Employee Medical Dental

Synod of the Pacific

Benefits Services

The Synod of the Pacific offers comprehensive medical, dental and vision insurance coverage along with many voluntary benefits such as a 125 Flexible Spending Account, and several AFLAC plans, to all of its lay employees who work twenty hours or more per week. There are no physical examinations and no exclusions for pre-existing conditions.

The Synod has several medical plans it offers: Blue Cross HMO, Blue Cross PPO, and Blue Cross PPO Plus (HIA) and Kaiser plans in California; residents outside California are offered the Blue Cross PPO Plus (HIA) plan and Kaiser (depending on the State). Each plan includes complete head to toe coverage, a prescription plan and vision benefits; all this, plus competitive pricing too.

Our Self Insured Dental Plan thru Delta Dental allows you to choose your own dentist. In addition, there is a dentist Network available, if your provider is part of this network, you can enjoy less out of pocket expenses. All claims billing is done for you by your dentist’s office.

Eligibility l

You must be an employee of a church or affiliated organization of the Synod of the Pacific, working twenty hours or more per week.
Lay Employees (and their dependents) are eligible to participate in these programs after a sixty day waiting period, (from “date of hire”).
Ordained Clergy* may enroll immediately, coverage will begin the first day of the month following their date of hire. However, if the date of hire is the first day of the month, coverage would begin immediately.
Coverage must be provided by the employing organization, as part of its standard employee benefits package.
Employing organizations must provide all employees with fair and equal coverage within each basic employment classification. Basic Employment Classifications are:

1. Ordained Clergy*

2. Non-Ordained Exempt Staff

Christian Education Directors

Business Managers, etc.

3. Non-Exempt Staff

Clerical Staff

Custodians, etc.

Employing organizations must agree to pay at least the member portion of premiums.
Dependent coverage may be paid by plan members through pretax payroll deduction.

All terminations must be sent in writing to the Synod office no less than thirty days prior to employees last day. Coverage will end on the last day of the month; there are no pro-rated terminations.

Should you have any questions, please feel free to contact Carolyn Linzner at (800) 754-0669 or by email at carolyn@synodpacific.org.

* The Synod of the Pacific’s Health Benefits are available to Ordained Clergy on a voluntary basis. Our medical plans do not compete or replace the Board of Pension’s medical plan.

2010 Medical Plan Summaries

EFFECTIVE NOVEMBER 1, 2009

Anthem Blue Cross & Kaiser HMO & Blue Cross PPO PLANS

*Description*	*Anthem BC HMO*	Kaiser HMO	*Anthem Blue Cross PPO*		*Anthem Blue Cross* *PPO* *Plus (HIA)*
*Lifetime Maximum*	Unlimited		$5,000,000/member		$5,000,000/member
*Annual Deductible*	None		$250.00 – Individual $750.00 - Family		$1,500 – Individual($750-1st $ benefit) $3,000 – Family ($1500 - 1st $ benefit)
*Annual Out of Pocket Maximum* Individual Family	$ 500 $1,500	$1,500 $3,000	$2,000 – member/In-Network $6,000 – member/Non PPO Provider		$3,000 – Mem/$6,000 – Family/ In-Network $6,000 – Mem/$12,000 – Fam/Out-of-Network
			In Network	Out-Of-Network	In Network	Out-of-Network
*Professional*
Physician Visit	$20 Copay		$20 Copay	40%	10%	30%
Specialist	$20 Copay		$15 Copay	40%/after ded	10%	30%
Physical Therapy	$20 Copay		20%	40%	10%	30%
Home Health Care	$20 Copay	100%	20%	40%	10%	30%
*Hospital Services*
Inpatient	$250 Copay		20%	40%	10%	30%
Outpatient	100%	$20 Copay	20%	40%	10%	30%
Emergency Room	$100 Copay, waived if admitted		$100 Deductible, waived if admitted		10%
*Lab & X-Ray*	100%		20%	40%	10%	30%
*Durable Medical Equipment*	100%, $5,000 max	80%	20%	40%	10%	30%
*Preventive Care*
Adult	$20 Copay	$5 Copay	$20 Copay	40%	No Copay	30%
Children	$20 Copay	$5 Copay	$20 Copay	40%	No Copay	30%
*Maternity*
Office Visits	$20 Copay		$20 Copay	40%	10%	30%
Hospitalization	$250 per admission		20%	40%	10%	30%
*Mental Health*
Inpatient	Non - severe not covered	$250 per admission	20%	40%	10%	30%
Outpatient	$35 Copay, max 20 visits	$20 Copay max 20 visits	20%	40%	10%	30%
*Chemical Dependency*
Inpatient	$250 Copay		20%	40%	10%	30%
Outpatient	Not Covered	$20 Copay	20%	40%	10%	30%
*Chiropractic Benefit*	PCP referred	$15 Copay 30 visits	20%	40%	10%	30%
*Vision Benefit*	Covered thru VSP Plan		Covered thru VSP Plan		Covered thru VSP Plan
*Prescription Drug*
Generic	$10 Copay		$10 Copay	50%	10%	30%
Brand	$20 Copay		$20 Copay	50%	10%	30%
Non-Formulary	$40 Copay	Must be Formulary	$40 Copay	50%	10%	30%
Days Supply	30 days		30 days		30 days

2010 Delta Dental and Vision Benefits Summaries

EFFECTIVE November 1, 2009

Dental Benefits	In Network	Out of Network	Vision Benefits	In Network	Out of Network
Calendar Year Deductible Per Person Family Unit	$50 $50	$150 $150	Copayment Exam Materials	$10.00 $25.00
Annual Benefit Maximum Per Covered Person	$1,500	$1,500	Eye Exams	$100%	$46.00 max
Preventive Service (deductible waived) Emergency Palliative Treatment Oral Examination - every 6 months X-rays - four bitewings every 12 months, full mouth series every 5 years Teeth Cleaning - every 6 months Fluoride Treatment for Children Space Maintainers for Children Topical Sealants (up to age 16)	100%	100%	Lenses Frequency: Every 12 months Single Vision Bifocal Trifocal Lenticular Note: Percentages and dollar amounts are after copayment.	100% 100% 100% 100%	$47.00 max $66.00 max $85.00 max $125.00 max
Basic Service Laboratory Test Diagnostic Consultation - one per year Fillings: Amalgam, Silicate, Acrylic Crowns: Stainless Steel Repairs of dentures, bridgework, crowns Endodontic Services/Root canal Periodontal Services Oral Surgery - Uncomplicated extractns General Anesthesia - Surgical procedures only Injectable Antiobiotics	90%	80%	Contact Lenses Fequency: Every 12 Months Medically Necessary Elective (maximum) *Copay does not apply (If you choose contact lenses, you will not be eligible to receive lenses for 12 onths and frames for 24 months following the date contacts were obtained.)	100% $120.00	$210.00 max $120.00 max
Major Services Bridges Installation fixed or removable Dentures - Full or Partial Crowns: Acrylic Metal, Porcelain Inlays Onlays Posts	60%	50%	Frames Frequency: Every 24 Months	$120.00
Orthodontics (Under age 19) $1,500 Lifetime Maximum Deductible does not apply	50%	50%

Synod of the Pacific

2010 Medical and Dental Monthly Insurance Rates

EFFECTIVE NOVEMBER 1, 2009

DENTAL INSURANCE OPTIONAL VISION INSURANCE DENTAL/VISION PACKAGE


Delta Dental Insurance		Vision Plan (VSP)		Dental/Vision Package
Employee	$65.00	Employee	$18.00	Employee	$79.40
EE + Dependent	$115.00	EE + Dependent	$35.00	EE + Dependent	$143.00
EE + Family	$170.00	EE + Family	$55.00	EE + Family	$214.00

MEDICAL INSURANCE (Includes Vision Benefit)


California Plans		Outside California Plans
Blue Cross HMO
Employee	$637.12
EE + Spouse	$1,397.26	HMO NOT AVAILABLE
EE + Child(ren)	$1,143.23
Family	$1,966.64

Blue Cross PPO		BlueCard PPO
Employee	$683.68	Employee	$760.35
EE + Spouse	$1,493.67	EE + Spouse	$1,662.40
EE + Child(ren)	$1,223.03	EE + Child(ren)	$1,361.08
Family	$2,100.47	Family	$2,338.18

PPO Plus (HIA)		PPO Plus (HIA)
Employee	$596.10	Employee	$601.67
EE + Spouse	$1,294.74	EE + Spouse	$1,312.98
EE + Child(ren)	$1,065.25	EE + Child(ren)	$1,075.20
Family	$1,828.63	Family	$1,845.72

Kaiser Permanente HMO		Kaiser Northwest HMO
Employee	$594.33	Employee	$489.16
EE + Spouse	$1,284.69	EE + Spouse	$968.29
EE + Child(ren)	$1,060.35	EE + Child(ren)
Family	$1,810.71	Family	$1,448.44

Note: The Synod’s general participation guidelines state that the employer will pay the employee cost for HMO coverage.

These rates are guaranteed based on the Synod’s current participation. We do not anticipate any enrollment challenges; however,

it is our duty to inform our participants there is always the possibility of being re-rated should we not meet the carrier’s participation

requirements.

Please call or email Carolyn Linzner (carolyn@synodpacific.org), Benefits Coordinator, with your questions (800) 754-0669.

Downloads

Enrollment Froms	Benefit Summaries
Medical	Medical
Anthem Blue Cross	*California Plans*
Anthem Blue Cross Change Form	Blue Cross HMO
Kaiser Permanente (CA)	Blue Cross PPO
Kaiser Northwest (OR & WA)	Blue Cross PPO Plus (HIA)
	Kaiser Permanente (CA)
Dental and Vision
Delta Dental	*Out of State Plans*
VSP	Anthem BlueCard PPO
	Blue Cross PPO Plus (HIA)
Voluntary Benefits	Kaiser Northwest
Life Insurance
Reliance Life	Blue Cross Prescription Plan
	Prescription Mail Service
Section 125 FBA	Blue Cross Healthy Extensions
Section 125 Packet
	*Dental*
	Deltal Dental Benefits Highlights