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New Hire Benefit Worksheet - Centura Health

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<strong>New</strong> <strong>Hire</strong> <strong>Benefit</strong> <strong>Worksheet</strong><br />

Computer Enrollment Only<br />

2012/2013 Plan Year<br />

*Enrollment Deadline: ______________<br />

(31 days from your date of hire) Your date of hire counts as day one<br />

<strong>Benefit</strong> Effective Date: ____________<br />

(1 st day of month following 30 days of employment)<br />

Status: Full-time or Part-Time (circle one)<br />

*If you do not enroll in the benefits provided by the required enrollment deadline, 31-day time frame, you<br />

will need to wait until the next annual benefit enrollment period or until you experience a qualifying life<br />

event.<br />

Associate Last Name: _________________________ First Name: ______________________________<br />

Associate ID Number: _______________________ Work Facility: _____________________________<br />

Work Phone: ( ) _________________________ Home Phone: ( ) _______________________<br />

Username and Password<br />

• If you don’t know or have forgotten your username and password for My Virtual Workplace please<br />

contact the IT customer service center in the Denver Area at 303-643-4200; or Colorado Springs at<br />

719-776-4200; or Pueblo at 719-560-4200.<br />

Review benefits offered<br />

• For further benefit plan details, please review the Reference Guide or Summary Plan Descriptions<br />

found on My Virtual Workplace, Associate Services, and Human Resources site.<br />

Complete this worksheet prior to selecting your benefits online<br />

• This worksheet is to assist you in selecting your benefits.<br />

• Review your benefit options and pay period costs, then place an “X” in the box next to each selected<br />

option.<br />

• List your current dependents and mark the benefit plans you would like to enroll them in.<br />

• If you do not enroll during your 31-day enrollment period, full-time associates will be assigned basic life<br />

insurance and long term disability benefits. Part time associates will be assigned only basic life<br />

insurance.<br />

Enroll in your benefits<br />

• Bring this completed worksheet with you to the kiosk or computer to reference your selected benefit<br />

plans.<br />

• Log on to My Virtual Workplace and click on Associates tab and then Employee Self Service.<br />

• Re-enter your username and password and in the box labeled Employee Self-Service click on <strong>New</strong><br />

<strong>Hire</strong>, <strong>Benefit</strong>s, and <strong>New</strong> <strong>Hire</strong> Enrollment. You may now enroll in your benefits.<br />

• After reviewing your summary of benefits Click “Continue”.<br />

• In order to save and confirm your benefit elections, you must choose one of the following options:<br />

• 1) Click “Print” to SAVE and PRINT a copy of your benefits confirmation statement, or<br />

2) Click “Print and send an email” of your benefits confirmation to your <strong>Centura</strong> <strong>Health</strong> email address.<br />

• Once you have enrolled for your benefits and saved your elections, you cannot make any additional<br />

changes on-line during your 31-day enrollment period. You must contact the <strong>Benefit</strong>s Service Center at<br />

1-888-622-1111 for assistance.


Your Name________________________________ Associate ID #__________________________<br />

Definition of a dependent<br />

Please list below the individuals you wish to cover. Include all required* information and mark an “X” in<br />

each plan you wish to have your dependents covered. A dependent is defined as:<br />

• Your spouse through a civil/religious marriage or your common law spouse as recognized under<br />

Colorado law. <strong>Centura</strong> <strong>Health</strong> does not recognize same sex domestic partners as eligible<br />

dependents.<br />

• Your child (including birth children, stepchildren, legally adopted children, or children for whom you<br />

have legal custody) until the end of the month in which the child attains age 26 or if your child is:<br />

mentally or physically disabled provided he/she is dependent on you for a majority of his/her support.<br />

(Proof of incapacity must be provided to United <strong>Health</strong>care.) Please note, if you are enrolling your<br />

dependent that is over the age of 19, you are certifying that your dependent does not have<br />

access to other employer-sponsored insurance.<br />

* Beginning January 1, 2009 the Medicare Secondary Payer statute requires that all associates who<br />

enroll their dependents under a <strong>Centura</strong> medical plan must provide their dependent’s social security<br />

number upon enrollment. Failure to provide your dependents social security number may delay<br />

processing of your Qualifying Event worksheet.<br />

Name of<br />

Dependent<br />

Date<br />

of Birth<br />

Social<br />

Security #<br />

(Required)<br />

Relationship Gender Disabled Medical Dental Vision<br />

MEDICAL BENEFITS Associate Only Two-Party Family No Coverage<br />

United<strong>Health</strong>care HRA Plan<br />

Full-Time $30.21 $78.80 $180.35 $0.00<br />

Part-Time $34.74 $90.62 $207.40 $0.00<br />

United<strong>Health</strong>care HSA Plan<br />

Full-Time $23.51 $61.31 $140.32 $0.00<br />

Part-Time $27.04 $70.50 $161.36 $0.00<br />

<strong>New</strong> <strong>Hire</strong> <strong>Worksheet</strong> 12-13


Your Name________________________________ Associate ID #__________________________<br />

United<strong>Health</strong>care HSA PLAN ELECTIONS<br />

<strong>Health</strong> Savings Account<br />

Yes, I wish to contribute. Decide the amount you wish to contribute for the plan year. Then use the formula<br />

below to determine the amount per pay period. The maximum contribution amount for single<br />

United<strong>Health</strong>care HSA coverage is $100.00. The maximum contribution amount for two-party or family<br />

United<strong>Health</strong>care HSA coverage is $201.92. Please note that in order to enroll for the <strong>Health</strong> Savings<br />

Account you must elect the United<strong>Health</strong>care HSA Plan and you cannot be covered under another non high<br />

deductible health plan or a health care flexible spending account.<br />

In addition, I understand that <strong>Centura</strong> <strong>Health</strong> will make a prorated contribution on my behalf into the <strong>Health</strong><br />

Savings Account. Please refer to the Human Resources website for the HSA contribution proration chart.<br />

No, I do not want this benefit<br />

Annual Plan Year<br />

Contribution<br />

Divided By<br />

Number of Pay<br />

Periods Left<br />

from Effective<br />

Date<br />

Equals<br />

Total Pay Period<br />

Cost<br />

$ / =<br />

Limited Option FSA<br />

Yes, I wish to contribute. Decide the amount you wish to contribute for the plan year. Use the table to<br />

determine the amount per pay period. The maximum contribution amount is $96.15 per pay period. Please<br />

note that in order to enroll in the Limited Option FSA you must elect the United<strong>Health</strong>care HSA Plan. The<br />

Limited Option FSA only covers Dental and Vision related expenses.<br />

No, I do not want this benefit<br />

Annual Plan Year<br />

Contribution<br />

Divided By<br />

Number of Pay<br />

Periods Left<br />

from Effective<br />

Date<br />

Equals<br />

$ / =<br />

Total Pay Period<br />

Cost<br />

DENTAL BENEFITS Associate Only Two-Party Family No Coverage<br />

Preventive Dental Plan<br />

Full-Time $0.00 $2.24 $7.04 $0.00<br />

Part-Time $1.68 $3.92 $8.71 $0.00<br />

Preferred Dental Program<br />

Full-Time $5.26 $13.00 $24.23 $0.00<br />

Part-Time $6.67 $14.40 $25.64 $0.00<br />

VISION BENEFITS Associate Only Two-Party Family No Coverage<br />

Full-Time & Part-time $2.91 $5.47 $7.96 $0<br />

<strong>New</strong> <strong>Hire</strong> <strong>Worksheet</strong> 12-13


Your Name________________________________ Associate ID #__________________________<br />

SHORT TERM DISABILITY Coverage No Coverage<br />

Full-Time & Part-Time Yes $________Cost No<br />

<strong>Benefit</strong>: 26 week benefit at 50% of base weekly wage up to a maximum of $500 per week.<br />

Calculation: Multiply your hourly rate by your budgeted hours per pay period. Divide your answer by 100<br />

then multiply that answer by $.45<br />

Note: Use $25.00 as your hourly rate if your hourly rate is $25.00 or greater or if your annual salary is<br />

$52,000 or greater. A salary of $52,000 or greater is subject to the maximum of $9.00 per pay period.<br />

LONG TERM DISABILITY 60% <strong>Benefit</strong> 50% <strong>Benefit</strong> No Coverage<br />

Full-Time Employer Paid N/A N/A<br />

Part-Time<br />

60% <strong>Benefit</strong><br />

$________Cost<br />

50% <strong>Benefit</strong><br />

$________Cost<br />

No<br />

<strong>Benefit</strong>: 50% or 60% of base monthly salary up to $10,000 per month.<br />

Calculation: Multiply your hourly rate by your budgeted hours per pay period. Divide your answer by 100<br />

then multiply that answer by $.396 for a 50% benefit or multiply your answer by $.549 for a 60% benefit.<br />

HEALTH CARE FLEXIBLE SPENDING ACCOUNT<br />

Yes, I wish to contribute. Decide the amount you wish to contribute for the plan year. Use the table to<br />

determine the amount per pay period. The maximum contribution amount is $96.15 per pay period.<br />

No, I do not want this benefit<br />

Annual Plan Year<br />

Contribution<br />

Divided By<br />

Number of Pay<br />

Periods Left from<br />

Effective Date<br />

Equals<br />

Total Pay Period<br />

Cost<br />

$ / =<br />

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT<br />

Yes, I wish to contribute. Decide the amount you wish to contribute for the plan year. Use the table to<br />

determine the amount per pay period. The maximum contribution amount is $192.30 per pay period.<br />

No, I do not want this benefit<br />

Annual Plan Year<br />

Contribution<br />

Divided By<br />

Number of Pay<br />

Periods Left from<br />

Effective Date<br />

Equals<br />

Total Pay Period<br />

Cost<br />

$ / =<br />

<strong>New</strong> <strong>Hire</strong> <strong>Worksheet</strong> 12-13


Your Name________________________________ Associate ID #__________________________<br />

BASIC LIFE INSURANCE<br />

You are eligible to receive a life insurance benefit equal to one times your base annual salary provided by<br />

<strong>Centura</strong> at no cost to you. Imputed income will be assessed for any benefit over $50,000 as required by<br />

Section 79 of the Internal Revenue code. Associates with a base annual salary equal to the social security<br />

wage base of $110,100 or over, will receive an additional one times base annual salary of company<br />

provided life insurance to a maximum of $250,000.<br />

ASSOCIATE SUPPLEMENTAL LIFE INSURANCE<br />

Coverage $_____________________ (increments of $10,000)<br />

No Coverage<br />

Refer to the Life Insurance Rate Sheet located on My Virtual Workplace to find the pay period cost.<br />

NOTE: associates may purchase supplemental life insurance in increments of $10,000 not to exceed the<br />

lesser of 4x your base annual salary or $750,000. The combination of basic and supplemental life cannot<br />

exceed the lesser of 5x your base annual earnings or $750,000. If you enroll when you first become eligible<br />

for coverage you may elect up to the lesser of 3x your base annual salary or $500,000 without completing<br />

an Evidence of Insurability (EOI) form. All amounts over 3x your base annual salary or an increase to your<br />

coverage after your initial enrollment period are subject to approval. The EOI form will be mailed to you<br />

from the Life Insurance carrier with instructions for completion.<br />

SPOUSE AND CHILD LIFE INSURANCE<br />

Eligible dependents who meet any of the following criteria on the day they become eligible for benefits will<br />

not be covered until the applicable condition(s) end. Coverage will begin the following day.<br />

If an eligible Spouse or Dependent Child is hospitalized or confined because of illness or disease on the<br />

date that his or her coverage would be otherwise effective, his or her effective date will be delayed until he<br />

or she is released from such hospitalization or confinement. This does not apply to a newborn child.<br />

However, in no event will insurance on a dependent be effective before your insurance is effective.<br />

Life insurance benefits are not available for the following dependents when:<br />

• The associate does not have legal custody of the dependent<br />

SPOUSE LIFE INSURANCE<br />

Coverage $_____________________ (increments of $10,000)<br />

No Coverage<br />

Refer to the Life Insurance Rate Sheet located on My Virtual Workplace to find the pay period cost. The<br />

premiums are based on the associate’s age, not the age of the covered spouse.<br />

NOTE: <strong>New</strong>ly hired or newly eligible associates may elect any amount of coverage up to $200,000. If you<br />

enroll your spouse when he or she first becomes eligible for coverage you may elect up to $50,000 of<br />

spouse life insurance without submitting an Evidence of Insurability (EOI) form. However, if you choose to<br />

purchase more than $50,000 of spouse life insurance or an increase to his or her coverage after their initial<br />

enrollment period an EOI form must be submitted for approval by the insurance carrier. The EOI form will<br />

be mailed to you from the Life Insurance carrier with instructions for completion.<br />

<strong>New</strong> <strong>Hire</strong> <strong>Worksheet</strong> 12-13


Your Name________________________________ Associate ID #__________________________<br />

CHILD LIFE INSURANCE<br />

Coverage $_____________________ (increments of $2,000)<br />

No Coverage<br />

Select coverage from $2,000 to $20,000 in units of $2,000. Refer to the Life Insurance Rate Sheet located<br />

on My Virtual Workplace to find the pay period cost. (The child life cost is the same regardless of how many<br />

children are covered).<br />

ACKNOWLEDGEMENT<br />

I acknowledge receipt of the <strong>Benefit</strong> Enrollment materials and have read and understand my benefits. I<br />

authorize the elections, premiums, and contributions on this form. If I have elected no medical coverage, I<br />

certify that I have and will maintain adequate coverage under another medical plan. I also understand these<br />

elections cover the full plan year unless I have a qualifying life event.<br />

I acknowledge that if I have elected a <strong>Health</strong> Savings Account contribution through payroll deduction, I<br />

authorize <strong>Centura</strong> <strong>Health</strong> to provide information to Optum<strong>Health</strong> Bank to facilitate opening an account on<br />

my behalf.<br />

<strong>Centura</strong> may need to use and disclose my or my dependents, health information in order to carry out<br />

treatment, payment and health care operations functions as more fully described in the Notice of Privacy<br />

Practices. I understand that I am consenting to the use and disclosure of my or my dependents, health<br />

information for the purposes of payment, treatment and health care operations as required under applicable<br />

laws. "<strong>Health</strong> Information" refers to me, or my dependents, individually identifiable health information.<br />

“<strong>Health</strong> Care Operations" includes general, administrative, and business functions necessary for <strong>Centura</strong> to<br />

operate its health plan in an efficient, safe and legal manner. I have received a copy of <strong>Centura</strong> <strong>Health</strong><br />

<strong>Benefit</strong>s Notice of Privacy Practices or have had the opportunity to print out or otherwise receive the Notice<br />

of Privacy Practices.<br />

I understand that if I fail to enroll in the benefits provided within the 31-day time frame, enrollment<br />

deadline, I will need to wait until the next open enrollment period or experience a qualifying life<br />

event.<br />

Signature_____________________________________<br />

Date_________________________________<br />

<strong>New</strong> <strong>Hire</strong> <strong>Worksheet</strong> 12-13

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