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Health care plan rates: Long-term disability

Long-term disability rates

January 1 – June 30, 2021

Full-Time Employees Earning < $62,100

Monthly Premium Contributions
University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $0.00 $0.00
YOUR HSA-Eligible Plan $0.00 $0.00
Quarterly Premium Contributions
University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $0.00 $0.00
YOUR HSA-Eligible Plan $0.00 $0.00

Full-Time Employees Earning $62,100 – $132,500 and Part-Time Employees < $132,500 with more than 5 Years of Service

Monthly Premium Contributions
University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $58.76 $117.52
YOUR HSA-Eligible Plan $1.36 $2.72
Quarterly Premium Contributions
University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $176.28 $352.56
YOUR HSA-Eligible Plan $4.08 $8.16

Part-Time Employees Earning < $132,500 with less than 5 Years of Service

Monthly Premium Contributions

University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $108.16 $216.32
YOUR HSA-Eligible Plan $54.76 $109.52

Quarterly Premium Contributions

University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $324.48 $648.96
YOUR HSA-Eligible Plan $164.28 $328.56

Employees Earning > $132,500

Monthly Premium Contributions

University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $157.54 $315.08
YOUR HSA-Eligible Plan $107.52 $215.04

Quarterly Premium Contributions

University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $472.62 $945.24
YOUR HSA-Eligible Plan $322.56 $645.12

Share of Dental Premiums

Monthly Premium Contributions

University Dental Plans**
Single Family
Traditional Dental Plan $4.38 $8.94
Medallion Dental Plan $13.76 $28.22

* The rates above apply only to Faculty/Staff/SEIU members on Long-Term Disability who are Medicare-eligible and whose spouse or domestic partner are also Medicare-eligible. Medicare is the primary payer for health care expenses and the above plans through the University are the secondary payer. Therefore, the above University Health Care Plans will not cover any expenses that would have been covered under Medicare Part A and Part B if you were enrolled (commonly known as “carve out” plans).

** Eligibility rules apply

Full-Time Employees Earning < $62,100

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $105.32 $339.20 $248.76 $189.50
YOUR HSA-Eligible Plan $10.76 $34.66 $25.42 $19.36
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $315.96 $1,017.60 $746.28 $568.50
YOUR HSA-Eligible Plan $32.28 $103.98 $76.26 $58.08

Full-Time Employees Earning $62,100 – $132,500 and Part-Time Employees < $132,500 with more than 5 Years of Service

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $164.08 $528.44 $387.54 $295.32
YOUR HSA-Eligible Plan $12.12 $39.02 $28.62 $21.78
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $492.24 $1,585.32 $1,162.62 $885.96
YOUR HSA-Eligible Plan $36.36 $117.06 $85.86 $65.34

Part-Time Employees Earning < $132,500 with less than 5 Years of Service*

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $213.48 $687.54 $504.22 $384.26
YOUR HSA-Eligible Plan $65.52 $211.02 $154.76 $117.90
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $640.44 $2,062.62 $1,512.66 $1,152.78
YOUR HSA-Eligible Plan $196.56 $633.06 $464.28 $353.70

Employees Earning > $132,500

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $262.86 $846.58 $620.84 $473.14
YOUR HSA-Eligible Plan $118.28 $380.94 $279.36 $212.86
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $788.58 $2,539.74 $1,862.52 $1,419.42
YOUR HSA-Eligible Plan $354.84 $1,142.82 $838.08 $638.58

* The rates above apply to Faculty/Staff/SEIU members on Long-Term Disability who are not eligible for Medicare. The University Health Care Plan will be primary payer for health care expenses.

Full-Time Employees Earning < $62,100

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $0.00 $189.58 $105.32 $84.18
YOUR HSA-Eligible Plan $0.00 $19.36 $10.76 $8.60
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $0.00 $568.74 $315.96 $252.54
YOUR HSA-Eligible Plan $0.00 $58.08 $32.28 $25.80

Full-Time Employees Earning $62,100 – $132,500 and Part-Time Employees < $132,500 with more than 5 Years of Service

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $58.76 $354.10 $222.84 $190.00
YOUR HSA-Eligible Plan $1.36 $23.18 $13.48 $11.02
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $176.28 $1,062.30 $668.52 $570.00
YOUR HSA-Eligible Plan $4.08 $69.54 $40.44 $33.06

Part-Time Employees Earning < $132,500 with less than 5 Years of Service*

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $108.16 $492.42 $321.64 $278.94
YOUR HSA-Eligible Plan $54.76 $172.70 $120.28 $107.14
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $324.48 $1,477.26 $964.92 $836.82
YOUR HSA-Eligible Plan $164.28 $518.10 $360.84 $321.42

Employees Earning > $132,500

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $157.54 $630.68 $420.40 $367.82
YOUR HSA-Eligible Plan $107.52 $320.42 $225.80 $202.10
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $472.62 $1,892.04 $1,261.20 $1,103.46
YOUR HSA-Eligible Plan $322.56 $961.26 $677.40 $606.30

*The rates above apply to Faculty/Staff/SEIU members on Long-Term Disability who are Medicare-eligible or whose dependents are Medicare-eligible. For the Medicare-eligible member only, Medicare is the primary payer for health care expenses and the University Health Care Plans are the secondary payer. Therefore, the University Health Care Plans will not cover any expenses that would have been covered under Medicare Part A and Part B if the Medicare-eligible member were enrolled (commonly known as “carve out” plans). The University Health Care Plans will continue to be primary payer for health care expenses for members not eligible for Medicare.

July 1 – December 31, 2021

Full-Time Employees Earning < $62,100

Monthly Premium Contributions
University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $0.00 $0.00
YOUR HSA-Eligible Plan $0.00 $0.00
Quarterly Premium Contributions
University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $0.00 $0.00
YOUR HSA-Eligible Plan $0.00 $0.00

Full-Time Employees Earning $62,100 – $132,500 and Part-Time Employees < $132,500 with more than 5 Years of Service

Monthly Premium Contributions
University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $61.14 $122.28
YOUR HSA-Eligible Plan $1.78 $3.56
Quarterly Premium Contributions
University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $183.42 $366.84
YOUR HSA-Eligible Plan $5.34 $10.68

Part-Time Employees Earning < $132,500 with less than 5 Years of Service

Monthly Premium Contributions

University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $112.56 $225.12
YOUR HSA-Eligible Plan $57.00 $114.00

Quarterly Premium Contributions

University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $337.68 $675.36
YOUR HSA-Eligible Plan $171.00 $342.00

Employees Earning > $132,500

Monthly Premium Contributions

University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $163.94 $327.88
YOUR HSA-Eligible Plan $111.90 $223.80

Quarterly Premium Contributions

University Health Care Plans Single Employee & Spouse/ Domestic Partner
YOUR PPO Plan $491.82 $983.64
YOUR HSA-Eligible Plan $335.70 $671.40

Share of Dental Premiums

Monthly Premium Contributions

University Dental Plans**
Single Family
Traditional Dental Plan $4.50 $9.16
Medallion Dental Plan $14.10 $28.88

Quarterly Premium Contributions

University Dental Plans**
Single Family
Traditional Dental Plan $13.50 $27.48
Medallion Dental Plan $42.30 $86.64

* The rates above apply only to Faculty/Staff/SEIU members on Long-Term Disability who are Medicare-eligible and whose spouse or domestic partner are also Medicare-eligible. Medicare is the primary payer for health care expenses and the above plans through the University are the secondary payer. Therefore, the above University Health Care Plans will not cover any expenses that would have been covered under Medicare Part A and Part B if you were enrolled (commonly known as “carve out” plans).

** Eligibility rules apply

Full-Time Employees Earning < $62,100

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $109.62 $353.00 $258.90 $197.22
YOUR HSA-Eligible Plan $11.20 $36.08 $26.46 $20.16
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $328.86 $1,059.00 $776.70 $591.66
YOUR HSA-Eligible Plan $33.60 $108.24 $79.38 $60.48

Full-Time Employees Earning $62,100 – $132,500 and Part-Time Employees < $132,500 with more than 5 Years of Service

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $170.76 $549.96 $403.32 $307.34
YOUR HSA-Eligible Plan $12.98 $41.78 $30.64 $23.32
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $512.28 $1,649.88 $1,209.96 $922.02
YOUR HSA-Eligible Plan $38.94 $125.34 $91.92 $69.96

Part-Time Employees Earning < $132,500 with less than 5 Years of Service*

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $222.18 $715.52 $524.74 $399.90
YOUR HSA-Eligible Plan $68.20 $219.60 $161.06 $122.70
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $666.54 $2,146.56 $1,574.22 $1,199.70
YOUR HSA-Eligible Plan $204.60 $658.80 $483.18 $368.10

Employees Earning > $132,500

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $273.56 $881.04 $646.12 $492.40
YOUR HSA-Eligible Plan $123.10 $396.44 $290.74 $221.52
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $820.68 $2,643.12 $1,938.36 $1,477.20
YOUR HSA-Eligible Plan $369.30 $1,189.32 $872.22 $664.56

* The rates above apply to Faculty/Staff/SEIU members on Long-Term Disability who are not eligible for Medicare. The University Health Care Plan will be primary payer for health care expenses.

Full-Time Employees Earning < $62,100

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $0.00 $197.32 $109.62 $87.60
YOUR HSA-Eligible Plan $0.00 $20.16 $11.20 $8.96
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $0.00 $591.96 $328.36 $262.80
YOUR HSA-Eligible Plan $0.00 $60.48 $33.60 $26.88

Full-Time Employees Earning $62,100 – $132,500 and Part-Time Employees < $132,500 with more than 5 Years of Service

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $61.14 $368.50 $231.90 $197.72
YOUR HSA-Eligible Plan $1.78 $25.14 $14.76 $12.12
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $183.42 $1,105.50 $695.70 $593.16
YOUR HSA-Eligible Plan $5.34 $75.42 $44.28 $36.36

Part-Time Employees Earning < $132,500 with less than 5 Years of Service

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $112.56 $512.48 $334.74 $290.28
YOUR HSA-Eligible Plan $57.00 $179.76 $125.20 $111.50
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $337.68 $1,537.44 $1,004.22 $870.84
YOUR HSA-Eligible Plan $171.00 $539.28 $375.60 $334.50

Employees Earning > $132,500

Monthly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $163.94 $656.34 $437.50 $382.78
YOUR HSA-Eligible Plan $111.90 $333.48 $235.00 $210.32
Quarterly Premium Contribution
University Health Care Plans Single Family Employee & Spouse/ Domestic Partner Employee & Child(ren)
YOUR PPO Plan $491.82 $1,969.02 $1,312.50 $1,148.34
YOUR HSA-Eligible Plan $335.70 $1,000.44 $705.00 $630.96

*The rates above apply to Faculty/Staff/SEIU members on Long-Term Disability who are Medicare-eligible or whose dependents are Medicare-eligible. For the Medicare-eligible member only, Medicare is the primary payer for health care expenses and the University Health Care Plans are the secondary payer. Therefore, the University Health Care Plans will not cover any expenses that would have been covered under Medicare Part A and Part B if the Medicare-eligible member were enrolled (commonly known as “carve out” plans). The University Health Care Plans will continue to be primary payer for health care expenses for members not eligible for Medicare.

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