Craig® — Join Jenny Craig and receive afree30-daytrial,50%offthe6-monthprogramand20%offtheJennyRewardsprogram.Call800-96JENNY.

Weight Watchers® — Take $10 off a 3-month subscription to Weight Watchers Online. See website for details

Family & Home American Baby Magazine – Receive a free subscription Safe Beginnings – Save 15% call 800-598-8911

SeniorLink – Save 15% on advise on caring for seniors, plus 90 days free services on Helplink Emergency

Response System Call 866-797-2336

VPIPetInsurance–5% off Pet insurance Call 877-PETS-VPI

Fitness & Health Lindora Lean for Life – Save 20% on weight loss programs call 1-800 LINDORA

Global Fit – Membership discounts of up to 60% to local, regional and national fitness clubs.

SelfHelpWorks – Receive a 30 day free guest pass and a 30% discount call 877 719 9860

ChooseHealthy – Take the alternative path with discounts on health and wellness products, fitness club

memberships, visits to massage therapists and more.

Vision, Hearing, DentalHearPO–Low Price guarantee on the seven top companies that work with HearPO call 888-901-7150

Eyewear Discounts – Save 30% on eyeglasses, 20% on most non prescriptions sunglasses

PremierLASIK–Save 15% on LASIK with all in network providers call 866 7672179

TruVision – Members receive 10% off vision corrections procedures

Drugstore.com

Medicine & TreatmentDrugstore.com – Save 5% on select products and free shipping on orders of $49 or more

National Allegy supply – 15% discount on mattress encasings, air filtration products, compressors and other

products call 800 522 1448

We’vejustscratchedthesurfacehere.Gotoanthem.com for specific information on all these services, offers and more.

How does this legislation impact me?It impacts you two ways:

1. Setting Your Contribution Because OTC drugs and medicines now require a prescription effective January 1, 2011, you might want to consider this when deciding on your healthcare HSA contribution.

2. Using Your Account Dollars Effective January 1, 2011, OTC drugs and medicines are considered ineligible expenses unless you have a prescription from your physician. ExamplesofOTCDrugsandMedicinesRequiring aPrescriptioneffective2011:

•AcidControllers •Allergy&Sinus •AntibioticProducts •Anti-diarrheal •Anti-Gas •Anti-Itch&InsectBite •Anti-ParasiticTreatments •Aspirin •BabyRashOintments/Creams •ColdSoreRemedies •Cough,Cold&Flu •DigestiveAids •HemorrhoidPreps •Laxatives •MotionSickness •PainRelief •RespiratoryTreatments •SleepAids&Sedatives •StomachRemedies

For more information, go to www.irs.gov

Stay Well, Save Time and Money with Anthem.com



6

Medical Insurance Employees are eligible for the Anthem Blue Cross and Blue Shield Lumenos High Deductible HealthPlan(HDHP).Youcanalsowaivethehealth insurance.

•PairtheHighDeductibleHealthPlanwithanHSAorHRA

•Ifyouwaivehealthinsurancecoverageduringopen enrollment for a 12 month period you canbepaid$1,216ifyouarenotcarriedasa dependent under a City of Dayton plan. In other words, your coverage is with an employer or institution other than the City of Dayton. Proofofothercoveragemustbeprovidedtoreceive the incentive. The incentive is paid in yourbi-weeklypayattherateof$46.77foreachofthe26paychecks.Youmustcompletea Waiver of Health Insurance Form each year to receive the cash incentive. The rules are listed on the Waiver of Health Insurance Form contained in this packet.

Medical and Prescription Drug CardThe 2012 plan pays 100% of medical expenses after the combined medical and prescription drug deductible has been met. TheseRxco-paymentswillapplyaftermeeting your combined medical and drug $2,100/$4,200deductible.

PrescriptionDrugCardTiersandCo-payments

Tier 1 – generic $10 Tier 2 – formulary $20 Tier 3 – brand $30

The co-payments will go towards your out-of-pocket maximum which is now $3,000 for a singleand$6,000forafamily.ThismaximumoutofpocketincludesthedeductibleplusRxco-payments.

Your Monthly Contributions for Medical Insurance Single:$70 Family:$160 Effective January through

December, 2012

Your contribution for medical insurance will be deducted from your paycheck on a pre-tax basis starting with the first paycheck you receive in January 2012.

HDHP Summary of BenefitsA benefit summary is included in this booklet. YoumayalsoreviewaSummaryPlanDescription for more detailed information of covered benefits and exclusions. Ask Human Resourcesforacopy.

Below is a high level overview:

•TheHighDeductibleHealthPlanpays 100% for:

o In-network preventive care o Covered in-network medical expenses

in excess of the deductible

•You’reresponsibleformedicalexpensesthatfall within the plan deductibles for in and out of network services:

o Single coverage: $2,100 oFamilycoverage:$4,200

Forthoseenrolledasafamily(2ormore), one person in the family could meet the full family deductible: Example: Ifthefamilydeductibleis$4,200,then “1” family member could potentially havetopaythefull$4,200beforeinsurancepays any portion of the claim. After the family deductible has been met by “1” or “multiple” family members, the insurance carrier will begin to pay their portion.

•HSAorHRAfundscanbeusedtopayfor your deductible medical costs. The City is providing funding for these accounts in January 2012 in the amounts of:

o Single coverage: $1,500 o Family coverage: $3,000

Medical Insurance EnrollmentYou do not need to complete enrollment forms unless you wish to make changes.

PleasenotethatperIRSguidelines,you may begin, end or modify HSA contributions at any time on a prospective basis.

Enroll as a New Benefit or Add Eligible DependentsIf you wish to enroll as a new benefit, you must complete a new Anthem Enrollment form.

Dependents that become eligible for coverage duringtheplanyear(e.g.,birth,marriage),mustbe added to your coverage within 30 days of the date of the event, otherwise you must wait until open enrollment. Contact the Human ResourcesDepartmentforanappointmenttoenroll a dependent during the plan year.

As a reminder, dependents must meet the eligibility requirements set forth by Anthem BlueCross&BlueShield.PleaserefertoyourAnthem Certificate of Coverage for a definition of eligible dependents.

Medical, Dental, and Supplemental Life Insurance Enrollment Instructions FOP

You’re making important benefit decisions for you and your family. This information will help you understand:

Medical Coverage, including the new Drug Card

Additional Benefits

Employee Premium(s)

Medicare and Prescription Drug Coverage Notice

Waiver of Insurance and Payroll Deduction Forms

7

Medical Summary of BenefitsLumenos High Deductible Health Plan (w/Rx Copay after deductible)Effective 01/01/2012Pleasenote:AswereceiveadditionalguidanceandclarificationfromtheU.S.DepartmentofHealthandHumanServices,wemayberequiredtomake additional changes to your benefits.

Covered Benefits Network Non-Network

DeductibleFamily coverage requires the family deductible to be met before coinsurance applies. The single deductible does not apply to family coverage. Network and Non-Network deductibles are combined.

Single: $2,100 Family:$4,200

Out-of-Pocket Limit IncludesdeductibleandRxco-pays

Single: $3,000 Family:$6,000

Single:$6,000 Family: $12,000

Physician Home and Office ServicesIncludingOfficeSurgeries,allergyserum,allergyinjectionsandallergytesting

Deductible + 0% Deductible + 20%

Preventive Care Services Services include but are not limited to: RoutineExams,Mammograms,PelvicExams,Paptesting,PSAtests, Immunizations,Annualdiabeticeyeexam,RoutineVisionandHearingexams •PhysicianHomeandOfficeVisits •OtherOutpatientServices@Hospital/AlternativeCareFacility

No co-payment/coinsurance Deductible + 20%

Emergency and Urgent Care

Emergency Room Services @ Hospital (facility/othercoveredservices) (co-paymentwaivedifadmitted)


Urgent Care Center Services Deductible + 0% Deductible + 20%

Inpatient and Outpatient Professional Services Include but are not limited to: MedicalCarevisits(1perday),IntensiveMedicalCare,ConcurrentCare,Consultations, Surgery and administration of general anesthesia and Newborn exams


•All enrollment/change forms must be received by the Human Resources Department in City Hall Room 330 no later than November 28, 2011 at 5:00 p.m.



Covered Benefits Network Non-Network

Inpatient Facility Services (Network/Non-Networkcombined)Unlimiteddaysexceptfor: •60daysforphysicalmedicine/rehab(limitincludesDayRehabilitationTherapyServicesonanoutpatientbasis)

•180daysforskillednursingfacility


Outpatient Surgery Hospital/Alternative Care Facility •Surgeryandadministrationofgeneralanesthesia


Other Outpatient Services(Network/Non-networkcombined) including but not limited to: •NonSurgicalOutpatientServices Forexample:MRIs,C-Scans,Chemotherapy,Ultrasoundsand other diagnostic outpatient services.

•HomeCareServices230visits(excludesIVTherapy)•DurableMedicalEquipmentandOrthotics(excluding ProstheticDevices,LimbsandMedicalSupplies)

•ProstheticDevices•ProstheticLimbs•PhysicalMedicineTherapyDay•Rehabilitationprograms


•HospiceCare Deductible + 0% Deductible + 0%

•AmbulanceServices Deductible + 0% Deductible + 0%

Accidental Dental Services (networkandnon-networkcombined)


Outpatient Therapy Services (CombinedNetwork&Non-Networklimitsapply)

•PhysicianHomeandOfficeVisits Deductible + 0% Deductible + 20%

•OtherOutpatientServices@Hospital/AlternativeCareFacility Deductible + 0% Deductible + 20%

Limits apply to: •CardiacRehabilitation:36visits •PulmonaryRehabilitation:20visits •PhysicalTherapy:30visits •OccupationalTherapy:30visits •ManipulationTherapy:24visits •Speechtherapy:20visits

Behavioral Health Services: Mental Illness and Substance Abuse •InpatientFacilityServices •PhysicianHomeandOfficeVisits •OtherOutpatientServices@Hospital/AlternativeCareFacility


Human Organ and Tissue Transplants Acquisition and transplant procedures, harvest and storage.


Prescription Drugs

Network Retail Pharmacies: (30-daysupply)Includesdiabeticteststrip

$10/$20/$30 50%,minimum$75

Anthem Rx Direct Mail Service: (90-daysupply)Includesdiabeticteststrip

$10$50/$90 Not covered

- Specialty medications are limited up to a 30 day supply regardless of whether they are retail or mail service

- Member may be responsible for additional cost when not selecting the available generic drug.

Lifetime Maximum Unlimited Unlimited

Medical Summary of Benefits

This benefit summary is intended only to highlight your benefits and should not be relied upon to fully determine coverage. This benefit plan may not cover all of your healthcare expenses. More complete descriptions of benefits and the terms under which they are provided are contained in the certificate of coverage that you will receive upon enrolling in the plan

8

Additional Benefits for You to Consider

Dental InsuranceWell cared for teeth and gums have a signifi-cantimpactonyouroverallhealth.Researchshows that regular visits to a dentist can help in early detection and management of serious physical illness such as diabetes. The City of Dayton offers a dental plan through AFSCME Care.

For 2012 there are no changes in benefits or employee costs.

To Enroll or Add Dependent(s)If you need to enroll as a new benefit, you must submit a Superior Dental enrollment form. You may also add additional eligible dependents at this time too. Dependents that become eligible for coverage during the plan year(e.g.,birth,marriage)mustbeaddedtoyour coverage within 30 days of the date of the event, otherwise you must wait until open enrollment.ContacttheHumanResourcesDepartment for an appointment to enroll a dependent during the plan year. Be sure to complete the enrollment form and return to HumanResourcesbythedeadlinedate.

Supplemental Life InsuranceLife insurance is an important part of your family’s financial plan and it’s essential to protect your family’s standard of living and avoid leaving debt behind. In addition to the base life policy that we offer you, you have the opportunity to purchase supplemental life in-surance and increase your coverage each year. Supplemental Life Insurance is offered by The Hartford.

To Apply :You may apply for supplemental life insurance bycompletinga“PersonalHealthApplica-tion.” Supplemental life coverage is issued in $10,000 increments. To determine the maximum amount of coverage you are eligible for, multiply your annual salary by 5 and round up to the next $10,000 increment.

If you already have coverage you can increase your coverage by $10,000 without proof of insurability until you reach $200,000 in cover-age. Any amount over $200,000 requires proof of insurability

Enrollment•Yourenrollmentformmustbecompleted

at an enrollment meeting or in the Human ResourcesDepartment.

•Whenyouenrollyouwillneedtoknowthebirth dates and social security numbers of your beneficiaries.

•EnrollmentformsmustbereceivedintheHumanResourcesDepartmentnolaterthanNovember 28, 2011 at 5:00 p.m.

Incentive to Waive Coverage

If you waive health insurance coverage during open enrollment for a 12 month period you can be paid $1,216 if you are not carried as a dependent under a City of Dayton plan. In other words, your coverage is with an employer or institution other than theCityofDayton.Proofofothercoveragemust be provided to receive the incentive. The incentive is paid in your bi-weekly pay attherateof$46.77foreachofthe26paychecks. You must complete a Waiver of Health Insurance Form each year to receive the cash incentive. The rules are listed on the Waiver of Health Insurance Form contained in this packet.

Dependent Eligibility for Adult Children

InaccordancewiththePatientProtectionandAffordability Care Act, adult children that are the natural child, step child or adopted child of youoryourspousecanbecoveredtoage26,regardless of marital status, as long as they do not have access to other employer sponsored coverage. Also, under the State of Ohio law, adult children that are the natural child, step child or adopted child of you or your spouse, who live in the State of Ohio or are a full-time student at an accredited higher education in-

stitution, and is not eligible for other employer based coverage or Medicaid / Medicare, can be covered under the City of Dayton plan untilage28. Pleasenotethattherearetaxconsequences for adult children between the agesof26and28. Also,pleasenotethatyourHealthSavingsAccount(HSA)mayormaynotbe used to reimburse for expenses incurred by theseadultchildren. Pleasecontactyourtaxadvisor for clarification.



9

Non Creditable Medicare Part D Notice (Plan with RX)

Important Notice From the City of Dayton About Your Prescription Drug Coverage and MedicarePleasereadthisnoticecarefullyandkeepitwhere you can find it. This notice has informa-tion about your current prescription drug cover-age with City of Dayton and about your options under Medicare’s prescription drug coverage. This information can help you decide whether ornotyouwanttojoinaMedicaredrugplan.Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are three important things you need to know about your current coverage and Medi-care’s prescription drug coverage:

1. Medicare prescription drug coverage became availablein2006toeveryonewithMedi-care.YoucangetthiscoverageifyoujoinaMedicarePrescriptionDrugPlanorjoinaMedicareAdvantagePlan(likeanHMOorPPO)thatoffersprescriptiondrugcoverage.All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. The City of Dayton has determined that the prescription drug coverage offered by the AnthemBlueCross&BlueShieldPlanis,onaverage for all plan participants, NOT expect-ed to pay out as much as standard Medicare prescription drug coverage pays. Therefore, your coverage is considered Non-Creditable Coverage. This is important because, most likely, you will get more help with your drug costsifyoujoinaMedicaredrugplan,thanif you only have prescription drug coverage fromtheAnthemBlueCross&BlueShieldPlan.Thisalsoisimportantbecauseitmaymeanthatyoumaypayahigherpremium(apenalty)ifyoudonotjoinaMedicaredrugplan when you first become eligible.

3. You can keep your current coverage from AnthemBlueCross&BlueShield.However,because your coverage is non-creditable, you have decisions to make about Medicare pre-scription drug coverage that may affect how much you pay for that coverage, depending

onifandwhenyoujoinadrugplan.Whenyou make your decision, you should compare your current coverage, including what drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverageinyourarea.Readthisnoticecare-fully - it explains your options.

When Can You Join A Medicare Drug Plan?

YoucanjoinaMedicaredrugplanwhenyoufirst become eligible for Medicare and each yearfromOctober15ththroughDecember7th.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

SincethecoverageunderAnthemBlueCross&Blue Shield is not creditable, depending on how long you go without creditable prescription drug coverageyoumaypayapenaltytojoinaMedi-care drug plan. Starting with the end of the lastmonththatyouwerefirsteligibletojoinaMedicaredrugplanbutdidn’tjoin,ifyougo63continuous days or longer without prescription drug coverage that’s creditable, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that cov-erage. For example, if you go nineteen months without creditable coverage, your premium may consistentlybeatleast19%higherthantheMedicare base beneficiary premium. You may havetopaythishigherpremium(penalty)aslong as you have Medicare prescription drug coverage. In addition, you may have to wait untilthefollowingNovembertojoin.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

IfyoudecidetojoinaMedicaredrugplan,yourcurrent City of Dayton coverage will not be affected. You can keep this coverage if you elect partDandthisplanwillcoordinatewithPartDcoverage. However, if you enrolled in the HSA account you can no longer contribute to the account.

IfyoudodecidetojoinaMedicaredrugplanand drop your current City of Dayton coverage, be aware that you and your dependents will not be able to get this coverage back until the next open enrollment period.

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact the person listed below for further infor-mation. NOTE: You’ll get this notice each year. You will also get it before the next period you can joinaMedicaredrugplanandifthiscoveragethrough City of Dayton changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare&You”handbook.You’llgetacopyof the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

•Visitwww.medicare.gov

•CallyourStateHealthInsuranceAssistanceProgram(seetheinsidebackcoverofyourcopyofthe“Medicare&You”handbookfortheirtelephonenumber)forpersonalizedhelp

•Call1-800-MEDICARE(1-800-633-4227). TTYusersshouldcall1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213(TTY1-800-325-0778).

Name of Entity/Sender: City of Dayton

Contact-Position/Office: PeggyThumser, HumanResources

Address: 101 West Third St, Dayton,Ohio45401

PhoneNumber: 937-333-4064

Your Prescription Drug Coverage and Medicare

1 0

Waiver of Health Insurance Form

InaccordancewiththetermsoftheCityofDaytonPremiumOnlyPlan,youmaywaivecoverageundertheCityofDaytonGroupHealthBenefitPlanin exchange for additional taxable cash compensation. In order to receive this cash payment, you cannot be carried as the policyholder or spouse underaCityofDaytonplan.ThefollowingrulesapplyforyoutowaivecoverageundertheCityofDaytonGroupHealthBenefitPlaninexchangeforadditional taxable cash compensation.

1. You must submit this City of Dayton Waiver of Health Insurance Form with proof of other health coverage during Open Enrollment to receive the full incentive payment. This City of Dayton Waiver of Health Insurance Form must be completed and submitted with proof of other health coverage to theHumanResourcesDepartmentonorbeforeNovember28,2011at5:00p.m.YoumustsubmitthisCityofDaytonWaiverofHealthInsuranceForm to receive the incentive payment even if you previously waived coverage under the City’s health plan. A new waiver form and proof of insurance must be submitted each plan year to receive the incentive, even if you waived coverage in the previous year.

2.IfyouelecttoparticipateintheCityofDaytonGroupHealthBenefitPlan,youmaynotdropcoverageforyou(and/oryourspouseanddependents)duringtheplanyear(January1stthroughDecember31st)unlessthereisaChangeinStatusasdefinedundertheCityofDaytonPremiumOnlyPlan.ThismeansonceyoustarttoparticipateintheCity’shealthplanyoumustcontinuetoparticipateintheplanandpayyourshareofthepre-miumsuntilthenextJanuary1stunlessthereisaChangeinStatusasdefinedundertheCityofDaytonPremiumOnlyPlan.YoumustcontacttheHumanResourcesDepartmentwithinthirtydaysofexperiencingaChangeinStatus.IfyoudropcoverageundertheCityofDaytonGroupHealthBenefitPlanduringtheplanyearandyoucompletethisCityofDaytonWaiverofHealthInsuranceFormwithinthirtydaysoftheChangeinStatus,you will receive a pro-rated portion of the incentive payment.

3.Ifyou(and/orafamilymember)arenotparticipatingintheCityofDaytonGroupHealthBenefitPlan,you(and/orfamilymember)mayonlyentertheplanduringtheplanyearifyouexperienceaqualifyingevent.Thequalifyingeventsthatwillallowyou(andyourfamilymembers)toenrollinthe plan mid-year are:

(i)You(oryourspouseand/ordependent)hadothercoverageatthetimeoftheOpenEnrollment;and

(ii)Theothercoverageterminatesforcertainqualifyingreasons.

You also may enroll yourself, your spouse, and any new family member in the plan mid-year if you become married or you acquire a dependent through birth, adoption or placement for adoption.

YoumustapplyforcoverageundertheCity’shealthplanwithinthirty(30)daysoftheseevents.Otherwise,youmustwaituntilthenextOpenEnroll-ment.

4.IfyoudonotparticipateintheGroupHealthBenefitPlanasanEmployee,orthespouseordependentofanEmployee,fortheentireplanyear,youwillreceive$1,216lessallapplicabletaxes.Thisamountwillbepaidinyourbi-weeklypayattherateof$46.77foreachof26paychecks.

IhavereadandunderstandtheinformationexplainingmyrightstoparticipateintheCityofDaytonGroupHealthBenefitPlanandIhaveelectedtowaivecoverageundertheCityofDaytonGroupBenefitHealthPlaninexchangeforadditionaltaxablecashcompensation.

Employee’sPrintedName SocialSecurityNumber

Employee’s Signature Date

I am attaching the following documents to prove that I have other health coverage:

NameofPolicyHolder PolicyHolderSSNumber

YourRelationshiptoPolicyHolder InsurancePlan

CHECK ONE OF THE FOLLOWING:

_____PolicyholderhasCityCoverage _____PolicyholderdoesnothaveCityCoverage

By signing this waiver, I understand that I cannot re-enroll in the City of Dayton Group Health Plan until the first day of the next plan year (January 1st) unless there is a Special Enrollment Period as defined by the City of Dayton Group Health Benefit Plan.

FOP



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HSA Payroll Deduction Authorization Form ThisformauthorizestheCityofDaytontoinitiateapayrolldeductionand/oradjustentriestoyourHealthSavingsAccount(HSA)establishedwiththebanks the City of Dayton has contracted with to maintain these accounts.

Deductions for the HSA will be taken each pay on a pre-tax basis. You may revoke your authorization or change your contribution amount by giving atleastten(10)businessdayswrittennoticetothePayrollOffice.However,youmaynotchangebankinginstitutionsuntilthenextOpenEnrollmentperiod.DeductionswillalsostoponcePayrollisnotifiedyouarenolongereligibletobeintheHealthSavingsAccountProgram.

Note:Eachyear,theIRSsetsamaximumannualcontributionamountfromallsources(includingemployeeand/oremployers)thatmaybedepositedinto your Health Savings Account. Anything contributed over this limit may have tax liability consequences. The City of Dayton is not respon-sible for monitoring the contributions to your Health Savings Account or to determine if you are eligible for a Health Savings Account.

Based on your estimates, enter the amount you want to contribute per paycheck and/or annually to your HSA account in the box below.

Bankinginstitution(circleonlyone):5/3rd BankORCODE Credit UnionORDayton Firefighters Credit Union

Amount to be withheld each pay: $_____________ Total amount per year to be withheld: $_____________

This payroll deduction will automatically renew each year unless you complete a new form.

YoucancheckwithHumanResourcesorPayrolltodeterminemaximumcontributionlimitsforeachyear.Employees55orolderbyyear’sendarealso eligible for an additional catch-up contribution.

Maximumcontributionsfor2012are$3,100foremployeeonlyand$6,250forafamily.

Do you currently have SINGLE or FAMILY(circleone)HealthInsuranceCoverage?

Areyoueligiblefor“CatchUp”contributions(age55orolder)?YESNO(circleone).

I hereby authorize the pre-tax reduction of my salary, on a per paycheck basis, by the amount designated above.

Iunderstandthatanywithdrawals/distributionsmadefrommyHSAfornon-qualifiedtypesofexpenseswillbetaxableandmaybesubjecttoaddi-tionalpenaltiesinaccordancewithInternalRevenueService(IRS)regulations.Ifurtherunderstandthatitismysoleresponsibilitytoreportanysuchnon-qualifyingwithdrawals/distributionstotheIRS.

___________________________________________________ ____________________

PrintName EmployeeID#

___________________________________________________ ____________________

Department/Division PhoneNumber

___________________________________________________ ____________________

Employee Signature Date

Sendorfax(333-3554)thecompletedformtothePayrollOffice.

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PREMIUM ONLY PLAN ENROLLMENT NOTICETheCityofDaytonPremiumOnlyPlan(the“POP”)isdesignedtoallowyoutopayyourportion of the premiums for the City’s health and/or dental plans on a pre-tax basis. This means the amount you pay for the premiums willnotbesubjecttofederalandstateincometax. As a result, you realize an immediate tax savingsthroughthePOP.Ifyouwaivecoverageunder the City’s group health plan you may qualify for additional cash compensation.

Participationinthehealthand/ordentalplansaswellasthePOPisvoluntary.Therefore,youcan decline to participate in the health and dentalplansandthePOP.However,ifyouelectto participate in the health and/or dental plans, youwillautomaticallyparticipateinthePOP.

ThePOPalsoallowsyoutowaivecoverageunder the City’s group health plan, which may qualify you for the cash compensation. If you want to waive coverage under the City’s group health plan for additional cash compensation, you must complete a City of Dayton Waiver of Health Insurance Form. You can get the City of Dayton Waiver of Health Insurance form at the CityofDaytonHumanResourcesDepartment.

AccordingtorulesissuedbytheIRS,onceyoubeginparticipatinginthePOPyoumaynotdropoutofthePOPorvarytheamountofyourpre-tax contributions until the first day of the next plan year. However, you may drop out ofthePOPorvarytheamountofyourpre-taxcontributionsunderthePOPatanytimeifanyofthefollowingeventsoccur:(i)achangeinyour legal marital status including marriage, death of a spouse, divorce, legal separation and annulment;(ii)achangeinthenumberofyourdependents including the birth, death, adoption andplacementofadoptionofachild;(iii)achange in your employment status or a change in your spouse or dependent’s employment status including the termination or commence-ment of employment, a strike, lockout or the commencement or termination of an unpaid leaveofabsence;(iv)achangeinyouroryourspouse’s or dependent child’s employment status that effects that individual’s eligibility un-deracafeteriaplan(includingthePOP)oranybenefitplan(includingthishealthplan);(v)yourdependent child or spouse satisfied or ceases to satisfy the eligibility requirements because of age, student status or similar circumstances; (vi)thecommencementorterminationofadoptionproceedings;(vii)changeinyouror

your spouse’s or dependent child’s residence that impacts their eligibility under the group healthplan;(viii)ajudgment,decreeorcourtorder resulting from a divorce, legal separation, annulmentorchangeinlegalcustody(includingaqualifiedmedicalchildsupportorder)thatrequires coverage under a group health plan foryourchildorfosterchild;(ix)entitlementor loss of Medicare or Medicaid by you or your spouseordependentchild;(x)thecommence-ment or return from a period of absence under theFamilyandMedicalLeaveAct;(xi)eligibilityforCOBRAcoverage(orsimilarcoverageunderstatelaw)offeredbytheCity;(xii)anychangeresulting from a change made under a plan of your spouse’s, former spouse’s or dependent child’s employer that is listed on this form.

If any of these events, occur it is imperative that youcontactthePlanAdministrator,inwriting,withinthirty(30)days.IfyoudonotcontactthePlanAdministrator,inwriting,withinthirty(30)days you will not be able to modify your election underthePOPuntilthefirstdayofthenextplanyear.ThePlanAdministratorwillprovideyou with a Change in Election Form for you to completeonceyounotifythePlanAdministratorthat one of these events has occurred.

In addition, if there is an insignificant change in the amount of premiums for the group health plan during the plan year, the amount you are contributingunderthePOPwillautomaticallybeadjustedtoreflectthechange.Ontheotherhand, if there is a significant increase in the cost of the coverage or coverage under the health plan is significantly curtailed or ceases during the plan year, you may revoke your electionunderthePOPandmaymakeanewelection on a prospective basis under another group health plan, if any, that provides similar coverage. Also, if a new benefit is added during the plan year, you may elect coverage under the newly-added option for the remainder of the plan year.

Finally,youshouldcontactthePlanAdministra-tor if you have any questions regarding whether you can waive coverage under the City group health plan in exchange for additional cash compensation and the rules governing those waivers.

Again, it is important to note that these rules havebeenissuedbytheIRSandtheCitymustfollowtherules.Otherwise,thePOPwillbecome disqualified.

If you have any questions, please contact thePlanAdministratorimmediately:

PlanAdministrator(HumanResources)

City of Dayton

101WestThirdStreet,Room330

Dayton,OH45402

Important Notice for All Employees Premium Only Plan CITY OF DAYTON



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ContactsMedical/Prescription DrugPlan

Anthem Blue Cross and Blue Shield Group#00171521

1-888-224-4902 6a.m.–8p.m.CT

www.anthem.com

DentalPlan Superior Dental Care

Group#D1885

937-438-0283 1-800-762-3159 Monday–Friday/7:30a.m.-5p.m.ET

www.superiordental.com

AFSCME Care 800-562-1822 8a.m.–4:30p.m.ET

Health Savings Account CODE Credit Union 1-937-222-8971 Dayton Location Monday - Friday / 8:30 a.m. – 5:30 p.m. Englewood Location Monday–Thursday/9a.m.–5p.m. Friday9a.m.–6p.m./Saturday9a.m.-noon

www.codecu.org

Dayton Firefighters Credit Union

1-937-228-1614 M/T/W/F / Lobby 10 a.m. – 3:30 p.m. Drive Thru 10 a.m. – 5:30 p.m. Thursday–Lobby&DriveThru/10a.m.–6p.m.

www.dffcu.org

Fifth Third Bank 1-888-350-5353 Monday–Friday/7a.m.–Midnight Saturday 8 a.m. – 5 p.m.

www.53HSA.com

Legal Disclaimer: This Summary of Benefits only highlights and summarizes the benefits available through the City of Dayton. This is only a summary and cannot be relied on to fully determine coverage. You must refer to each Certificate of Coverage for a complete listing of the covered services, limitations, exclusions and a description of all the terms and conditions of coverage. If the summary listedinthisbrochureconflictsinanywaywiththeCertificateofCoverage(and,ifapplicable,thegrouppolicy)issuedtotheCityofDayton,theCertificateofCoverage(and,ifapplicable,thegrouppolicy)prevailsoverthissummary.

Health Enrollment MeetingsMonday

November 14, 2011 1:00PM-3:00PM AirportTerminalConferenceRoom5(AVIATION EMPLOYEES ONLY)

TuesdayNovember 15, 2011 10:00AM-2:00PM AFSCME 101 Union Hall located at 15 Gates Street

MondayNovember 21, 2011 10:00AM-2:00PM AFSCME 101 Union Hall located at 15 Gates Street

NOTE: Meeting format has changed for 2012The City of Dayton will be holding Open House Benefit Sessions this year in lieu of formal presentations. Feelfreetostopinatanytimeduringthehourslistedbelow.Representativesfromthevariouscarriers will be there to answer your questions and to assist you in completing any necessary paperwork.

Only employees needing additional benefit information or making changes need to attend the Benefit Meetings.

Documents

TABLE OF CONTENTS - Dayton, Ohiogo.cityofdayton.org/enews/ENEWSNOV11final/2012 FOP.pdfOpen Enrollment Material 2012 Summary of Health Insurance Benefits TABLE OF CONTENTS Welcome letter