department of education division of human resources

DEPARTMENT OF EDUCATION

DIVISION OF HUMAN RESOURCES

Benefits Administration Guidelines

The Government of the United States Virgin Islands

Health Insurance Program

Review of Points1. Introduction2. Overview of Fundamental Polices

I - Legislative Compliance II- Participation in Non-Contributory

Benefits III – Annual Enrollment Period

INTRODUCTION The Health Insurance Program for Government

Employees, Retirees and their Dependents, is administered by the Health Insurance Office, under the Division of Personnel. Included in the program are the employees and dependents of the Virgin Islands Port Authority and the University of the Virgin Islands.

In order to ensure consistency, and maintain accountability in the administration of the group program., the following policies and procedures were implemented effective October1, 2001. For additional information regarding the Government of the US Virgin Islands’ Health Insurance Program, you may contact the Health Insurance Office at 714-5000.

Enrollment Criteria & Eligibility I -Current Employees & Retirees-Basic Life II - Current Employees & Retirees -Dependent

Life III- Current Employees & Retirees-Supplement

Life IV- Current Employees & Retirees-Medical and

Dental V - Newly Hired Employees VI – New Retires

Summary of Benefits

I – Medical CoverageII – Dental CoverageIII – Life Coverage

Overview of Fundamental Policies

I. Legislative Compliance In accordance with the Virgin Islands Code

Title 3, Section 634. Subsection A, all full-time employees will be required to enroll for medical coverage unless they can provide proof of medical coverage via another source.

Participation in Non-Contributory Benefits

All full time employees are eligible to receive a $10,000 non-contributory basic life and accidental death and dismemberment benefit, whether or not they enroll for health benefits. A completed enrollment form must be forwarded to the Health Insurance Office appropriately signed and dated, indicating a designated beneficiary.

Annual Enrollment PeriodEmployees and retirees will be allowed

to enroll or make changes to any line of coverage only during annual enrollment periods, unless a qualifying event occurs before such time. Qualifying events include, but are not limited to births adoptions, change in dependent’s age, marriage, divorce death

Annual Enrollment Period-cont.

Qualifying events include, but are not limited to births adoptions, change in dependent’s age, marriage, divorce, death or similar occurrence.

Specifics of Fundamental Policies

1. An employee refusing medical coverage must present proof of coverage via another source.

2. An employee or retiree who did not enroll for medical insurance when first eligible, will be allowed to do so only during an annual enrollment period, unless a qualifying event occurs before the annual enrollment period


3. An employee or retiree who does not wish to enroll for medical insurance is eligible to enroll for basic life insurance and supplemental life when first eligible or during the annual enrollment period, and dependent life insurance when first eligible, at annual enrollment or when a qualifying event occurs.


4. An employee or retiree electing life insurance benefits only must submit a completed enrollment form indicating a designated beneficiary. Current employees and retirees who have not submitted a completed form previously, may do so during an annual enrollment period.


5. During annual enrollment periods, an employee or retiree currently enrolled may elect to increase supplemental life insurance amounts in increments of $5,000 without evidence of insurability, or with evidence of insurability increase their life insurance coverage to any amount. When first eligible, an employee may elect supplemental life insurance coverage in any amount without evidence of insurability.


6. During annual enrollment periods, an employee or retiree not currently enrolled may elect dependent life insurance for a spouse or children with evidence of insurability. When first eligible an employee may elect dependent life insurance coverage without evidence of insurability.

Special Policy Note

Only one parent is allowed to cover dependent children for dependent life insurance, as only one (1) dependent life benefit is applicable and payable per child.

Enrollment Criteria & Eligibility

I. Current Employee and Retiree (Basic Life & Accidental Death & Dismemberment Insurance

During annual enrollment periods, no action is necessary for employees and retirees who are enrolled for basic life and accidental death and dismemberment insurance to continue coverage for this benefit. Current employees and retirees not enrolled for basic life and accidental death and dismemberment insurance, will be allowed to enroll for these benefits during annual enrollment periods.

Enrollment Criteria & Eligibility

I. Current Employee and Retiree (Basic Life & Accidental Death & Dismemberment Insurance

Current employees and retirees not enrolled for basic life and accidental death and dismemberment insurance, will be allowed to enroll for these benefits during annual enrollment periods.

Enrollment Criteria & Eligibility II. Current Employees and retirees( Dependent Life Insurance)

During annual enrollment periods, no action is necessary for employees and retirees who are enrolled for dependent life insurance to continue coverage for this benefit. Employees and retirees not enrolled for dependent life insurance will be allowed to enroll for these benefits during annual enrollment periods, with evidence of insurability.

Enrollment Criteria & Eligibility III. Current Employees and retirees( Dependent Life Insurance)

During the enrollment periods, no action is necessary for employees and retirees to maintain their current supplemental life insurance amount . . To newly elect or increase the current benefit amount in more than $5,000 increments, during annual enrollment periods, employees and retirees must submit evidence of insurability.

Enrollment Criteria & Eligibility IV. Current Employees and Retirees (Medical and Dental)

During annual enrollment periods, no action is necessary for employees and retirees to maintain their current medial and dental insurance selections. During this time, employees and retires may enroll, cancel or make changes to their medical and dental selections.

Enrollment Criteria & Eligibility V. Newly Hired Employees Newly hired employees will be immediately

eligible for coverage. Within 30 days of becoming eligible for coverage, new employees may elect medical and dental, and supplemental life in any amount, and / or dependent life insurance. After such time, these employees will be regarded as current employees, and the criteria outlined in items: I, II, III and IV will apply.

Enrollment Criteria & Eligibility New Retirees Newly eligible retirees will be immediately

eligible to continue or cancel current and/ or newly applicable benefits. Within 30 days of the retirement effective date, an updated enrollment form must be completed, without which, any previously selected and /or newly applicable benefits will take effect. Thereafter, these retirees will be regarded as current retirees, and the criteria outlined in items I II III and IV above will apply.

Summary of Benefits(Refer to Benefit Booklets for more

Details)

I. Medical Effective 10/1/01 In Network Out of

Network Deductible - Individual $50 $250

Family $100 $500 Out of Pocket Maximum Individual $1,500 $3,000 Family $3,000 $6,000 Preventative Care & Office Visits

100% after co pay See Benefits Booklet

Other Covered Expenses

80% after co-pay 60%

II. Dental (Effective 10/1/01)

Deductible Individual $25/ Family -$100 Annual Maximum $1,000 Orthodontia Lifetime Maximum $1000 (for

Dependent Children to age 19) Reimbursement level based on fee schedule

(flat dollars amounts, no percentage levels used)

III Life, AD&D, Supplemental &Dependent Life (Effective 7/1/02

Basic Life Employees $10,000 Accidental Death & Dismemberment $10,000 Supplemental Life Employees Plan A 1,2,3, or 4 times salary rounded up to

the next higher $1,000 to a maximum of $400,000

III Life, AD&D, Supplemental &Dependent Life (Effective 7/1/02

Plan B $5000, $10,000, $15,000, $25,000, $50,000 or $75,000

Basic Life Retirees $5,000 Supplemental Life Retirees $5,000, $10,000,

$15,000, $20,000, $25,000, $30,000, $50,000 or $75,000

Dependent Life Spouse -$5,000 Child - $2,000

6. Highlights of Life Insurance Plan

Effective July 1,2002, MetLife will be the life insurance carrier. An enhanced supplemental life benefit will be offered. In addition to the current benefits, options are available to purchase supplemental life insurance based on a multiple of basic salary. This affords participants the opportunity to increase their current supplemental life benefit. The enhanced supplemental life benefit also increases the maximum supplemental life benefit from $75,000 to $400, 000.

Highlights of Life Plan- cont. Employees currently enrolled for

supplemental life may choose to continue such benefits of transfer coverage as follows without evidence of insurability: Plan B Plan A $5000,$10,000 or $50,000 – 1 times salary to next higher $1,000 $25,000 - 2 times salary to next higher $1,000 $50,000 - 3 times salary to next higher $1,000 $75,000 - 4 times salary to next higher $1,000

Any increases in excess of the established parameters, or in excess of $5,000, will require evidence of insurability.

Highlights of Life Plan- cont. Example- To determine supplemental life benefit

amount: Jane Doe has a $75,000 supplemental life benefit. Jane wishes to increase her current benefit. She is thinking of transferring to 4 times her salary, which is currently $15,000. At 4 times her salary her salary her supplemental life benefit would be $60,000., which turns out to be less than her current $75,000 supplemental life benefit. In James’s case, it would be more beneficial for her to maintain plan B, than to transfer to plan A.

Special Life Plan Notesto Remember

Participants are allowed to elect supplemental life benefits based on Plan A or B, an transfer from Plan B (current options) to Plan A (new options).

Be sure that employee would receive a greater benefit by transferring to a multiple of their salary, if that is their desire.

No evidence of insurability will be required even though transferring from plan B to A will result in increasing the supplemental life insurance benefit by more than $5,000.

7. PAYROLL DEDUCTION Effective October 1, 2002. Payroll deductions for supplemental

life will be shown as a separate deduction from the health (medical and dental) deduction. The single flat rate based on the benefit amount chosen is no longer available to our group policy. The deduction for supplemental life will now be based on the employees age, and the supplemental life benefit amount chosen.

The impact of these age-banded rates is that the younger population would pay significantly less for the benefit amount currently in effect, or slightly less of the same for an increased supplemental life benefit. Similarly, the deduction for dependent life will be shown a a separate deduction , and based on the age of the dependent spouse. The deduction for dependent life for children will remain at a flat amount.

Payroll Deduction- cont. Example – To determine supplemental life payroll deduction:

Jane Doe has a $50,000 supplemental life benefit for which he currently pays $9.27. Jan wishes to increase his supplemental life benefit by transferring to plan A. Based on the established parameters to transfer coverage. Jan is eligible to receive 3 times his alary without completing the evidence of insurability form. (To increase to 4 times his salary, Jan would need to complete the evidence of insurability form). His current salary is $30,000, and he is currently 34 years old, but he will be 35 by October 1, 2002. At 3 times his salary, Jan is eligible to purchase $90,000. Jan’s payroll deduction for supplemental life is:

Payroll Deduction- cont.

Jan’s payroll deduction for supplemental life is:

Determining Supplemental Life Payroll Deduction (cont.)

Using the chart: Age 35-39 at $30,000 (since 30 x 3 is 90) $1.935 x 3 = $5.805 Or Age 35-39 at $45,000 (since 45 x 2 is 90) $2.903 x 2= $5.806 (there may be slight differential in calculations due to rounding of

decimals) Notes: The bi-weekly deduction based on age is reflected on the payroll

deduction worksheet. Be sure to use the age of employee as of the date when the deduction would take effect, not the date that the form is completed. (for 2002 annual enrollment, the effective date is 10/1/02).

Payroll Deduction-(cont.) Even if no change is made to the supplemental life benefit

amount currently in effect, there will be a change in the payroll deduction. In most cases, there will be a reduction in the deduction amount; however, in some instances there may be increases. Please refer to the payroll deduction worksheet to determine the new amount.

If as a result of the age-banded rates, an unacceptable payroll deduction is effected, the participant has two (2) months of four (4) pay periods from the deduction start date, to notify the Health Insurance Office to adjustment the deduction. If this timeframe expires and the participant has not contacted the Health Insurance Office, the deduction will continue until the next annual enrollment period.

General Information Eligible Employees

An employee must consistently work 40 hours a week in order to be eligible to participate in the health insurance program. This includes full-time regular employees, temporary and provisional employees.

Eligible Dependents Eligible dependents include spouses, natural or adopted children under age

19 and children over age 10, but under age 25 who are full-time students. Siblings and parents are not considered eligible dependents. Proof of legitimate dependency will be required at time of enrollment.

Beneficiaries A beneficiary is someone appointed to receive the proceeds of a life

insurance benefit upon death. It is advisable not to appoint minor children: instead appoint a legal guardian in trust for minor children. A beneficiary can be changed at any time.

General Information- cont. Changes

An updated enrollment form is needed when the following changes occur:

Name change (attached supporting documents) Address change Beneficiary change Dependent status change (attached supporting

documents) Benefit Selection change (at annual enrollment, unless a

qualifying event occurs).

General Information-contQualifying Events

These are life-changing events such as births, adoptions, marriage, divorces, death, changes in employment, retirement, or loss of coverage. When these events occur, participants and / of dependents have a 30-day window of opportunity to enroll for benefits, for which they or their dependents become eligible as a result of the event.

General Information-cont. Coverage Effective Date

Coverage is effective the first of the month following a qualifying event, except in case of newborns, where coverage is effective on the date of birth.

Note: To facilitate internal processing, enrollments received from the 1st through the 6th of the month will be processed to take effect the 1st of the following month. Enrollments received from the 7th through the end of the same month will be processed to take effect the 1st of the month following the next month.

Coverage Termination Date Coverage terminates on the last day of the month, following

a qualifying event, or the employee’s separation date.

General Information-cont. Conversion Rights

After separation, an employee is eligible to convert their group policy to an individual policy. There is a 30-day window of opportunity, within which the employee must submit their notice of conversion to the Insurance Company. After such time, they are no longer eligible to exercise their conversion right.

Payroll Deduction Start Date Deductions will commence on the 2nd pay period of the

month following the effective date of coverage. Payroll Deduction Stop Date

Deduction will cease on the 1st pay period of the month following the termination date of coverage.

General Information-cont. Premium Payments and Refunds

In some instances, additional premium payments may become due as a result of a qualifying event. At such time, the participant and /or dependent will be required to make such payment in order to effect coverage. If a refund becomes due as the result of a qualifying event, the Health Insurance Office will process the same accordingly.

Note: During annual enrollments, if there are unavoidable delays in processing enrollment information timely to meet the effective or termination date, participants will not be required to remit additional premiums to effect coverage, nor will they be given refunds for overpayments.

General Information-cont.

Leave Without Pay During an unpaid leave, employees participating in

the health insurance program are required to remit premiums for missed health insurance payroll deductions. These payments in the form of money orders, should be payable to the Health Insurance Fund. Failure to remit premiums will result in termination of benefits.

General Information-cont. Procedures for Retiring

When an employee, who is covered under the health insurance program, is planning to retire, the Health Insurance Office must be notified. A new enrollment form must be completed indicating their retirement date, and the benefits and deductions applicable to retirees will take effect on the first of the month following the retirement date.

Note: Retirement is a qualifying event for covered participants.

General Information-cont. Retirement Benefits

At retirement, basic life insurance is reduced to $5,000, and accidental death and dismemberment is not available. The maximum amount of supplemental life benefits available to retirees is $75,000. The medical and dental remain the same

Note: An employee who is enrolled in Plan A (multiple of salary) for the supplemental life insurance, will be entitled to the Plan B (flat amount) equivalent at retirement.

General Information-cont. Death Benefits

Upon death, the designated beneficiary will be eligible to receive the life insurance proceeds of the participant. For dependent life benefits, the beneficiary is the employee. Life insurance benefits are payable by the contracted Insurance Company through the Health Insurance Office.

Q: When may I enroll for Coverage?

A: You may enroll for coverage within 30 days of your date of hire, or during an annual enrollment period. If you are not currently enrolled for coverage, you may be eligible to enroll for coverage during the next annual enrollment period.

Frequently Asked Questions

Q: Once I have enrolled, may I cancel my coverage at any time?

In accordance with the Virgin Islands Code, all Government employees must have medical coverage, either through the Government’s Plan or via another source. As an active employee, you may cancel your coverage at any time, if a qualifying event occurs, which makes you eligible to received coverage elsewhere.

Frequently Asked Questions-cont.

When may I add my dependents to my coverage? You may add your dependents to your coverage

within 30 days of you or them becoming eligible for coverage ( at employment of as qualifying events occur). You will need to submit documents of proof ( such as birth certificates, court documents, marriage certificates, etc.) If they are not added at that time, you may add them during an annual enrollment period. Evidence of insurability will be required for dependent life insurance.


Can I cover all children who live with me? You may only cover those children who are

your natural children ( including step children or legally adopted). To cover any other children under your health insurance, you must present a document showing court appointed guardianship.


Can I drop my dependents from my coverage at any time? You may drop your dependents from your

coverage at annual enrollment, or at any time if a qualifying event occurs. You will need to provide proof of the qualifying event in order to cancel coverage.


Do I need to enroll for this coverage if I have coverage elsewhere? If you have coverage elsewhere, or as a

dependent under this plan, you may or may not elect to enroll for medical coverage. If you elect not to enroll for basic, supplemental, and dependent life insurance.


Can I be covered under this plan if I lose my other coverage? Losing your coverage is regarded as a

qualifying event. As such, you will have 30 days from the date you lose coverage to enroll within that time, you may enroll for coverage during the next annual enrollment period.


If I no longer work for the Government, can I continue my health coverage? You may convert from group policy to an

individual policy administered directly between you and the Insurance Company. You will have to submit your conversion application within 30 days of your separation.

II. Regarding Life Coverage

Can I enroll for Supplemental Life benefits without taking health coverage? As an employee, you are eligible to enroll for Life

insurance, including supplemental life, without enrolling for health coverage. If you do not enroll when you are first eligible, you may enroll at the annual enrollment, at which time, you may be required to provided evidence of insurability for supplemental life insurance benefits.

II. Regarding Life Coverage

If I am enrolled for supplemental life benefits, when can I increase my benefit amount. You may increase your supplemental life

benefit amount at annual enrollment only. Evidence of insurability will be required for increases in excess of $5,000.

Regarding Life Coverage-cont. If I am participating in Plan A (multiple of salary) for

supplemental life and I receive a salary increase, will I need to complete the evidence of insurability form to receive an increased benefit? As long as you are maintaining your current benefit

selection, you will not need to complete the evidence of insurability form to receive an increased benefit. You will only need to complete an enrollment form indicating your new salary amount in order to start the new deduction. The form must be completed within 30 days of the effective date of the increase.

Regarding Life Coverage-cont. If I am participating in Plan B (flat amount), when may

I increase my supplemental life benefit by transferring to Plan A (multiple of salary)? You may transfer to Plan A if you were at the maximum

benefit amount for Plan B, and you receive a salary increase, which would result in an increased supplemental life benefit in you transferred to Plan A. You will need to complete an enrollment form indicating your transfer and new salary amount in order to start the new deduction. The form must be completed within 30 days of the effective date of the increase. You may also transfer at annual enrollment.

Regarding Life Coverage-cont.Can I continue my supplemental life

coverage if I no longer work for the Government? You may continue your supplemental and

dependent life coverage directly with the Insurance Company, if you no longer work for the Government.

Review of Points Covered1. Introduction2. Overview of Fundamental Polices

I - Legislative Compliance II- Participation in Non-Contributory

Benefits III – Annual Enrollment Period

department of education division of human resources

Documents

annual enrollment period

medical insurance

life coverage

annual enrollment period

dependent life insurance

basic life insurance

health insurance office

government employees