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Full Time Employee Hire and Benefit Enrollment Information
The following forms must be completed and returned to the Human Resources Office, J101, in order to be placed on
payroll. Questions can be directed to Human Resources staff at (989)686-9107.
Employee Name: _________________________________________________________ Date of Hire: ______________
Home Phone Number: _________________________________________________ ________
Address: _______________________________________________________
ETHNICITY: (please circle one)
(1-Not Hispanic or Latino) (2-Hispanic or Latino)
GENDER: (please circle one)
(1-Female) (2- Male)
RACE: (please circle one or more):
(African American) (American Indian or Alaskan Native) (Asian) (Caucasian)
(Native Hawaiian or Other Pacific Island)
By signing this form, you are verifying that you have completed the payroll forms and agree to review all of the items listed
below within the first 30 days of employment, including all required training modules.
Employee Signature: _________________________________________________________ Date: _______________________
All new employees are required to review each of the items listed below Family Medical Leave Act – Employee Rights and Responsibilities
General Emergency Evacuation Procedures & Guidelines
HIPAA (Health Insurances Portability and Accountability Act)
Injury/Accident Reporting
Notice Regarding Medicare and Your Prescription Drug Coverage
Regulations and Rules of Conduct
Health Insurance Marketplace Coverage Options
Required Training Modules: Bloodborne Pathogens, Bystander Intervention, Copyright pt1 Provisions, Copyright pt6 Guidelines, Sexual Harassment, Diversity, FERPA, Hazard Communications, Title IX – Higher Ed and SaVE Act.
Additional Information
Delta College's Vision and Mission Statement
Tobacco Free Campus
Delta College Emergency Procedures
Delta College Latex – Safe Product Use Procedure
Electronic Resources – For access to Delta's electronic resources please go through the signup process. You must have completed and returned your payroll paperwork prior to sign up.
Flexible Spending Accounts - Plan Summary (must enroll in the first 30 days)
Payroll dates - employees are paid biweekly on Fridays for the previous 2 weeks (7 days in arrears)
Employment Application – All employees must submit a completed application
Emergency Information
W-4 Form – Federal
W-4 Form – Michigan SW-4 Form – Saginaw (Residents of the City of Saginaw or Employees working within the City of Saginaw ONLY) Employment Eligibility Verification Form (I-9) (identification required - refer to form for options)
Direct Deposit – (OPTIONAL FORM) Employees not selecting direct deposit must pick up their checks at the Cashier’s
Office. Drug Free Work Place Act Hepatitis B Vaccination Acknowledgement and Release Form – Required for Category A Employees only
Retirement Election – (choose one) MPSERS or ORP – Current Retirement Benefits at a Glance
OPTION #1: Michigan Public School Employees Retirement System (MPSERS): MPSERS website
Employer and/or employee contributions. New Employees who elect the Michigan Public School Employees
Retirement System will receive their Member ID in a personalized Welcome Letter. You should receive your
Welcome Letter approximately two weeks after your first pay period. This letter will direct you to log into your
miAccount where you can nominate a beneficiary. Eligible employees who elect MPSERS first will have 90 days
from their full-time date of hire to transfer over to the ORP. Any contributions paid by the employee are also
transferable. After 90 days the election to transfer is irrevocable. Anyone who elects the ORP first will not have
the option to transfer to MPSERS.
OPTION #2 (only available for Full-Time Faculty or Full-time AP staff):
Optional Retirement Plan (ORP) TIAA: ORP-Plan Document
Employer contributes 10%; No employee contribution permitted. This defined contribution plan does not
provide medical, dental, vision or hearing at retirement.
Enroll online at TIAA
Benefits Enrollment Form Health Insurance / Delta Dental Insurance
Health/Vision/Hearing Coverage and Policy Information (Contact HR for information regarding the direct purchase of
insurance options for individuals not covered through a group plan)
Dental Coverage and Policy Information
Life Insurance Enrollment Form-Basic/Optional/Dependent Life Insurance & Group Long Term Disability Insurance
Life Insurance and Long Term Disability - Overview
Long Term Disability:
Two Year Waiting Period (college pays for this benefit after 24 consecutive months) or 90 Day Waiting Period (Payroll
Deduction - employee pays for the first 24 months)
Leave Plans (refer to Benefit Summary)
Category A employee ☐ Yes ☐ NO
o If Category A, employee must complete the attached Hepatitis B Vaccination Form. Form and Exposure
Manual notes Category A positions.
o Exposure Manual is available for review on the Senate Portal page
Center for Organizational Success (COS) / New Employee Orientation (NEO)
Review of Human Resources/Benefits Portal
Review of MyDelta and Web Time Entry
Review of Procedure Manual and Senate Polices within Portal
Emergency Procedures
☐ N-O-R-A: Need Officer Right Away ☐ Emergency Text Notification/Nixle ☐ Adverse Weather
Human Resources staff will provide overview of Educational Opportunities & review the Benefit Summary
Facilities Management Union Employees Only:
34 item checklist Building Entrance Key Consolidated Rules and Regulations
Custodial Handbook Custodial Supply Request Forms
Safety Glasses Work Order Forms Delta College Facilities Management Dress Code
Tuition Reimbursement Program- General Laborers Union Contract
Food Services Union Employees Only:
Assign a Locker Assign a Uniform Tour of the Kitchen
Tour of the College (Cashier’s Office, Public Safety, Parking, Elevators, Coffee n’ More)
Contact Information for the Department Adverse Weather Policy
Call-in Procedure Union Information Food Safety Information and Video
Rev. 1/10/17
Delta College Emergency Information
Employee Name: __________________________________
Position: _________________________________________
Faculty
Staff
Full-time
Part-time
IN CASE OF AN EMERGENCY NOTIFY:
First choice:
Name
Address
Day Phone
Evening Phone
Relationship
Second choice:
Name
Address
Day Phone
Evening Phone
Relationship
1. Do you have any health and/or medication information you want the College to know in
the event of emergency situations:
2. Additional Comments:
Form W-42021
Employee’s Withholding Certificate
Department of the Treasury Internal Revenue Service
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
Give Form W-4 to your employer.
Your withholding is subject to review by the IRS.
OMB No. 1545-0074
Step 1:
Enter
Personal
Information
(a) First name and middle initial Last name
Address
City or town, state, and ZIP code
(b) Social security number
Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.
(c) Single or Married filing separately
Married filing jointly or Qualifying widow(er)
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the estimator at www.irs.gov/W4App, and privacy.
Step 2:
Multiple Jobs
or Spouse
Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spousealso works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . .
TIP: To be accurate, submit a 2021 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.
Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)
Step 3:
Claim
Dependents
If your total income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000 $
Multiply the number of other dependents by $500 . . . . $
Add the amounts above and enter the total here . . . . . . . . . . . . . 3 $
Step 4
(optional):
Other
Adjustments
(a)
Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income . . . . . . . . . . . . 4(a) $
(b)
Deductions. If you expect to claim deductions other than the standard deductionand want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here . . . . . . . . . . . . . . . . . . . . . 4(b) $
(c) Extra withholding. Enter any additional tax you want withheld each pay period . 4(c) $
Step 5:
Sign
Here
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
Employee’s signature (This form is not valid unless you sign it.) Date
Employers
Only
Employer’s name and address First date of employment
Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 10220Q Form W-4 (2021)
Form W-4 (2021) Page 2
General Instructions
Future Developments
For the latest information about developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.
Purpose of Form
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld, you will generally owe tax when you file your tax return and may owe a penalty. If too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to your personal or financial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form W-4, see Pub. 505, Tax Withholding and Estimated Tax.
Exemption from withholding. You may claim exemption from withholding for 2021 if you meet both of the following conditions: you had no federal income tax liability in 2020 and you expect to have no federal income tax liability in 2021. You had no federal income tax liability in 2020 if (1) your total tax on line 24 on your 2020 Form 1040 or 1040-SR is zero (or less than the sum of lines 27, 28, 29, and 30), or (2) you were not required to file a return because your income was below the filing threshold for your correct filing status. If you claim exemption, you will have no income tax withheld from your paycheck and may owe taxes and penalties when you file your 2021 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing “Exempt” on Form W-4 in the space below Step 4(c). Then, complete Steps 1(a), 1(b), and 5. Do not complete any other steps. You will need to submit a new Form W-4 by February 15, 2022.
Your privacy. If you prefer to limit information provided in Steps 2 through 4, use the online estimator, which will also increase accuracy.
As an alternative to the estimator: if you have concerns with Step 2(c), you may choose Step 2(b); if you have concerns with Step 4(a), you may enter an additional amount you want withheld per pay period in Step 4(c). If this is the only job in your household, you may instead check the box in Step 2(c), which will increase your withholding and significantly reduce your paycheck (often by thousands of dollars over the year).
When to use the estimator. Consider using the estimator at www.irs.gov/W4App if you:
1. Expect to work only part of the year;
2. Have dividend or capital gain income, or are subject to additional taxes, such as Additional Medicare Tax;
3. Have self-employment income (see below); or
4. Prefer the most accurate withholding for multiple job situations.
Self-employment. Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from the wages you receive as an employee. If you want to pay these taxes through withholding from your wages, use the estimator at www.irs.gov/W4App to figure the amount to have withheld.
Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.
Specific Instructions
Step 1(c). Check your anticipated filing status. This will determine the standard deduction and tax rates used to compute your withholding.
Step 2. Use this step if you (1) have more than one job at the same time, or (2) are married filing jointly and you and your spouse both work.
Option (a) most accurately calculates the additional tax you need to have withheld, while option (b) does so with a little less accuracy.
If you (and your spouse) have a total of only two jobs, you may instead check the box in option (c). The box must also be checked on the Form W-4 for the other job. If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is roughly accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two jobs.
!CAUTION
Multiple jobs. Complete Steps 3 through 4(b) on only one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying job.
Step 3. This step provides instructions for determining the amount of the child tax credit and the credit for other dependents that you may be able to claim when you file your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 972, Child Tax Credit and Credit for Other Dependents. You can also include other tax credits in this step, such as education tax credits and the foreign tax credit. To do so, add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step 3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return.
Step 4 (optional).
Step 4(a). Enter in this step the total of your other estimated income for the year, if any. You shouldn’t include income from any jobs or self-employment. If you complete Step 4(a), you likely won’t have to make estimated tax payments for that income. If you prefer to pay estimated tax rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals.
Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on your 2021 tax return and want to reduce your withholding to account for these deductions. This includes both itemized deductions and other deductions such as for student loan interest and IRAs.
Step 4(c). Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet, line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe.
Form W-4 (2021) Page 3
Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)
If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.
Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App.
1
Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have onejob, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter that value on line 1. Then, skip to line 3 . . . . . . . . . . . . . . . . . . . . . 1 $
2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3.
a
Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the “Higher Paying Job” row and the annual wages for your next highest paying jobin the “Lower Paying Job” column. Find the value at the intersection of the two household salaries and enter that value on line 2a . . . . . . . . . . . . . . . . . . . . . . . 2a $
b
Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount on line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2b $
c Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . . . . . . 2c $
3 Enter the number of pay periods per year for the highest paying job. For example, if that job paysweekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . . 3
4
Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter thisamount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additionalamount you want withheld) . . . . . . . . . . . . . . . . . . . . . . . . . 4 $
Step 4(b)—Deductions Worksheet (Keep for your records.)
1
Enter an estimate of your 2021 itemized deductions (from Schedule A (Form 1040)). Such deductionsmay include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of your income . . . . . . . . . . . . 1 $
2 Enter: { • $25,100 if you’re married filing jointly or qualifying widow(er)• $18,800 if you’re head of household• $12,550 if you’re single or married filing separately
} . . . . . . . . 2 $
3 If line 1 is greater than line 2, subtract line 2 from line 1 and enter the result here. If line 2 is greater than line 1, enter “-0-” . . . . . . . . . . . . . . . . . . . . . . . . . . 3 $
4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other adjustments (from Part II of Schedule 1 (Form 1040)). See Pub. 505 for more information . . . . 4 $
5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 . . . . . . . . . . . 5 $
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person with no other entries on the form; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.
Form W-4 (2021) Page 4
Married Filing Jointly or Qualifying Widow(er)
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 - 9,999
$10,000 - 19,999
$20,000 - 29,999
$30,000 - 39,999
$40,000 - 49,999
$50,000 - 59,999
$60,000 - 69,999
$70,000 - 79,999
$80,000 - 89,999
$90,000 - 99,999
$100,000 - 109,999
$110,000 - 120,000
$0 - 9,999 $0 $190 $850 $890 $1,020 $1,020 $1,020 $1,020 $1,020 $1,100 $1,870 $1,870
$10,000 - 19,999 190 1,190 1,890 2,090 2,220 2,220 2,220 2,220 2,300 3,300 4,070 4,070
$20,000 - 29,999 850 1,890 2,750 2,950 3,080 3,080 3,080 3,160 4,160 5,160 5,930 5,930
$30,000 - 39,999 890 2,090 2,950 3,150 3,280 3,280 3,360 4,360 5,360 6,360 7,130 7,130
$40,000 - 49,999 1,020 2,220 3,080 3,280 3,410 3,490 4,490 5,490 6,490 7,490 8,260 8,260
$50,000 - 59,999 1,020 2,220 3,080 3,280 3,490 4,490 5,490 6,490 7,490 8,490 9,260 9,260
$60,000 - 69,999 1,020 2,220 3,080 3,360 4,490 5,490 6,490 7,490 8,490 9,490 10,260 10,260
$70,000 - 79,999 1,020 2,220 3,160 4,360 5,490 6,490 7,490 8,490 9,490 10,490 11,260 11,260
$80,000 - 99,999 1,020 3,150 5,010 6,210 7,340 8,340 9,340 10,340 11,340 12,340 13,260 13,460
$100,000 - 149,999 1,870 4,070 5,930 7,130 8,260 9,320 10,520 11,720 12,920 14,120 15,090 15,290
$150,000 - 239,999 2,040 4,440 6,500 7,900 9,230 10,430 11,630 12,830 14,030 15,230 16,190 16,400
$240,000 - 259,999 2,040 4,440 6,500 7,900 9,230 10,430 11,630 12,830 14,030 15,270 17,040 18,040
$260,000 - 279,999 2,040 4,440 6,500 7,900 9,230 10,430 11,630 12,870 14,870 16,870 18,640 19,640
$280,000 - 299,999 2,040 4,440 6,500 7,900 9,230 10,470 12,470 14,470 16,470 18,470 20,240 21,240
$300,000 - 319,999 2,040 4,440 6,500 7,940 10,070 12,070 14,070 16,070 18,070 20,070 21,840 22,840
$320,000 - 364,999 2,720 5,920 8,780 10,980 13,110 15,110 17,110 19,110 21,190 23,490 25,560 26,860
$365,000 - 524,999 2,970 6,470 9,630 12,130 14,560 16,860 19,160 21,460 23,760 26,060 28,130 29,430
$525,000 and over 3,140 6,840 10,200 12,900 15,530 18,030 20,530 23,030 25,530 28,030 30,300 31,800
Single or Married Filing Separately
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 - 9,999
$10,000 - 19,999
$20,000 - 29,999
$30,000 - 39,999
$40,000 - 49,999
$50,000 - 59,999
$60,000 - 69,999
$70,000 - 79,999
$80,000 - 89,999
$90,000 - 99,999
$100,000 - 109,999
$110,000 - 120,000
$0 - 9,999 $440 $940 $1,020 $1,020 $1,410 $1,870 $1,870 $1,870 $1,870 $2,030 $2,040 $2,040
$10,000 - 19,999 940 1,540 1,620 2,020 3,020 3,470 3,470 3,470 3,640 3,840 3,840 3,840
$20,000 - 29,999 1,020 1,620 2,100 3,100 4,100 4,550 4,550 4,720 4,920 5,120 5,120 5,120
$30,000 - 39,999 1,020 2,020 3,100 4,100 5,100 5,550 5,720 5,920 6,120 6,320 6,320 6,320
$40,000 - 59,999 1,870 3,470 4,550 5,550 6,690 7,340 7,540 7,740 7,940 8,140 8,150 8,150
$60,000 - 79,999 1,870 3,470 4,690 5,890 7,090 7,740 7,940 8,140 8,340 8,540 9,190 9,990
$80,000 - 99,999 2,000 3,810 5,090 6,290 7,490 8,140 8,340 8,540 9,390 10,390 11,190 11,990
$100,000 - 124,999 2,040 3,840 5,120 6,320 7,520 8,360 9,360 10,360 11,360 12,360 13,410 14,510
$125,000 - 149,999 2,040 3,840 5,120 6,910 8,910 10,360 11,360 12,450 13,750 15,050 16,160 17,260
$150,000 - 174,999 2,220 4,830 6,910 8,910 10,910 12,600 13,900 15,200 16,500 17,800 18,910 20,010
$175,000 - 199,999 2,720 5,320 7,490 9,790 12,090 13,850 15,150 16,450 17,750 19,050 20,150 21,250
$200,000 - 249,999 2,970 5,880 8,260 10,560 12,860 14,620 15,920 17,220 18,520 19,820 20,930 22,030
$250,000 - 399,999 2,970 5,880 8,260 10,560 12,860 14,620 15,920 17,220 18,520 19,820 20,930 22,030
$400,000 - 449,999 2,970 5,880 8,260 10,560 12,860 14,620 15,920 17,220 18,520 19,910 21,220 22,520
$450,000 and over 3,140 6,250 8,830 11,330 13,830 15,790 17,290 18,790 20,290 21,790 23,100 24,400
Head of Household
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 - 9,999
$10,000 - 19,999
$20,000 - 29,999
$30,000 - 39,999
$40,000 - 49,999
$50,000 - 59,999
$60,000 - 69,999
$70,000 - 79,999
$80,000 - 89,999
$90,000 - 99,999
$100,000 - 109,999
$110,000 - 120,000
$0 - 9,999 $0 $820 $930 $1,020 $1,020 $1,020 $1,420 $1,870 $1,870 $1,910 $2,040 $2,040
$10,000 - 19,999 820 1,900 2,130 2,220 2,220 2,620 3,620 4,070 4,110 4,310 4,440 4,440
$20,000 - 29,999 930 2,130 2,360 2,450 2,850 3,850 4,850 5,340 5,540 5,740 5,870 5,870
$30,000 - 39,999 1,020 2,220 2,450 2,940 3,940 4,940 5,980 6,630 6,830 7,030 7,160 7,160
$40,000 - 59,999 1,020 2,470 3,700 4,790 5,800 7,000 8,200 8,850 9,050 9,250 9,380 9,380
$60,000 - 79,999 1,870 4,070 5,310 6,600 7,800 9,000 10,200 10,850 11,050 11,250 11,520 12,320
$80,000 - 99,999 1,880 4,280 5,710 7,000 8,200 9,400 10,600 11,250 11,590 12,590 13,520 14,320
$100,000 - 124,999 2,040 4,440 5,870 7,160 8,360 9,560 11,240 12,690 13,690 14,690 15,670 16,770
$125,000 - 149,999 2,040 4,440 5,870 7,240 9,240 11,240 13,240 14,690 15,890 17,190 18,420 19,520
$150,000 - 174,999 2,040 4,920 7,150 9,240 11,240 13,290 15,590 17,340 18,640 19,940 21,170 22,270
$175,000 - 199,999 2,720 5,920 8,150 10,440 12,740 15,040 17,340 19,090 20,390 21,690 22,920 24,020
$200,000 - 249,999 2,970 6,470 9,000 11,390 13,690 15,990 18,290 20,040 21,340 22,640 23,880 24,980
$250,000 - 349,999 2,970 6,470 9,000 11,390 13,690 15,990 18,290 20,040 21,340 22,640 23,880 24,980
$350,000 - 449,999 2,970 6,470 9,000 11,390 13,690 15,990 18,290 20,040 21,340 22,640 23,900 25,200
$450,000 and over 3,140 6,840 9,570 12,160 14,660 17,160 19,660 21,610 23,110 24,610 26,050 27,350
MI-W4 (Rev. 12-20)
EMPLOYEE’S MICHIGAN WITHHOLDING EXEMPTION CERTIFICATE STATE OF MICHIGAN - DEPARTMENT OF TREASURY This certificate is for Michigan income tax withholding purposes only. Read instructions on page 2 before completing this form.
Issued under P.A. 281 of 1967. 41. Full Social Security Number 42. Date of Birth
43. Name (First, Middle Initial, Last) 4. Driver’s License Number or State ID
Home Address (No., Street, P.O. Box or Rural Route) 45. Are you a new employee? (mm/dd/yyyy)
Yes If Yes, enter date of hire........ City or Town State ZIP Code
No
6. Enter the number of personal and dependent exemptions (see instructions) ........................................................... 46.
$ .007. Additional amount you want deducted from each pay (if employer agrees) ...................................................................7.
8. I claim exemption from withholding because (see instructions):
a. A Michigan income tax liability is not expected this year.
b. Wages are exempt from withholding. Explain: ___________________________________________________________________________________________________
c. Permanent home (domicile) is located in the following Renaissance Zone: _____________________________________________________________________
EMPLOYEE: If you fail or refuse to file this form, your employer must withhold Michigan income tax from your wages without allowance for any exemptions. Keep a copy of this form for your records. See additional instructions on page 2.
Under penalty of perjury, I certify that the number of withholding exemptions claimed on this certificate does not exceed the number I am allowed to claim. If claiming exemption from withholding, I certify that I do not anticipate a Michigan income tax liability this year.
9. Employee’s Signature 4Date
EMPLOYER: Complete the below section. 10. Employer’s Name 411. Federal Employer Identification Number
Address (No., Street, P.O. Box or Rural Route) City or Town State ZIP Code
Name of Contact Person Contact Phone Number
INSTRUCTIONS TO EMPLOYER: Keep a copy of this certificate with your records. All new hires must be reported to the State of Michigan. See www.mi-newhire.com for information.
In addition, a copy of this form must be sent to the Michigan Department of Treasury if the employee claims 10 or more exemptions or claims they are exempt from withholding. Send a copy to:
Michigan Department of Treasury Tax Technical Section P.O. Box 30477 Lansing, MI 48909
INSTRUCTIONS TO EMPLOYEE’S MICHIGAN WITHHOLDING EXEMPTION CERTIFICATE (Form MI-W4)
You must submit a Michigan withholding exemption certificate (form MI-W4) to your employer on or before the date that employment begins. If you fail or refuse to submit this certificate, your employer must withhold tax from your compensation without allowance for any exemptions. Your employer is required to notify the Michigan Department of Treasury if you have claimed 10 or more personal or dependency exemptions or claimed that you are exempt from withholding.
You MUST provide a new MI-W4 to your employer within 10 days if your residency status changes or if your exemptions decrease because: a) your spouse, for whom you have been claiming an exemption, is divorced or legally separated from you or claims his/her own exemption(s) on a separate certificate, or b) a dependent no longer qualifies under the Internal Revenue Code.
Line 5: If you check “Yes,” enter your date of hire.
Line 6: Personal and dependency exemptions. The number of exemptions claimed here may not exceed the number of exemptions you are entitled to claim on a Michigan Individual Income Tax Return (Form MI-1040). Dependents include qualifying children and qualifying relatives under the Internal Revenue Code, even if your AGI exceeds the limits to claim federal tax credits for them.
Do not claim the same exemptions more than once or tax will be under-withheld. Specifically, do not claim:
• Your personal exemption if someone else will claim you as their dependent.
• Your personal exemption with more than one employer at a time.
• Your spouse’s personal exemption if they claim it with their employer.
• Your dependency exemptions if someone else (for example, your spouse) is claiming them with their employer.
Line 7: You may designate additional withholding if you expect to owe more than the amount withheld.
Line 8a: You may claim exemption from Michigan income tax withholding if all of the following conditions are met:
i) Your employment is intermittent, temporary, or less than full time;
ii) Your personal and dependency exemptions exceed your annual taxable compensation;
iii) You claimed exemption from federal withholding; and
iv) You did not incur a Michigan income tax liability for the previous year.
Line 8b: Reasons wages might be exempt from withholding include:
• You are a nonresident spouse of military personnel stationed in Michigan.
• You are a resident of one of the following reciprocal states while working in Michigan: Illinois, Indiana, Kentucky, Minnesota, Ohio, or Wisconsin.
• You are an enrolled member of a federally-recognized tribe that does not have a tax agreement with the state of Michigan, you reside within that tribe’s Indian Country (as defined in 18 USC 1151), and compensation from this job will be earned within that Indian Country.
Line 8c: For questions about Renaissance Zones, contact your local assessor’s office.
City of Saginaw Withholding Information
Rev 07/2019
In accordance with the City of Saginaw Income Tax Ordinance, all Delta College employees who are
residents of the City of Saginaw or work within the City of Saginaw are required to have city income tax
withholdings from their payroll and must complete a Form SW-4 Withholding Certificate.
Delta College is located within University Center, Delta College is not located within the City of Saginaw.
Except for the following site locations, which are within the City of Saginaw:
The Downtown Saginaw Center
Saginaw MiWorks!
St. Mary’s of Michigan clinical site
Covenant Healthcare clinical sites
For detailed requirements of the City of Saginaw Income Tax Ordinance, please review the City of
Saginaw Withholding Tax Guide.
Please complete the following Form SW-4 Withholding Certificate, SW-4, if either of below
apply:
You work within the City of Saginaw (see above listing of Delta College site locations within the
City of Saginaw)
o If you split your time at a City of Saginaw location and non City of Saginaw location,
there is a section on the form where you can note you work X% amount of time in the
City of Saginaw and X% amount of time at another Delta College location
You reside within the City of Saginaw
OR
_____Check here if you do not live nor work in the City of Saginaw, and do not want City of Saginaw
taxes withheld (If you check this, you do not need to compete the following SW-4 form)
Employee Name: ______________________________________
Date: ________________________________
Form SW-4 Instructions - revised 1/05/10
Purpose: Complete form SW-4 so your employer can withhold the correct amount of city income taxes from your pay. Dependents: To qualify as your dependent (line 4 below), a person
(a) Must receive more than one-half of his or her support from you for the year, and (b) Must have less than $750.00 gross income during the year (except your child who is a student or who is under 19 years of
age, and (c) Must not be claimed as an exemption by such person’s husband or wife, and (d) Must be a citizen or resident of the United States, and (e) Must have your home as his/her principal residence and be a member of your household for the entire year, or Must be related
to you as follows: Your son or daughter, grandchild, step-son/daughter, son/daughter-in-law, father, mother, grandparent, step-father/mother, father/mother-in-law, brother, sister, stepbrother/sister, half brother/sister, brother/sister-in-law, uncle, aunt, nephew, or niece (but only if related by blood).
Changes in exemptions: You must file a new certificate within 10 days if the number of exemptions previously claimed by you decreases for any of the following reasons:
(a) Your wife/husband for whom you have been claiming exemption is divorced or legally separated, or claims her/his own exemption on a separate certificate.
(b) The support of a dependent for whom you claimed exemption is taken over by someone else. (c) You find that a dependent for whom you claimed exemption will receive $750.00 or more income of his/her own during the
year (except your child who is a student and who is under 19 years of age). Other Decreases: Such as the death of a wife, husband, or a dependent, do not affect your withholding until the next year, but require the filing of a new certificate by December 1 of the year in which they occur. Change of Residence: You must file a new certificate within 10 days after you change your residence from or to a taxing city.
Employee: File this form with your employer. Otherwise your employer must withhold City of Saginaw income tax from your earnings without exemptions. Employer: Keep this certificate with your record. If the information submitted by the employee is not believed to be true, correct and complete the City of Saginaw must be advised.
FORM SW-4 EMPLOYEE’S WITHHOLDING CERTIFICATE FOR
CITY OF SAGINAW INCOME TAX
City Resident or Non-City Resident
Your Social Security Number:
Full Name: (First, Middle and Last Name)
Home Address: (Number & Street)
State: Zip Code:
City: Under 25%
40%
60%
80%
100%
City: Main place of employment: Print name of each city where you work for this employer and circle closest % of total earnings in each. This is for withholding purposes only.
City: Under 25%
40%
60%
80%
100%
1. Exemptions for yourself: Yourself age 65 or over Blind
2. Exemptions for your spouse:
Yourself age 65 or over Blind
3. Enter Total number of boxes checked in 1& 2:
4. Other Exemptions: Number of exemptions Number of exemptions for your children for your other dependents
5. Enter total number of Other Exemptions in box 4 below:
6. Add the number of exemptions which you have claimed in box 3 & 5 and write the total below:
7. Write the additional amounts you want withheld from each paycheck, if any:
Employer’s Name and Address:
I certify that the information submitted on this certificate is true, correct and complete to the best of my knowledge and belief. SIGNATURE: DATE:
USCIS Form I-9
OMB No. 1615-0047 Expires 10/31/2022
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 10/21/2019 Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)
Address (Street Number and Name) Apt. Number City or Town State ZIP Code
Date of Birth (mm/dd/yyyy)
- -
Employee's E-mail Address Employee's Telephone Number U.S. Social Security Number
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until (See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1 Do Not Write In This Space
Signature of Employee Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)
Last Name (Family Name) First Name (Given Name)
Address (Street Number and Name) City or Town State ZIP Code
Employer Completes Next Page
Form I-9 10/21/2019 Page 2 of 3
USCIS Form I-9
OMB No. 1615-0047 Expires 10/31/2022
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1
Citizenship/Immigration Status
List AIdentity and Employment Authorization Identity Employment Authorization
OR List B AND List C
Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)
Today's Date (mm/dd/yyyy)Signature of Employer or Authorized Representative Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial
B. Date of Rehire (if applicable)Date (mm/dd/yyyy)
Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED
Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
4. Employment Authorization Document that contains a photograph (Form I-766)
5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:
Documents that Establish Both Identity and
Employment Authorization
6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;
and(2) An endorsement of the alien's
nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are unable to present a document
listed above:
1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
9. Driver's license issued by a Canadian government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish Identity
LIST B
OR AND
LIST C
7. Employment authorization document issued by the Department of Homeland Security
1. A Social Security Account Number card, unless the card includes one of the following restrictions:
2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)
3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
4. Native American tribal document
6. Identification Card for Use of Resident Citizen in the United States (Form I-179)
Documents that Establish Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3Form I-9 10/21/2019
Examples of many of these documents appear in the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
-- This page is left blank intentionally --
DELTA COLLEGE BENEFITS ENROLLMENT FORM PLAN YEAR: 2021
Section A - Employee Information
Employee Name: Social Security No:
Address: City/State/Zip:
Email Address: Employee ID#:
Phone: Sex: Date of Hire: Date of Birth:
Section B – Select Action (circle one)
Effective Date of Qualifying Event:
Open Enrollment
New Hire/Full-time Position
Resignation/Retirement
Birth of Child
Marriage
Divorce
Other:
Qualifying events must be communicated within 30 days to Human Resources. Failure to notify Human Resources within 30 days may cause the employee to be liable for insurance claims and college paid health, vision and dental premiums. Documentation is required for qualifying events to be processed. (Additions - marriage licenses and birth certificates. Removal - divorce decree)
Section C – Benefit Elections
Health/Vision/Dental Insurance (circle election below)
1) Decline health insurance but receive College paid vision and dental insurance
Vision
Single
2 Person
Family
Dental
Single
2 Person
Family
2) PPO Plan
Single
2 Person
Family
20% cost share of premium
$111 / month
$267 / month
$334 / month
3) High Deductible Health Plan (HDHP) with Health Savings Account (HSA)
Single
2 Person
Family
20% cost share of premium
$90 / month
$217 / month
$271 / month
20% deductible reimbursement
Deductible will be funded one time by the College between 2019-2021
$23.34 / month
$46.66 / month
$46.66 / month
HSA Additional Employee Contribution
Single ($3600-1400 college-pd = $2200 max) 2P/Family ($7200-2800 college-pd = $4400 max)
$ / pay
$ / pay
$ / pay
Flexible Spending Accounts
Health Care Cannot participate if you & your spouse have an HSA. maximum $2,750 annually
$ Annual Amount
Dependent Care maximum $5,000 annually
$ Annual Amount
Section D – Dependent Information
Name (First, MI, Last)
Social Security #
Birth Date
M/F
Check One Add Remove
Spouse
Dep. 1
Dep. 2
Dep. 3
Dep. 4
COBRA NOTIFICATION ADDRESS: _________________________________________________________________
Complete only if you are discontinuing coverage for a covered member
Section E - Authorization
I acknowledge that:
I have reviewed Delta College’s benefit plan documents for which I am enrolling.
By signing this form, I make a binding election concerning my benefits for the plan year of January 1 – December 31, 2021.
I understand that I will not be able to change my elections unless I have a qualifying event. (marriage, divorce, death, birth or adoption of a child, termination of employment of a spouse, or other such qualifying events allowed by the plans)
I authorize Delta College to reduce my annual salary in accordance with my elections.
Eligible deductions will be taken on a pre-tax basis and my social security benefits may be reduced.
Delta College may reduce or cancel my compensation reduction or otherwise modify this agreement in the event that it is advisable in order to satisfy certain provisions of the IRS.
I will be offered the opportunity to change my benefit elections for the following plan year during open enrollment.
If I do not complete and return a new election form during open enrollment, these elections will remain in place for future plan years except for Flexible Spending.
Any Flex Spending payroll contribution not collected must be paid to Delta College within 30 days of the payroll date it was due. Failure to pay within this timeframe will terminate participation in the Flex Spending Plan for the remainder of the year.
The Flex Spending debit card is to be used exclusively for qualified expenses incurred during the Plan Year. If used for an unqualified expense or if substantiation is not provided, I authorize Delta College to take an after-tax deduction from my paycheck to cover the expense.
I understand that I could forfeit Flex Spending Plan contributions if I fail to incur eligible expenses during the Plan Year or fail to submit payment requests with in the timeframe specified by the Plan Document.
Employees on a sick or FMLA leave continue to be responsible for paying their share of premiums for benefit plans. If the employee fails to pay their share of the premiums, the coverage will be terminated with prior notice.
The primary insured/HSA account holder cannot have dual coverage. Each spouse must open a separate HSA. I affirm that the information provided is correct. I understand that if I submit false information, I may be held financially
responsible for all claims filed and be required to reimburse the College for any payments made on behalf of or for the benefit of an ineligible dependent.
Employee Signature: Date:
HUMAN RESOURCES OFFICE USE ONLY
Transfer
Benefit
Benefit Effective/Separation Date
Colleague Processed
From:
PPO / HDHP-HSA
COBRA
To:
Dental
PREL / PBEN
Vision
1095C
Flexible Spending
Notify Arcadia / Payroll
GEF02-1 Please Retain A Copy Of The Fully-Completed Form For Your
ADM Records And Return The Original To Your Employer (Continued on Following Page)
1 Delta College (10/09)
Metropolitan Life Insurance Company, New York, NY ENROLLMENT FORM FOR DELTA COLLEGE SECTION TO BE COMPLETED BY EMPLOYER
Name of Employer Delta College
Group Customer # 119873
Report # 119873
Sub Division Branch
Employer’s Street Address City State Zip Code Employee’s Work Location
Date of Hire (Mo./Day/Yr.) Employee’s Basic Annual Earnings (BAE) $
Employee’s Occupation Coverage Effective Date (Mo./Day/Yr.)
Work Status: New Hire Active Retired Disabled Rehire On Layoff/Leave of Absence
Hours Worked Per Week Hourly Paid Salaried
Full-Time Part-Time
Reason for Enrollment: New Coverage New Hire/First Time Eligible Late Enrollee (Statement of Health Required) Change in Coverage Amount Requested Change in Enrollment Other Than Coverage Amount Family Status Change (not applicable to new enrollments) Date (Mo./Day/Yr.)
SECTION TO BE COMPLETED BY EMPLOYEE Name (print) First Middle Last Social Security # Date of Birth (Mo./Day/Yr.) Male
Female Address Street City State Zip Code Marital Single Married
Status: Widowed Divorced
E-mail Address Phone No. (include area code) COVERAGE REQUEST DATA: I have received and read a copy of my employer’s current announcement of the group plan. I want to be covered under the group plan for the benefits for which I am or may become eligible, requested below. I request the following coverage: Employee Coverage
Basic Life (Employer Paid) Basic Accidental Death & Dismemberment (AD&D) (Employer Paid) Supplemental/Optional Life
You may elect a multiple of $10,000 up to a maximum of $500,000. Note: Amounts exceeding $80,000 require a Statement of Health form. Amount Requested: $
Long term Disability (LTD) Dependent Spouse Coverage
Dependent Spouse Life* You may elect a multiple of $5,000 up to a maximum of $250,000. Note: Amounts exceeding the lesser of 1x Basic Annual Earnings or $50,000 require a Statement of Health form. Amount Requested: $
Dependent Child Coverage Dependent Child Life*
$2,000 $4,000 $6,000 $8,000 $10,000 *Amounts will be subject to state limits, if applicable.If applying for Dependent coverage (Spouse and Child), complete section below: Number of dependents (including spouse) Name of Spouse (Last, First, MI) Date of Birth Sex (M/F)
Name(s) of Child(ren) (Last, First, MI) Date of Birth Sex (M/F) Is child a full-time student? Yes
Yes
Yes
Yes
1961 Delta Road University Center MI 48710
GEF02-1a (Continued on Following Page)
DEC 2
Have you smoked cigarettes, pipes or cigars, used snuff or chewed Employee tobacco within one year from the date of this enrollment form? Yes No Have you been Hospitalized (as defined below) during the 90 days Employee Spouse Child(ren) preceding the date of this enrollment form? Yes No Yes No Yes No If the answer to the Hospitalization question is “Yes,” a Statement of Health form is required for each person answering “Yes.” Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.
GEF02-1
ADM
DECLARATION SECTION Each person signing below declares that all the information given in this enrollment form, including any medical questions, is true and complete to the best of his/her knowledge and belief. Each person understands that this information will be used by MetLife to determine his or her insurability. The employee declares that he or she is actively at work on the date of this enrollment form and, for purposes of any contributory life insurance, that he or she was actively at work for at least 20 hours during the 7 calendar days preceding the date of enrollment. In addition if the employee is not actively at work on the scheduled Effective Date of contributory life insurance, such insurance will not take effect until the employee returns to active work. On the date dependent insurance for a person is scheduled to take effect, the dependent must not be confined at home under a physician’s care, receiving or applying for disability benefits from any source, or Hospitalized. If the dependent does not meet this requirement on such date, the insurance will take effect on the date the dependent is no longer confined, receiving or applying for disability benefits from any source, or Hospitalized. For the Accelerated Benefits Option Life Insurance may include an Accelerated Benefits Option under which a terminally ill insured can accelerate a portion of his or her life insurance amount. Receipt of accelerated benefits may affect eligibility for public assistance and an interest and expense charge may be deducted from the accelerated payment. For Changes Requested After Initial Enrollment Period Expires I understand that if life or disability coverage is not elected, or if the maximum coverage is not elected, evidence of insurability satisfactory to MetLife may be required to elect or increase such coverage after the initial enrollment period has expired. Coverage will not take effect, or it will be limited, until notice is received that MetLife has approved the coverage or increase. For Payroll Deduction Authorization By the Employee I authorize my employer to deduct the required contributions from my pay for the coverage requested in this enrollment form. This authorization applies to such coverage until I rescind it in writing. Fraud Warning: If you reside in or are applying for insurance under a policy issued in one of the following states, please read the applicable warning. New York [only applies to Accident and Health Benefits (AD&D/Disability/Dental)]: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, and may subject such person to criminal and civil penalties. New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Kansas, Oregon, and Vermont: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto may be guilty of insurance fraud, and may be subject to criminal and civil penalties. Puerto Rico: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who presents, helps or has presented, a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollars nor more than ten thousand (10,000), or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years.
GEF02-1a
DEC 3
Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. All other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and civil penalties. BENEFICIARY DESIGNATION FOR EMPLOYEE INSURANCE (Dependent Insurance is Payable to the Employee) The Employee signing below names the following person(s) as primary beneficiary(ies) for any MetLife payment upon his or her death. For any other type of beneficiary, please use a beneficiary designation form available from your employer. The Employee understands that he or she has the right to change this designation at any time.
Primary Beneficiary Full Name (Last, First, Middle Initial) Relationship Date of Birth
(Mo./Day/Yr.) Address (Street, City, State, Zip) Share %
Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL: 100% If the Primary Beneficiary(ies) die before me, I designate as Contingent Beneficiary(ies):
Contingent Beneficiary Full Name (Last, First, Middle Initial) Relationship Date of Birth
(Mo./Day/Yr.) Address (Street, City, State, Zip) Share %
Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL: 100%
Signature(s): The employee must sign in all cases. The person signing below acknowledges that they have read and understand the statements and declarations made in this enrollment form.
Employee Signature Print Name Date Signed (Mo./Day/Yr.)
Sign Here
CPN-ENROLL-2005
Privacy Notice
If you submit a request for insurance (enrollment form) we will evaluate it. We will review the information you give to us and we may confirm it or add to it in the ways explained below.
This Privacy Notice is given to you on behalf of METROPOLITAN LIFE INSURANCE COMPANY.
Please read this Privacy Notice carefully. It describes in broad terms how we learn about you and how we treat the information we get about you. (If anyone else is to be insured, what we say here also applies to information about him or her.) We are required by law to give you this notice.
Why We Need to Know about You: We need to know about you (and anyone else to be insured) so that we can provide the insurance and other products and services you’ve asked for. We may also need information from you and others to help us verify identities in order to prevent money laundering and terrorism.
What we need to know includes address, age and other basic information. But we may need more information, including finances, employment, health, hobbies or business conducted with us, with other MetLife companies
(our “affiliates”) or with other companies.
How We Learn about You: What we know about you (and anyone else to be insured) we get mostly from you. But we may also have to find out more from other sources in order to make sure that what we know is correct and complete. Those sources may include adult relatives, employers, consumer reporting agencies, health care providers and others. Some of our sources may give us reports and may disclose what they know to others. We may ask for medical information about you from these sources. The Authorization that you sign when you request insurance permits these sources to tell us about you. So we may, for instance:
• Ask for a medical exam
• Ask health care providers to give us health data, including information about alcohol or drug abuse We may also ask a consumer reporting agency for a “consumer report” about you (or anyone else to be insured). Consumer reports may tell us about a lot of things, including information about your finances, employment, hobbies, mode of living, work history, and driving record.
The information may be kept by the consumer reporting agency and later given to others as permitted by law. The agency will give you a copy of the report it provides to us, if you ask the agency and can provide adequate identification. If you write to us and we have asked for a consumer report about you, we will tell you so and give you the name, address and phone number of the consumer reporting agency.
Another source of information is MIB Group, Inc. (“MIB”). It is a non-profit association of life insurance companies. We and our reinsurers may give MIB health or other information about you. If you apply for life or health coverage from another member of MIB, or claim benefits from another member company, MIB will give that company any information it has about you. If you contact MIB, it will tell you what it knows about you. You have the right to ask MIB to correct its information about you. You may do so by writing to MIB, Inc., P.O. Box 105, Essex Station, Boston, MA 02112, by calling MIB at (866) 692-6901 (TTY (866) 346-3642 for the hearing impaired), or by contacting MIB at www.mib.com.
How We Protect What We Know About You: Because you entrust us with your personal information, we treat what we know about you confidentially. Our employees are told to take care in handling your information. They may get information about you only when there is a good reason to do so. We take steps to make our computer data bases secure and to safeguard the information we have.
2
CPN-ENROLL-2005
How We Use and Disclose What We Know About You: We may use anything we know about you to help us serve you better. We may use it, and disclose it to our affiliates and others, for any purpose allowed by law. For instance, we may use your information, and disclose it to others, in order to:
• Help us evaluate your request for a product or service
• Help us process claims and other transactions
• Confirm or correct what we know about you
• Help us prevent fraud, money laundering, terrorism and other crimes by verifying what we know about you
• Help us comply with the law
• Help us run our business
• Process data for us
• Perform research for us
• Audit our business Other reasons we may disclose what we know about you include:
• Doing what a court or government agency requires us to do; for example, complying with a search warrant or subpoena
• Telling another company what we know about you, if we are or may be selling all or any part of our business or merging with another company
• Giving information to the government so that it can decide whether you may get benefits that it will have to pay for
• Telling a group customer about its members’ claims or cooperating in a group customer’s audit of our service
• Telling your health care provider about a medical problem that you have but may not be aware of
• Giving your information to a peer review organization if you have health insurance with us
• Giving your information to someone who has a legal interest in your insurance, such as someone who lent you money and holds a lien on your insurance or benefits
Generally, we will disclose only the information we consider reasonably necessary to disclose. We may use what we know about you in order to offer you our other products and services. We may share your information with other companies to help us. Here are our other rules on using your information to market products and services:
• We will not share information about you with any of our affiliates for use in marketing its products to you, unless we first notify you. You will then have an opportunity to tell us not to share your information by “opting out.”
• Before we share what we know about you with another financial services company to offer you products or services through a joint marketing arrangement, we will let you “opt-out.”
• We will not disclose information to unaffiliated companies for use in selling their products to you, except through such joint marketing arrangements.
• We will not share your health information with any other company, even one of our affiliates, to permit it to market its products and services to you.
How You Can See and Correct Your Information: Generally, we will let you review what we know about you if you ask us in writing. (Because of its legal sensitivity, we will not show you anything that we learned in connection with a claim or lawsuit.) If you tell us that what we know about you is incorrect, we will review it. If we agree with you, we will correct our records. If we do not agree with you, you may tell us in writing, and we will include your statement when we give your information to anyone outside MetLife.
You Can Get Other Material from Us: In addition to any other privacy notice we may give you, we must give you a summary of our privacy policy once each year. You may have other rights under the law. If you want to know more about our privacy policy, please contact us at our website, www.metlife.com, or write to your MetLife Insurance Company, c/o MetLife Privacy Office - Inst, P.O. Box 489, Warwick, RI 02887-9954. Please identify the specific product or service you are writing about.
Rev. 4/5/2017
DELTA COLLEGE
NEW HIRE DIRECT DEPOSIT
Direct deposit advices are delivered to employees online via WebAdvisor.
For questions about direct deposits contact payroll at 989-686-9388
Employee ID or SSN: ______________________________
Employee Name ______________________________________________________________________
Employee Phone Number: _________________________
MAY TAKE UP TO ONE MONTH TO GO INTO EFFECT
Bank/Credit Union Name __________________________________________________________________
Address ___________________________________________________ City, State ________________________________________
Bank Routing Number ________________________________________ (Contact your Institution for this number)
Type of account for Deposit _____ Checking ______ Savings
Account Number _______________________________ Dollar Amount $ _________________________________
Enter ‘Total Check’ to have your entire check deposited or enter a specific dollar amount to have a portion of you check deposited
ADDITIONAL DEPOSIT (Optional)
Bank/Credit Union Name __________________________________________________________________
Address ___________________________________________________ City, State ________________________________________
Bank Routing Number ________________________________________ (Contact your Institution for this number)
Type of account for Deposit _____ Checking ______ Savings
Account Number _______________________________ Dollar Amount $ _________________________________
AUTHORIZATION
* I authorize Delta College and the financial institution listed to deposit my pay automatically to my account each payday. Adjusting entries to
correct errors are also authorized. This authority will remain in effect until I have cancelled it in writing.
* I understand that if I am setting up a new direct deposit or changing account numbers or banking institutions, that I will receive a printed
paycheck in the interim until my direct deposit is officially established. Paychecks are available for pickup at the Cashier’s Office.
SIGNATURE __________________________________________ DATE _____________________
Rev. 12/2016
DELTA COLLEGE POSITION STATEMENT
ON DRUG-FREE WORK PLACE ACT OF 1988
By signing below, this indicates that I acknowledge receipt of the Delta College Position
Statement on the Drug-Free Workplace Act of 1988.
________________________
Print Name Human Resources Office
________________________ ______________________
Employee Signature Received by
______________________ __________________________
Date Date
INTRODUCTION
Under the Drug-Free Work Place Act of 1988 effective March 18, 1989, all Federal grant
recipients are required to publish a statement, notifying employees that the unlawful
manufacture, distributions, dispensation, possession, or use of a controlled substance is
prohibited in the work place, specifying the sanctions that will take place against violators of
their policy. The following is the position statement of Delta College pursuant to the
requirements of such act.
DRUG-FREE WORK PLACE ACT OF 1988 STATEMENT
No member of the college community shall manufacture, possess, distribute or use any
prohibited drug in either the refines or crude form, except:
(1) Controlled substance for personal usage must be under a current prescription of a
licensed physician.
(2) Those specifically authorized to Delta College by federal or state authorizing agencies for
educational purposes, nor shall any member of the college community possess property,
which is used, or intended for use, as a container for any controlled substances.
Such policy is specifically applicable to college employees during the course of their
employment or at their work place. Employees who admit to violating such policy or are found
to be in violation by a judicial process of the state or Delta College shall be suspended from
employment.
Employees who are certified to medically dependent (hereafter dependent employees) by a
licensed physician will be considered to have a health problem and eligible for medical leave
Rev. 12/2016
provided they participate in a recognized medically supervised program of treatment for
chemical dependency under the following conditions:
(a) Dependent employees will first obtain Delta’s written consent to participate in a specified
treatment program.
(b) Dependent employees who voluntarily enroll in such a recognized program may use
personal and/or vacation time, if medical leave is not available, or may apply to borrow
sick leave. Otherwise, such employees will be considered to be on an approved leave of
absence (without pay) for the period of the rehabilitation program.
(c) During the period of enrollment in the program, such employees will comply with all
medical decisions made by the treating or supervising physician of the program under the
above conditions after being given the opportunity to participate, will be subject to
disciplinary action including suspension for a stated period of time, or termination of
employment
(d) A dependent employee will be given only one opportunity for rehabilitation. If after
returning to work it is determined by Delta that such employee has again violated any of
Delta's rules and regulations related to possession or use of illegal drugs, or that such
employee has been convicted of a drug related violation in the workplace, such employee
will be subject to immediate discharge.
(e) Dependent employees who do not participate in a rehabilitation program under the above
conditions after being given the opportunity to participate, will be subject to disciplinary
action including suspension for a stated period of time, or termination of employment.
All employees are notified that as a condition of employment each employee shall abide by the
terms of this statement and must further notify Delta College of any criminal drug statute
conviction for a violation occurring in the workplace no later than five (5) days after receiving
such conviction.
Upon such notification, if funded under a Federal Grant, The Human Resources Office of the
college must notify the granting agency within (10) days.
Delta College has established and is making a good faith effort to maintain a drug-free
workplace through the implementation of a drug-free awareness program to inform and educate
employees about:
(1) The dangers of drug abuse in the workplace,
(2) The policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance program; and
(4) The penalties that may be imposed upon employees from drug violations occurring in the
workplace.
Employees should make a copy of this policy for their own records.
Rev. 1/10/17
DELTA COLLEGE EMPLOYEES
ACKNOWLEDGEMENT AND RELEASE FORM
HEPATITIS B VACCINATION
Only complete if you are a Category A Employee
Please check with your supervisor for clarification if you are unsure whether or not your position
is considered Category A.
The following jobs have been identified as requiring procedures or tasks which involve exposure or reasonably anticipated
exposure to blood or other potentially hazardous material:
Public Safety Coaches
Dental Assisting - Faculty, Staff & Students Dental Hygiene - Faculty, Staff & Students
Exploratory Teaching - Faculty, Staff & Students Facilities Management Staff
Fire Science Technology – Faculty, Staff & Students Multimedia Learning Lab (MLL) Technicians
Nursing LPN - Faculty, Staff & Students Nursing RN - Faculty, Staff & Students
Phlebotomy - Faculty, Staff & Students Designated Ctr Personnel -Planetarium, Saginaw & Midland
Respiratory Care - Faculty, Staff & Students Surgical Technology - Faculty, Staff & Students
Lifeguards Operations Assistants
Science courses with microbiology components and/or involving human specimen collection - Faculty, Staff & Students
involved in BIO 102 and BIO 203
I understand that due to my occupational exposure to blood or other potentially infectious materials I
may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be
vaccinated with hepatitis B vaccine, at no charge to me.
IF YOU CHOOSE TO DECLINE….
If I decline the vaccination at this time, I understand that I continue to be at risk of acquiring hepatitis B,
a serious disease. If in the future I still have occupational exposure risk and want to be vaccinated, I can
receive the vaccine series at no charge to me.
MAKE YOUR DECISION, CHECK ONE OF THE FOLLOWING:
_____ I have ALREADY RECEIVED the hepatitis B vaccine and decline the vaccination provided by
Delta College.
_____ I WOULD LIKE TO RECEIVE the hepatitis B vaccine series provided by Delta College.
_____ I DECLINE the vaccine and release Delta College from liability should I become
infected.
EMPLOYEE’S NAME (print): _______________________________________________________
EMPLOYEE’S SIGNATURE: __________________________________ DATE:______________
DEPARTMENT/DIVISION: ___________________________ PHONE: ______________________
Rev. 12/20/2016
REQUIRED TRAINING MODULES
All employees are required to view the: Bloodborne Pathogens, Bystander
Intervention, Copyright pt1 Provisions, Copyright pt6 Guidelines, Sexual
Harassment, Diversity, FERPA, Hazard Communications, Title IX – Higher Ed and
SaVE Act modules
Delta College employees have access to training modules at the following link: http://www.gcntraining.com/site.cfm
Username: delta
You can create a UID (Personal ID) by clicking Create New Account. Your User ID
should simply be your First Name, Middle Initial and Last Name.
Additional instructions for accessing the Global Compliance Network are available on
the FAQ tab at the following link: http://www.gcntraining.com/site.cfm?faq
After you review each module, click the submit button at the bottom and this will register
you on the completion report that Human Resources will run to verify all modules were
reviewed.
If you have any questions or difficulties accessing these resources, please the Human
Resources Office at 686-9107.
EMPLOYEE RIGHTSUNDER THE FAMILY AND MEDICAL LEAVE ACT
Eligible employees who work for a covered employer can take up to 12 weeks of unpaid, job-protected leave in a 12-month period for the following reasons:
• The birth of a child or placement of a child for adoption or foster care;• To bond with a child (leave must be taken within 1 year of the child’s birth or placement);• To care for the employee’s spouse, child, or parent who has a qualifying serious health condition;• For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job;• For qualifying exigencies related to the foreign deployment of a military member who is the employee’s spouse,
child, or parent.
An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up to 26 weeks of FMLA leave in a single 12-month period to care for the servicemember with a serious injury or illness.
An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted, employees may take leave intermittently or on a reduced schedule.
Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an employee substitutes accrued paid leave for FMLA leave, the employee must comply with the employer’s normal paid leave policies.
While employees are on FMLA leave, employers must continue health insurance coverage as if the employees were not on leave.
Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it with equivalent pay, benefits, and other employment terms and conditions.
An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or trying to use FMLA leave, opposing any practice made unlawful by the FMLA, or being involved in any proceeding under or related to the FMLA.
An employee who works for a covered employer must meet three criteria in order to be eligible for FMLA leave. The employee must:
• Have worked for the employer for at least 12 months; • Have at least 1,250 hours of service in the 12 months before taking leave;* and • Work at a location where the employer has at least 50 employees within 75 miles of the employee’s worksite.
*Special “hours of service” requirements apply to airline flight crew employees.
Generally, employees must give 30-days’ advance notice of the need for FMLA leave. If it is not possible to give 30-days’ notice, an employee must notify the employer as soon as possible and, generally, follow the employer’s usual procedures.
Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determine if the leave qualifies for FMLA protection. Sufficient information could include informing an employer that the employee is or will be unable to perform his or her job functions, that a family member cannot perform daily activities, or that hospitalization or continuing medical treatment is necessary. Employees must inform the employer if the need for leave is for a reason for which FMLA leave was previously taken or certified.
Employers can require a certification or periodic recertification supporting the need for leave. If the employer determines that the certification is incomplete, it must provide a written notice indicating what additional information is required.
Once an employer becomes aware that an employee’s need for leave is for a reason that may qualify under the FMLA, the employer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must also provide a notice of rights and responsibilities under the FMLA. If the employee is not eligible, the employer must provide a reason for ineligibility.
Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will be designated as FMLA leave.
Employees may file a complaint with the U.S. Department of Labor, Wage and Hour Division, or may bring a private lawsuit against an employer.
The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local law or collective bargaining agreement that provides greater family or medical leave rights.
LEAVE ENTITLEMENTS
BENEFITS &PROTECTIONS
ELIGIBILITY REQUIREMENTS
1-866-4-USWAGE
www.dol.gov/whd
For additional information or to file a complaint:
(1-866-487-9243) TTY: 1-877-889-5627
U.S. Department of Labor Wage and Hour Division
THE UNITED STATES DEPARTMENT OF LABOR WAGE AND HOUR DIVISION
WH1420 REV 04/16
REQUESTING LEAVE
EMPLOYER RESPONSIBILITIES
ENFORCEMENT
Rev 12/2016
HIPAA NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
If you have any questions about this Notice, please contact:
Delta College
HIPAA Privacy Officer
1961 Delta Road
University Center, MI 48710
(989) 686-9106
Notice Effective Date: April 14, 2004
THIS NOTICE GIVES YOU INFORMATION REQUIRED BY LAW about the duties and privacy practices of
the Delta College Group Health Plans (the “Plans”) to protect the privacy of your medical information. The Delta
College Group Health Plans consist of the following components:
· Blue Cross/Blue Shield Medical Plans
· Delta Dental Plan
· Blue Cross/Blue Shield Vision Plans
· Flexible Spending Plan Health Care Expense Reimbursement Account
The Plans provide health and/or dental benefits to you as described in your summary plan descriptions. The Plans
receive and maintain your medical information in the course of providing these health benefits to you. The Plans
may hire business associates to help provide these benefits to you. These business associates also receive and
maintain your medical information in the course of assisting the Plans. The Plans are sponsored by Delta College
(the “Plan Sponsor”). The Plans are all subject to the same federal privacy law, and are part of an Organized
Health Care Arrangement (“OCHA”) that follows the same privacy policies and procedures.
This notice applies to the Flexible Spending Plan Health Care Expense Reimbursement Account. Blue Cross and
Blue Shield of Michigan and Delta Dental each issued a Notice of Privacy Practices for their plans, which
describes how they may use and disclose health information in connection with the coverage they provide for the
Delta College Group Health Plans.
Our purpose for providing you with this notice is to tell you how the Plans and the third parties that assist in plan
administration will use and disclose health information about you. The description of the uses and disclosures of
medical information applies to the Plans and to the entities that perform services for the Plans or perform the
functions of the Plans.
The Plans are required to follow the terms of this notice until it is replaced. The Plans reserve the right to change
the terms of this notice at any time. If the Plans make changes to this notice, the Plans will revise it and send a
new notice to all subscribers covered by the Plans at that time. The Plans reserve the right to make the new
changes apply to all of your medical information maintained by the Plans before and after the effective date of the
new notice.
For ease of reference, this Notice will use the word “Plan” to mean each of the Plans identified above.
Rev 12/2016
Purposes for Which the Plan May Use or Disclose Your Medical Information
The Plan may use and disclose your medical information without your consent or authorization for the
following purposes:
Health Care Providers’ Treatment Purposes. The Plan may disclose your medical information to your health
care providers, at their request, for your treatment by them. For example, the Plan may disclose to your primary
care physician the name of a specialist who is treating you so that they may coordinate your care.
Payment. The Plan may use or disclose your medical information to determine eligibility for plan benefits, to
facilitate payment for the treatment and services you receive from health care providers, to determine benefit
responsibility under the Plan, or to coordinate plan coverage. For example, the Plan may tell your health care
provider about your medical history to determine whether a particular treatment is experimental, investigational,
or medically necessary or to determine whether the Plan will cover the treatment.
Health Care Operations. The Plan may use or disclose your medical information as necessary to operate the
Plan, including plan management and administrative activities. For example, the Plan may (i) conduct quality
assessment and improvement activities, (ii) underwriting, premium rating, or other activities relating to the
creation, renewal or replacement of a contract of health insurance, (iii) authorize business associates to perform
data aggregation services, (iv) engage in care coordination or case management, and (v) manage, plan or develop
the Plan’s business.
As required by law. The Plan must allow the U.S. Department of Health and Human Services to audit the
Plan’s records. The Plan may also disclose your medical information as authorized by and to the extent necessary
as required by federal, state or local law, including compliance with workers’ compensation or other similar laws.
To Business Associates. The Plan may disclose your medical information to business associates the Plan hires to
assist the Plan. Each business associate of the Plan must agree in writing to ensure the continuing confidentiality
and security of your medical information.
To Plan Sponsor. The Plan may disclose to the Plan Sponsor, in summary form, claims history and other similar
information. Such summary information does not disclose your name or other distinguishing characteristics. The
Plan may also disclose to the Plan Sponsor the fact that you are enrolled in, or disenrolled from the Plan. The
Plan may disclose your medical information to the Plan Sponsor for plan administrative functions that the Plan
Sponsor provides to the Plan if the Plan Sponsor agrees in writing to ensure the continuing confidentiality and
security of your medical information. The Plan Sponsor must also agree not to use or disclose your medical
information for employment-related activities.
To Plans in the OHCA. Your medical information may be shared, used and disclosed among the Plans sponsored
by Delta College and their business associates for purposes of facilitating and coordinating health care treatment,
payments and operations, including the health care operations of the Organized Health Care Arrangement
(“OHCA”).
The Plan may also use and disclose your medical information as follows:
To comply with legal proceedings, such as a court or administrative order or subpoena;
To law enforcement officials for limited law enforcement purposes;
To a family member, friend or other person, for the purpose of helping you with your health care or with
payment for your health care, if you are in a situation such as a medical emergency and you cannot give
your agreement to the Plan;
To your personal representatives appointed by you or designated by applicable law;
For research purposes in limited circumstances;
To a coroner, medical examiner, or funeral director about a deceased person;
Rev 12/2016
To an organ procurement organization in limited circumstances;
To avert a serious threat to your health or safety or the health or safety of others;
To a governmental agency authorized to oversee the health care system or government programs;
To federal officials for lawful intelligence, counterintelligence and other national security purposes;
To public health authorities for public health purposes;
To appropriate military authorities, if you are a member of the armed forces.
Uses and Disclosures with Your Permission
The Plan will not use or disclose your medical information for any other purposes unless you give the Plan your
written authorization to do so. If you give the Plan written authorization to use or disclose your medical
information for a purpose that is not described in this notice, then, in most cases, you may revoke it in writing at
any time. Your revocation will be effective for all your medical information the Plan maintains, unless the Plan
has taken action in reliance on your authorization.
Your Rights
You have certain rights with respect to your health information. To exercise these rights, you or your personal
representative must make your request, in writing, directed to the Delta College HIPAA Privacy Officer. The
HIPAA Privacy Officer will give you the necessary information and forms for you to complete and return to the
HIPAA Privacy Officer. In some cases, the Plan may charge you a nominal, cost-based fee to carry out your
request.
You have the right to:
· Request restrictions on certain uses and disclosures of your health information; however the Plan is not required
to agree to a requested restriction;
· Receive confidential communications of your health information. You may request that the Plan communicates
with you about your health information by alternative means or at an alternative location;
· Inspect and obtain a copy of your health information, except with regard to psychotherapy notes or information
compiled in reasonable anticipation of certain civil, criminal or administrative proceedings;
· Request an amendment to your health information that the Plan has created, except with regard to those portions
of your health information that you are precluded from inspecting and copying as set forth above.
· Obtain an accounting of certain disclosures of your health information; and
· Receive a paper copy of this notice in addition to any electronic copy you may receive.
Complaints
If you believe your privacy rights have been violated by the Plan, you have the right to complain to the Plan or to
the Secretary of the U.S. Department of Health and Human Services. You may file a complaint to the Plan, in
writing, directed to the Delta College HIPAA Privacy Officer. You will not be penalized or retaliated against if
you choose to file a complaint.
Delta College
HIPAA Privacy Officer
1961 Delta Road
University Center, MI 48710
(989) 686-9106
Important Notice from Delta College
About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about
your current prescription drug coverage with Delta College and about your options under Medicare’s
prescription drug coverage. This information can help you decide whether or not you want to join a
Medicare drug plan. If you are considering joining, you should compare your current coverage,
including which drugs are covered at what cost, with the coverage and costs of the plans offering
Medicare prescription drug coverage in your area. Information about where you can get help to make
decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s
prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare.
You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare
Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. 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. Delta College has determined that the prescription drug coverage offered by the Delta
College Health Plan is, on average for all plan participants, expected to pay out as much as
standard Medicare prescription drug coverage pays and is therefore considered Creditable
Coverage. Because your existing coverage is Creditable Coverage, you can keep this
coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare
drug plan.
When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from
October 15th through December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your
own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a
Medicare drug plan.
What Happens to Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you do decide to enroll in a Medicare prescription drug plan and drop your Delta College
prescription drug coverage, be aware that you and your dependents may not be able to get the
coverage back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Delta College and don’t
join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a
higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, 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 coverage. For example, if you go nineteen months without
creditable coverage, your premium may consistently be at least 19% higher than the Medicare base
beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have
Medicare prescription drug coverage. In addition, you may have to wait until the following October
to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You
will also get it before the next period you can join a Medicare drug plan, and if this coverage through
Delta College 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’ll get a copy of 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:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the
“Medicare & You” handbook for their telephone number) for personalized help
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
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 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare
drug plans, you may be required to provide a copy of this notice when you join to show
whether or not you have maintained creditable coverage and, therefore, whether or not you are
required to pay a higher premium (a penalty)
Date: October 12, 2020
Entity: Delta College
Contact: Shannon Mehl
Address: 1961 Delta Road
University Center, MI 48710
Phone: (989) 686-9106
INJURY/ACCIDENT REPORTING PROCEDURE
If an employee sustains a personal injury or occupational disease, which arises out of and in the course of employment, the employee must file a work-related claim of injury or illness.
1. All injuries/illnesses must be reported to Public Safety (Ext. 9111) within 24 hours of the injury/illness.
2. Injuries/illnesses requiring treatment must be done within ten days at Covenant Occupational Health Services located at 600 Irving Avenue, Saginaw, MI 48602. If treatment requires first aid only, the officer on duty shall administer first aid. If the employee needs to be transported to Covenant, Public Safety will make any decisions regarding transportation.
3. If at the time of the injury/illness you need to seek treatment, authorization must be given by Public Safety or the Human Resources Office (Ext. 9106) prior to receiving treatment. Employees electing to seek their own treatment will be responsible for all payments incurred.
4. If treatment is needed other than at the time of the injury, the employee must contact the Human Resources Office (9106 or 9107) for authorization to seek treatment at Covenant Occupational Health Services.
5. All employees seeking treatment due to a work related injury or illness will be drug and alcohol tested at the time of the visit.
6. The employee will be responsible for providing the Human Resources Office and their immediate supervisor with a copy of their physician's statement.
Human Resources will complete the appropriate forms to be forwarded to our Workers' Compensation Company, if necessary.
Any bills the employee receives as a result of the work-related injury/illness must be sent to the Human Resources Office.
Any lost time as a result of a work-related injury or illness will be reported as sick leave, if available.
Injuries/illnesses occurring off campus, which are work-related (i.e., at a College off campus facility or center, College sponsored trip, or approved off campus work assignment) shall be reported by phone as per instructions mentioned above.
Regulations and Rules of Conduct Delta College has adopted rules consistent with its goals and operations & enforces them with appropriate due process.
I. General Responsibility: Delta College has the responsibility to adopt and enforce rules which are consistent with Delta College goals and operations and to establish due process procedures in disciplinary cases.
II. Authority to Establish Standards of Conduct: Standards of conduct are established by rules of the College, as adopted by the Board of Trustees, and made known through College publications or by notices distributed or prominently posted on College bulletin boards and by law of the United States, State of Michigan, and County of Bay (public laws). Except in the case of interim or emergency-type rules as granted by Michigan Public Act No. 26 of 1970, such regulations will be established and amended with the advice of the College Senate, but final authority is through either the Delta College Board of Trustees or the laws of the United States, State of Michigan, or County of Bay.
III. Individual Responsibility: An individual having an institutional relationship to Delta College (member of College Community) is automatically placed under the rules of the College. "Institutional relationship to the College" means any connection of employment, enrollment, or service existing between any person and Delta College. As used herein, this phraseology is intended to prevent the application of these rules to purely personal or social relationships between or among students, Faculty members, Administration, or staff members outside of the College proper. Therefore, it is important for all members of the College Community to familiarize themselves with the rules and regulations affecting them.
IV. Effect of Violating Rules: A member of the College Community violating any of the rules of the College, or a public law, on campus or off campus at a Delta College sponsored activity is subject to disciplinary action by Delta College that is appropriate to the nature of the offense. Disciplinary action will be taken in accordance with applicable law, regulation, policies and procedures governing cases of violation.
V. Reports of Violations: Reporting of violations will be within the province of all members of the College Community because they have a common responsibility to maintain an orderly and efficient community for their mutual benefit. Violations may fall in one of several categories: (1) Minor offenses which are dealt with by reprimand; (2) Violations by students which are to be reported to the Vice President of Student and Educational Services; (3) Violations by Faculty or staff members which are to be reported to the President; (4) Civil or criminal violations which are to be reported to the Campus Police Department.
VI. Severance Provision: If any of the foregoing rules or any part of any such rule will be adjudged invalid by a court of competent jurisdiction, then such adjudication will not affect the validity of these rules as a whole or any provision or part of any such rule not so adjudged invalid.
Rules and Regulations:
A. Physical Force: No member of the College community shall use physical force, threaten physical force, or use
intimidation against any person engaged in an activity properly undertaken as part of an institutional relationship of the
College except as permitted under normal law enforcement procedures.
B. Disruption: No member of the College community shall interfere with a College function by depriving any person of
needed safety, quiet, or other physical conditions of work or study.
C. Interference: No member of the College community shall interfere with the free movement of any person engaged in an
activity properly undertaken as part of an institutional relationship to the College.
D. Compliance: In keeping with the system of voluntary compliance that underlies the College Regulations and Rules of
Conduct, no member of the College community shall fail to follow the reasonable instructions given by an appropriate
College official to cease specified conduct, if such conduct threatens disruption or interference with the rights of others,
College discipline, College functions, and/or order in the College community.
E. Identification: No member of the College community shall refuse to provide identification when requested to do so by
an identified employee of the College.
F. Forbidden Occupation: No member of the College community shall, subsequent to reasonable notice to leave given by
the College President, or an authorized designee, continue occupation of any College facility or property which is under
the direct control or responsibility of the College, especially if such occupation interferes with a College function or risks
injury to a person or property.
G. Facility Entry and Usage: No member of the College community shall gain or attempt to gain unauthorized entry to or
make unauthorized use of the College facilities or property.
H. Property: No member of the College community shall damage, deface, destroy, steal, or misappropriate the property of
the College, any member of the College community, or any visitor to the College campus.
I. Unauthorized Use of College Credit, Property, Etc.: No unauthorized member of the College community shall use the
College telephones, postal machines and meters, duplicating machines, motorized vehicles, or other equipment. This
provision shall be deemed to also include College billing, charging, and credit card numbers utilized for communications
or transportation purposes. Further it shall be a violation for any member of the College Community who has not been
issued a key by the College to possess or use College keys for any purpose whatsoever.
J. Counterfeiting, Altering and Copying: No member of the College community, shall falsely make, forge, manufacture,
print, reproduce, copy, tamper with, or alter any writing, document, record, or identification used or maintained by the
College or by members of the College community. No member of the College community shall knowingly possess,
display, or cause or permit to be displayed any writing, record, document, or identification form used or maintained by
the College or by members of the College community, knowing the same to be fictitious, altered, forged, counterfeited,
or made without proper authority.
K. Confidentiality of College Records: No person shall inspect, investigate, or use College files (i.e., Counseling, Financial
Aid, Placement, Records, Registration) without proper College authorization.
L. Firearms and Other Dangerous Material: The possession or use of firearms, firecrackers, explosives, toxic or dangerous
chemicals, or other lethal weapons, equipment or material is not permitted on College property at any time except
when specifically authorized by the College for educational purposes or when firearms used for recreational purposes
and transported through the campus meet the regulations of the Department of Public Safety.
M. Alcoholic Beverages: No member of the College community shall sell, be under the influence of, possess or consume
beer, wine, or other alcoholic beverages on College property, or any property which is under the direct control or
responsibility of the College. This regulation shall not apply to the President's home. This rule may be suspended from
time to time by authorization of the President.
N. Drugs: No member of the College community shall possess, sell, distribute, be under the influence of or use any
controlled substance in either the refined or crude form, except: (1) controlled substances for personal usage, and these
must be under a prescription of a licensed physician, or (2) those specifically authorized to Delta College by Federal or
State authorizing agencies for educational purposes. Nor shall any member of the College community possess property
which is used, or intended for use, as a container for any controlled substance, except where prescribed or authorized as
described in this paragraph.
O. Tobacco Free Policy: Effective August 1, 2007, Delta College became a tobacco free campus. Smoking and use of
tobacco products will not be permitted anywhere on the campus; including centers, campus buildings, sidewalks,
parking lots, building entrances and common areas, and in College-owned vehicles. The Administration shall fully
implement this policy and all applicable laws, regulations, and local ordinances related to smoking and tobacco use.
P. Selling, Soliciting, and Distributing: Any person who wishes to distribute, solicit, or sell information, materials, goods, or
services not within normal College activities and routine, must have the written permission of the Vice President of
Student Services or Vice President of Business and Finance or their designee.
Q. Private Business Ventures: Delta College facilities such as offices, computers, copiers, etc., are not to be used for private
business ventures. Also, Delta College's name is not to be associated in any way (such as use of letterhead, e-mail or
return address) with private business ventures.
R. Animals: People may not bring animals on campus or into College buildings. Leader dogs and animals used for
educational purposes are exceptions; however, all animals must remain under the control of their owners and be
properly licensed and medically treated as required by law.
S. Federal, State, Local Laws: Violations of Federal, State, or local laws, and violations of College policies, procedures, rules
and regulations, including rules of governing bodies such as the Higher Learning Commission or the National Junior
College Athletic Association, and including rules published in the College Catalog and student handbooks and manuals,
shall constitute violations of College rules. Such violations apply both on-Campus, and off-Campus in connection with
college-sponsored activities.
Rev. 1/12/2017
Public Safety - Evacuation Procedure
Emergency Contacts
On Campus – Call 9111
Off Campus or Centers – Call 989-686-9111 or Call 911
If Public Safety cannot be contacted – Call 911
Building Evacuation
1. All buildings will be evacuated when an alarm sounds and/or upon notification by the
Department of Public Safety or by the off campus learning center coordinators.
2. When the building alarm or fire alarm is activated during an emergency, leave by the nearest
marked exit and ask others to do the same.
3. ASSIST PERSONS WITH DISABILITIES IN EXITING THE BUILDING! Remember that the
elevators are reserved for persons with disabilities. DO NOT USE ELEVATORS IN CASE
OF FIRE.
4. Once outside proceed to a clear area that is at least 500 feet away from the building. Keep
streets, fire lanes, hydrant and walkways clear for emergency vehicles and personnel. Know
your area assembly points.
DO NOT return to an evacuated building unless told to do so by a College official.
Campus Evacuation
1. Evacuation of all or part of the campus grounds will be announced by the Department of
Public Safety as directed. 2. All persons (students and staff) are to immediately vacate the site in question and relocate to
another part of the campus grounds as directed.
IMPORTANT: After any evacuation, report to your designated safe area. Stay there until an
accurate headcount is taken. The Building Emergency Coordinator will take attendance and
assist in the accounting for all building occupants.
Rev. 2/2017
Notice of Employee Eligibility to Participate in 403(b) Retirement Plan
All employees, excluding student workers, are eligible to participate in the Delta College 403(b) Retirement Plan immediately upon hire. Eligible employees may elect to make pre-tax salary reduction contributions to the 403(b) plan up to the maximum allowed by the IRS each tax year. Each participating employee chooses among the available investment options offered by the approved investment vendors under the plan. Employee contributions and the related investment earnings are tax deferred until withdrawn from the plan.
Please contact Jeanne Doyle at extension 9390 or [email protected] with any questions.
Once you receive your employee login information, feel free to visit the Finance Department’s portal page to view vendor information, enrollment agreements and links to the Plan Document and Adoption Agreement.
Employees may enroll in the 403(b) plan by contacting one or more of the Delta College approved 403(b) vendors at any time throughout the year to speak to a representative.
After establishing a 403(b) account and making investment and beneficiary choices with a vendor representative, a completed Salary Reduction Agreement must be submitted to the Delta College Finance Office to begin making bi-weekly payroll deduction contributions to a 403(b) account. The Salary Reduction Agreement is available. This form may also be used to stop deductions or to make changes to the deduction amount. We ask that employees limit making changes to their salary reduction to 4 times per year.
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A: General Information
When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health
Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic
information about the new Marketplace and employmentbased health coverage offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The
Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible
for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance
coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or
offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on
your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for
a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be
eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does
not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your
employer that would cover you (and not any other members of your family) is more than 9.5% of your household income
for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the
Affordable Care Act, you may be eligible for a tax credit.1
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your
employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer
contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for
Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax
basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your summary plan description or
contact
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the
Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health
insurance coverage and contact information for a Health Insurance Marketplace in your area.
1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by
the plan is no less than 60 percent of such costs.
Form Approved
OMB No. 1210-0149 (expires 6-30-2023)
Shannon Mehl, Benefits Specialist @ 989-686-9106
PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an
application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to
correspond to the Marketplace application.
3. Employer name
4. Employer Identification Number (EIN)
\
5. Employer address 6. Employer phone number
7. City 8. State 9. ZIP code
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above) 12. Email address
Here is some basic information about health coverage offered by this employer:
As your employer, we offer a health plan to:
All employees. Eligible employees are:
Some employees. Eligible employees are:
With respect to dependents:
We do offer coverage. Eligible dependents are:
We do not offer coverage.
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be
affordable, based on employee wages.
** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount
through the Marketplace. The Marketplace will use your household income, along with other factors, to
determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to
week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed
mid-year, or if you have other income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the
employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your
monthly premiums.
X
X
X
Full-time employees working 30 or more hours per week on a regular basis.
Delta College 38-6034011
1961 Delta Road 989-686-9106
University Center Michigan 48710
Shannon Mehl, Benefits Specialist
Spouse and children until the age of 26. There are other circumstances that may apply, contact Shannon Mehl if you have any
questions.
The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for
employers, but will help ensure employees understand their coverage choices.
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?
Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the
employee eligible for coverage? (mm/dd/yyyy) (Continue) No (STOP and return this form to employee)
14. Does the employer offer a health plan that meets the minimum value standard*? Yes (Go to question 15) No (STOP and return form to employee)
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include
family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ 90.00 b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly
If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't
know, STOP and return form to employee.
16. What change will the employer make for the new plan year? Employer won't offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)
a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly
• An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the
plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
X
X
As a self-funded group, you are solely responsible for compliance with the federal Summary of Benefit and Coverage (SBC) rules, including SBC creation and distribution. BCBSM does not assume any responsibility for SBC rule compliance relating to your group health plan, or for creation or disclosure of compliant SBCs. This SBC template document is being provided as an example that may contain useful information concerning your BCBSM administered coverage as you create your own group health plan’s SBC. This SBC template document being provided is not fully compliant with the SBC federal rules. It is your responsibility to work with your legal counsel to ensure proper compliance with the federal SBC rules. This SBC template document does not constitute legal, tax, actuarial, accounting, benefit design, compliance or other advice. BCBSM disclaims any liability or responsibility for any non-compliance by your group health plan with SBC rules and regulations relating to creation, disclosure or other requirements. You should also note that there may be additional special circumstances which may be applicable to your specific group health plan situation which may affect SBC content, including but not limited to account type arrangements such as flexible spending accounts (FSA), health reimbursement arrangements (HRA), and health savings accounts, (HSA), or for example, wellness programs, reference based pricing or benefits, or coverage not administered by BCBSM, or whether the coverage provides minimum essential coverage. If you have an ASC Plan Modification, it may be defined here in only a limited way.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 DELTA COLLEGE
Note to ASC groups: Before completing this template, please reference the disclaimer on the attached cover page.
Simply Blue PPO HSASM ASC with Rx
Coverage for: Individual/Family | Plan Type: PPO
Group Number 007000338-0010 SBC000010763114 2 of 9
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call the number on the back of your BCBSM ID card to request a copy.
Important Questions Answers
Why this Matters: In-Network Out-of-Network
What is the overall deductible? $1,400 Individual/ $2,800 Family
$2,800 Individual/ $5,600 Family
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay.
Are there services covered before you meet your deductible?
Yes. Preventive care services are covered before you meet your deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?
No.
You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan? (May include a coinsurance maximum)
$2,250 Individual/ $4,500 Family
$4,500 Individual/ $9,000 Family
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met.
What is not included in the out-of-pocket limit?
Premiums, balance-billing charges, any pharmacy penalty and health care this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Will you pay less if you use a network provider?
Yes. See www.bcbsm.com or call the number on the back of your BCBSM ID card for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?
No. You can see the specialist you choose without a referral.
3 of 9
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
No Charge 20% coinsurance None
Specialist visit No Charge 20% coinsurance None
Preventive care/ screening/ immunization
No Charge Not covered
You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
No Charge 20% coinsurance None
Imaging (CT/PET scans, MRIs)
No Charge 20% coinsurance May require preauthorization
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsm.com/druglists
Generic or select prescribed over-the-counter drugs
$20 copay/prescription for retail 30-day supply; $40 copay/prescription for retail or mail order 90-day supply
In-Network copay plus an additional 20% coinsurance of the approved amount
Preauthorization, step therapy and quantity limits may apply to select drugs. Preventive drugs covered in full. 90-day supply not covered out of network. Select diabetic supplies and devices may be covered under the prescription drug program.
Preferred brand-name drugs
$60 copay/prescription for retail 30-day supply; $120 copay/prescription for retail or mail order 90-day supply
In-Network copay plus an additional 20% of the approved amount
Preauthorization, step therapy and quantity limits may apply to select drugs. Preventive drugs covered in full. 90-day supply not covered out of network. Pharmacy Specialty drugs obtained from
4 of 9
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Nonpreferred brand-name drugs
$80 copay/prescription or 50% coinsurance of the approved amount (whichever is greater), but no more than $100 copay/prescription for retail 30-day supply; $160 copay/prescription or 50% coinsurance of the approved amount (whichever is greater), but no more than $200 copay/prescription for retail or mail order 90-day supply
In-Network copay plus an additional 20% of the approved amount
other than an Exclusive Specialty Pharmacy Network provider will not be covered. Select diabetic supplies and devices may be covered under the prescription drug program.
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center)
No Charge 20% coinsurance None
Physician/surgeon fees No Charge 20% coinsurance None
If you need immediate medical attention
Emergency room care No Charge No Charge None
Emergency medical transportation
No Charge No Charge Mileage limits apply
Urgent care No Charge 20% coinsurance None
If you have a hospital stay
Facility fee (e.g., hospital room)
No Charge 20% coinsurance Preauthorization is required
Physician/surgeon fee No Charge 20% coinsurance None
If you need behavioral health services (mental health and substance use disorder)
Outpatient services No Charge
No Charge for mental health; 20% coinsurance for substance use disorder
None
Inpatient services No Charge 20% coinsurance Preauthorization is required.
If you are pregnant Office visits Prenatal: No Charge; deductible does not apply Postnatal: No Charge
Prenatal: 20% coinsurance
Postnatal: 20% coinsurance
Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound) and depending on the type of services cost share may apply. Cost sharing does not apply for preventive services.
5 of 9
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Childbirth/delivery professional services
No Charge 20% coinsurance None
Childbirth/delivery facility services
No Charge 20% coinsurance None
If you need help recovering or have other special health needs
Home health care No Charge No Charge Physician certification required.
Rehabilitation services No Charge 20% coinsurance Physical, Speech and Occupational Therapy is limited to a combined maximum of 30 visits per member, per calendar year.
Habilitation services Not covered Not covered None
Skilled nursing care No Charge No Charge Preauthorization is required. Limited to 90 days per member per calendar year
Durable medical equipment
No Charge No Charge Excludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required.
Hospice services No Charge No Charge Physician certification required. Visit limits apply.
If your child needs dental or eye care
For more information on pediatric vision or dental, contact your plan administrator
Children’s eye exam Not covered Not covered None
Children’s glasses Not covered Not covered None
Children’s dental check-up
Not covered Not covered None
6 of 9
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Acupuncture treatment
Cosmetic surgery
Dental care (Adult)
Infertility treatment
Long term care
Routine foot care
Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Bariatric surgery
Chiropractic care
Coverage provided outside the United States. See http://provider.bcbs.com
Hearing aids
Non-emergency care when traveling outside the U.S.
Private-duty nursing
Routine eye care (Adult)
7 of 9
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/healthreform, or the Department of Health and Human Services, Center for Consumer Information and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov or by calling the number on the back of your BCBSM ID card. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Blue Cross® and Blue Shield® of Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) Department of Insurance and Financial Services, P. O. Box 30220, Lansing, MI 48909-7720 or http://www.michigan.gov/difs or [email protected]
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) Language Access Services: See Addendum
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. ––––––––––––––––––––––
The plan would be responsible for the other costs of these EXAMPLE covered services. 8 of 9
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
(9 months of in-network pre-natal care and a hospital delivery)
The plan’s overall deductible $1,400
Specialist coinsurance 0% Hospital (facility) coinsurance 0% Other coinsurance 0%
This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)
Total Example Cost $12,700
In this example, Peg would pay:
Cost Sharing
Deductibles $1,400
Copayments $10
Coinsurance $0
What isn’t covered
Limits or exclusions $60
The total Peg would pay is $1,470
Managing Joe’s Type 2 Diabetes
(a year of routine in-network care of a well-controlled condition)
The plan’s overall deductible $1,400 Specialist coinsurance 0%
Hospital (facility) coinsurance 0% Other coinsurance 0%
This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)
Total Example Cost $5,600
In this example, Joe would pay:
Cost Sharing
Deductibles $1,400
Copayments $800
Coinsurance $0
What isn’t covered
Limits or exclusions $20
The total Joe would pay is $2,220
Mia’s Simple Fracture
(in-network emergency room visit and follow up care)
The plan’s overall deductible $1,400 Specialist coinsurance 0%
Hospital (facility) coinsurance 0% Other coinsurance 0%
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)
Total Example Cost $2,800
In this example, Mia would pay:
Cost Sharing
Deductibles $1,400
Copayments $10
Coinsurance $0
What isn’t covered
Limits or exclusions $0
The total Mia would pay is $1,410
If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered.
. 9 of 9
As a self-funded group, you are solely responsible for compliance with the federal Summary of Benefit and Coverage (SBC) rules, including SBC creation and distribution. BCBSM does not assume any responsibility for SBC rule compliance relating to your group health plan, or for creation or disclosure of compliant SBCs. This SBC template document is being provided as an example that may contain useful information concerning your BCBSM administered coverage as you create your own group health plan’s SBC. This SBC template document being provided is not fully compliant with the SBC federal rules. It is your responsibility to work with your legal counsel to ensure proper compliance with the federal SBC rules. This SBC template document does not constitute legal, tax, actuarial, accounting, benefit design, compliance or other advice. BCBSM disclaims any liability or responsibility for any non-compliance by your group health plan with SBC rules and regulations relating to creation, disclosure or other requirements. You should also note that there may be additional special circumstances which may be applicable to your specific group health plan situation which may affect SBC content, including but not limited to account type arrangements such as flexible spending accounts (FSA), health reimbursement arrangements (HRA), and health savings accounts, (HSA), or for example, wellness programs, reference based pricing or benefits, or coverage not administered by BCBSM, or whether the coverage provides minimum essential coverage. If you have an ASC Plan Modification, it may be defined here in only a limited way.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: Beginning on or after 01/01/2021 DELTA COLLEGE
Note to ASC groups: Before completing this template, please reference the disclaimer on the attached cover page.
Community Blue PPOSM ASC
Coverage for: Individual/Family | Plan Type: PPO
Group Number 007000338-0001 SBC000010762675 2 of 10
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call the number on the back of your BCBSM ID card to request a copy.
Important Questions Answers
Why this Matters: In-Network Out-of-Network
What is the overall deductible? $500 Individual/ $1,000 Family
$500 Individual/ $1,000 Family
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Are there services covered before you meet your deductible?
Yes. Preventive care services are covered before you meet your deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?
No.
You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan? (May include a coinsurance maximum)
$6,600 Individual/ $13,200 Family
$2,000 Individual/ $4,000 Family
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?
Premiums, balance-billing charges, any pharmacy penalty and health care this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Will you pay less if you use a network provider?
Yes. See www.bcbsm.com or call the number on the back of your BCBSM ID card for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?
No. You can see the specialist you choose without a referral.
3 of 10
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
$25 copay/office visit 20% coinsurance None
Specialist visit $25 copay/office visit 20% coinsurance None
Preventive care/ screening/ immunization
No Charge; deductible does not apply
Not covered
You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
No Charge 20% coinsurance None
Imaging (CT/PET scans, MRIs)
No Charge 20% coinsurance May require preauthorization
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbsm.com/druglists
Generic or select prescribed over-the-counter drugs
$15 copay/prescription for retail 30-day supply; $30 copay/prescription for retail or mail order 90-day supply; deductible does not apply
In-Network copay plus an additional 25% of the approved amount; deductible does not apply
Preauthorization, step therapy and quantity limits may apply to select drugs. Preventive drugs covered in full. 90-day supply not covered out of network. Select diabetic supplies and devices may be covered under the prescription drug program. Preferred brand-name
drugs
$50 copay/prescription for retail 30-day supply; $100 copay/prescription for retail or mail order 90-day supply; deductible does not apply
In-Network copay plus an additional 25% of the approved amount; deductible does not apply
4 of 10
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Nonpreferred brand-name drugs
$70 copay/prescription or 50% coinsurance of the approved amount (whichever is greater), but no more than $100 copay/prescription for retail 30-day supply; $140 or 50% coinsurance of the approved amount (whichever is greater), but no more than $200 copay/prescription for retail or mail order 90-day supply; deductible does not apply
In-Network copay plus an additional 25% of the approved amount; deductible does not apply
Generic and preferred brand-name specialty drugs
20% coinsurance of the approved amount, but no more than $200 copay/prescription for retail or mail order 30-day supply; deductible does not apply
In-Network copay plus an additional 25% of the approved amount; deductible does not apply
Preauthorization is required. Specialty drugs limited to a 15 or 30-day supply. Pharmacy Specialty drugs obtained from other than an Exclusive Specialty Pharmacy Network provider will not be covered. Nonpreferred brand-name
specialty drugs
25% coinsurance of the approved amount, but no more than $300 copay/prescription for retail or mail order 30-day supply; deductible does not apply
In-Network copay plus an additional 25% of the approved amount; deductible does not apply
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center)
No Charge 20% coinsurance None
Physician/surgeon fees No Charge 20% coinsurance None
If you need immediate medical attention
Emergency room care $250 copay/visit $250 copay/visit Deductible and copay waived if admitted or for an accidental injury
Emergency medical transportation
No Charge No Charge Mileage limits apply
Urgent care $40 copay/visit 20% coinsurance None
5 of 10
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
If you have a hospital stay
Facility fee (e.g., hospital room)
No Charge 20% coinsurance Preauthorization is required
Physician/surgeon fee No Charge 20% coinsurance None
If you need behavioral health services (mental health and substance use disorder)
Outpatient services No Charge
No Charge for mental health; 20% coinsurance for substance use disorder
Your cost share may be different for services performed in an office setting
Inpatient services No Charge 20% coinsurance Preauthorization is required.
If you are pregnant
Office visits
Prenatal: No Charge; deductible does not apply Postnatal: No Charge; deductible does not apply
Prenatal: 20% coinsurance Postnatal: 20% coinsurance
Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound) and depending on the type of services cost share may apply. Cost sharing does not apply for preventive services.
Childbirth/delivery professional services
No Charge 20% coinsurance None
Childbirth/delivery facility services
No Charge 20% coinsurance None
If you need help recovering or have other special health needs
Home health care No Charge No Charge Physician certification required.
Rehabilitation services No Charge 20% coinsurance Physical, Speech and Occupational Therapy is limited to a combined maximum of 60 visits per member, per calendar year.
Habilitation services
Not covered for Applied Behavioral Analysis; Not covered for Physical, Speech and Occupational Therapy
Not covered for Applied Behavioral Analysis; Not covered for Physical, Speech and Occupational Therapy
None
Skilled nursing care No Charge No Charge Preauthorization is required. Limited to 120 days per member per calendar year
Durable medical equipment
No Charge No Charge Excludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required.
Hospice services No Charge; deductible does not apply
No Charge; deductible does not apply
Physician certification required. Visit limits apply.
Children’s eye exam Not covered Not covered None
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Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
If your child needs dental or eye care For more information on pediatric vision or dental, contact your plan administrator
Children’s glasses Not covered Not covered None
Children’s dental check-up
Not covered Not covered None
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Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Acupuncture treatment
Cosmetic surgery
Dental care (Adult)
Infertility treatment
Long term care
Routine foot care
Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Bariatric surgery
Chiropractic care
Coverage provided outside the United States. See http://provider.bcbs.com
Hearing aids
Non-emergency care when traveling outside the U.S
Private-duty nursing
Routine eye care (Adult)
8 of 10
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/healthreform, or the Department of Health and Human Services, Center for Consumer Information and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov or by calling the number on the back of your BCBSM ID card. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Blue Cross® and Blue Shield® of Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) Department of Insurance and Financial Services, P. O. Box 30220, Lansing, MI 48909-7720 or http://www.michigan.gov/difs or [email protected]
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) Language Access Services: See Addendum
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. ––––––––––––––––––––––
The plan would be responsible for the other costs of these EXAMPLE covered services. 9 of 10
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
(9 months of in-network pre-natal care and a hospital delivery)
The plan’s overall deductible $500
Specialist copayment $25 Hospital (facility) coinsurance 0% Other coinsurance 0%
This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)
Total Example Cost $12,700
In this example, Peg would pay:
Cost Sharing
Deductibles $500
Copayments $10
Coinsurance $0
What isn’t covered
Limits or exclusions $60
The total Peg would pay is $570
Managing Joe’s Type 2 Diabetes
(a year of routine in-network care of a well-controlled condition)
The plan’s overall deductible $500 Specialist copayment $25
Hospital (facility) coinsurance 0% Other coinsurance 0%
This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)
Total Example Cost $5,600
In this example, Joe would pay:
Cost Sharing
Deductibles $500
Copayments $700
Coinsurance $0
What isn’t covered
Limits or exclusions $20
The total Joe would pay is $1,220
Mia’s Simple Fracture
(in-network emergency room visit and follow up care)
The plan’s overall deductible $500 Specialist copayment $25
Hospital (facility) coinsurance 0% Other coinsurance 0%
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)
Total Example Cost $2,800
In this example, Mia would pay:
Cost Sharing
Deductibles $500
Copayments $60
Coinsurance $0
What isn’t covered
Limits or exclusions $0
The total Mia would pay is $560
If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses – like the deductible, copayments, or coinsurance, or benefits not otherwise covered.
. 10 of 10
