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Public Employees’ Benefits Program
Plan Year 2016 Rates Effective July 1, 2015
Table of Contents
State Active Employee Rates
2
State Active Employee with Domestic Partner Rates (CDHP)
3
State Active Employee with Domestic Partner Rates (HMO Plans)
4
State Active Employee Leave Without Pay Rates
State Active Legislator Rates
5
6
State Retiree and Survivor Rates
7
State Retiree with Domestic Partner Rates
8
State Retiree Subsidy Adjustment Table
9
Non-State Active Employee Rates
10
Non-State Retiree and Survivor Rates
11
Non-State Retiree Subsidy Adjustment Table
12
Medicare Exchange Retiree HRA Contribution
13
Voluntary Dental Insurance Rates for Medicare Exchange Retirees
14
State Employee COBRA Rates
State Retiree COBRA Rates
Non-State Employee COBRA Rates
Non-State Retiree COBRA Rates
15
16
17
18
State Employee Rates
Rates Effective
July 1, 2015 – June 30, 2016
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Page 2
Statewide PPO
Statewide HMO
Consumer Driven Health Plan
Hometown Health Plan and
Health Plan of Nevada
Participant Premium
Participant Premium
43.78
170.13
173.36
463.74
94.59
305.52
223.95
599.12
State Employee with Domestic Partner Rates
Statewide PPO
Rates Effective
July 1, 2015 – June 30, 2016
Consumer Driven Health Plan
Participant Premium
Employee + DP
Pre-Tax Deduction
Post-Tax Deduction
173.36
43.78
129.58
Employee + DP's Child(ren)
94.59
43.78
50.81
Employee + Children of both
94.59
94.59
-
Employee + DP + EE's Child(ren)
223.95
94.59
129.36
Employee + DP + DP's Child(ren)
223.95
43.78
180.17
Employee + DP + Children of
both
223.95
94.59
129.36
Page 3
State Employee with Domestic Partner Rates
Statewide HMO
Rates Effective
July 1, 2015 – June 30, 2016
Hometown Health HMO Plan
and Health Plan of Nevada (HPN)
Participant Premium
Pre-Tax Deduction
Post-Tax Deduction
Employee + DP
463.74
170.13
293.61
Employee + DP's Child(ren)
305.52
170.13
135.39
Employee + Children of both
305.52
305.52
-
Employee + DP + EE's Child(ren)
599.12
305.52
293.60
Employee + DP + DP's Child(ren)
599.12
170.13
428.99
Employee + DP + Children of
both
599.12
305.52
293.60
Page 4
State Employee Leave Without Pay Rates
Rates Effective
July 1, 2015 – June 30, 2016
Employee Only
Statewide PPO
Statewide HMO
Consumer Driven Health Plan
Hometown Health Plan and
Health Plan of Nevada
Participant Premium
Participant Premium
625.37
773.33
Employee + Spouse/DP
1,105.33
1,472.39
Employee + Child(ren)
813.56
1,095.68
1,292.68
1,794.74
Employee + Family
State employees on Leave without Pay and employees on Military leave do not receive a subsidy.
Page 5
State Active Legislator Rates
Rates Effective
July 1, 2015 – June 30, 2016
Statewide PPO
Statewide HMO
Consumer Driven Health Plan
Hometown Health Plan and
Health Plan of Nevada
Participant Premium
Participant Premium
Employee Only
625.37
773.33
Employee + Spouse/DP
1,105.33
1,472.39
Employee + Child(ren)
813.56
1,095.68
1,292.68
1,794.74
Employee + Family
State active legislators do not receive a subsidy.
Page 6
State Retiree and Survivor Rates
Rates Effective
July 1, 2015 – June 30, 2016
Statewide PPO
Statewide HMO
Consumer Driven Health Plan
Hometown Health Plan and
Health Plan of Nevada
Participant Premium
Participant Premium
Retiree only
218.69
385.26
Retiree + Spouse
487.46
881.60
Retiree + Child(ren)
322.19
614.13
Retiree + Family
592.38
1,110.47
Surviving/Unsubsidized Spouse
607.46
755.42
Surviving/Unsubsidized Spouse +
Child(ren)
792.30
1,077.77
To determine your subsidy, refer to the State Retiree Subsidy Table on Page 9.
Note: Survivors and unsubsidized dependents are not eligible for a subsidy.
Page 7
State Retiree with Domestic Partner Rates
Rates Effective
July 1, 2015 – June 30, 2016
Statewide PPO
Statewide HMO
Consumer Driven Health Plan
Hometown Health Plan and
Health Plan of Nevada
Participant Premium
Participant Premium
Retiree + DP
487.46
881.60
Retiree + DP's Child(ren)
322.19
614.13
Retiree + Children of both
322.19
614.13
Retiree + DP + Ret's Child(ren)
592.38
1,110.47
Retiree + DP + DP's Child(ren)
592.38
1,110.47
Retiree + DP + Children of both
592.38
1,110.47
To determine your subsidy, refer to the State Retiree Subsidy Table on Page 9.
Page 8
State Retiree Subsidy Adjustment Table
State Retiree Subsidy
For Retirees Enrolled in the CDHP
or HMO Plans
Years of Service
5
6
7
8
9
10
11
12
13
14
15 (Base)
16
17
18
19
20
Page 9
State Subsidy
+331.16
+298.04
+264.93
+231.81
+198.70
+165.58
+132.46
+99.35
+66.23
+33.12
-33.12
-66.23
-99.35
-132.46
-165.58
 For participants who retired before January 1, 1994,
the participant premium for the selected plan and
tier is shown on the tables on the previous pages.
 For participants who retired on or after January 1,
1994, add or subtract the appropriate subsidy based
on the number of years of service to or from the
participant premium for the selected plan and tier.
 Those retirees with less than 15 Years of Service,
who were hired by their last employer on or after
January 1, 2010 and who are not disabled do not
receive a Years of Service Subsidy or Base Subsidy.
 Those retirees who were hired by their last employer
on or after January 1, 2012 do not receive a Years of
Service Subsidy or Base Subsidy.
 If you are a retiree (or survivor) enrolled in the
CDHP or an HMO plan and you pay for Medicare
Part B, deduct $104.90 from your premium cost.
Non-State Employee Rates
Rates Effective
July 1, 2015 – June 30, 2016
Statewide PPO
Statewide HMO
Consumer Driven Health Plan
Hometown Health Plan and
Health Plan of Nevada
Participant Premium
Participant Premium
Employee Only
1,001.65
820.73
Employee + Spouse
1,857.89
1,567.19
Employee + Child(ren)
1,745.12
1,195.55
Employee + Family
2,600.52
1,942.01
Page 10
Non-State Retiree and Survivor Rates
Rates Effective
July 1, 2015 – June 30, 2016
Statewide PPO
Statewide HMO
Consumer Driven Health Plan
Hometown Health Plan and
Health Plan of Nevada
Participant Premium
Participant Premium
Retiree only
983.74
802.82
Retiree + Spouse/DP
1,839.98
1,549.28
Retiree + Child(ren)
1,727.21
1,177.64
Retiree + Family
2,582.61
1,924.10
983.74
802.82
1,727.21
1,177.64
Surviving/Unsubsidized Spouse/DP
Surviving/Unsubsidized Spouse/DP +
Child(ren)
To determine your premium, refer to the Non-State Retiree Subsidy Adjustment Table on Page 12.
Note: Survivors and unsubsidized dependents are not eligible for a subsidy.
Page 11
Non-State Retiree Subsidy Adjustment Table
Non-State Retiree Subsidy
For Retirees Enrolled in the CDHP
or HMO Plans
Years of Service
5
6
7
8
9
10
11
12
13
14
15 (Base)
16
17
18
19
20
Page 12
Non-State Subsidy
-110.39
-143.50
-176.62
-209.73
-242.85
-275.97
-309.08
-342.20
-375.31
-408.43
-441.54
-474.66
-507.78
-540.89
-574.01
-607.12
 For participants who retired before January 1, 1994,
subtract the 15-year (base) subsidy from the
participant premium for the selected plan and tier.
 For participants who retired on or after January 1,
1994, subtract the appropriate subsidy based on the
number of years of service from the participant
premium for the selected plan and tier.
 Retirees with less than 15 Years of Service, who
were hired by their last employer on or after January
1, 2010 and who are not disabled do not receive a
Years of Service Subsidy or Base Subsidy.
 Retirees who were hired by their last employer on or
after January 1, 2012 do not receive a Years of
Service Subsidy or Base Subsidy.
 If you are a retiree (or survivor) enrolled in the
CDHP or an HMO plan and you pay for Medicare
Part B, deduct $104.90 from your premium cost.
Medicare Exchange Retiree HRA Contribution
HRA Contribution for Retirees
Enrolled in an Extend Health Plan
Years of Service
5
6
7
8
9
10
11
12
13
14
15 (Base)
16
17
18
19
20
Contribution
+55.00
+66.00
+77.00
+88.00
+99.00
+110.00
+121.00
+132.00
+143.00
+154.00
+165.00
+176.00
+187.00
+198.00
+209.00
+220.00
 Participants who retired before January 1, 1994 receive
the 15-year ($165) base contribution.
 For participants who retired on or after January 1, 1994,
the contribution is $11 per month per year of service
beginning with 5 years ($55) and a maximum of 20 years
($220).
 Spouses/domestic partners and surviving spouses
/domestic partners enrolled in the Medicare Exchange are
not eligible for an HRA contribution.
 Retirees with less than 15 Years of Service, who were
hired by their last employer on or after January 1, 2010
and who are not disabled do not receive a Years of Service
contribution.
 Retirees who were hired by their last employer on or after
January 1, 2012 do not receive a Years of Service
contribution.
 These amounts do not include the one-time $2 per month
per year of service ($360 for a retiree with 15 years of
service) contribution approved by the Board for Plan Year
2016.
Page 13
Voluntary Dental Insurance Rates for Medicare Exchange Retirees
Rates Effective
July 1, 2015 – June 30, 2016
State Retiree Rate
Non-State Retiree Rate
Participant Premium
Participant Premium
Retiree Only
35.34
35.75
Retiree + Spouse/DP
70.67
71.51
Surviving/Unsubsidized Spouse/DP
35.34
35.75
Page 14
COBRA Rates
State Employees
Rates Effective
July 1, 2015 – June 30, 2016
Participant
Statewide PPO
Statewide HMO
Consumer Driven Health Plan
Hometown Health Plan and
Health Plan of Nevada
Participant Premium
Participant Premium
637.88
788.80
Participant + Spouse/DP
1,127.44
1,501.84
Participant + Child(ren)
829.83
1,117.59
1,318.54
1,830.63
Participant + Family
 COBRA participants do not qualify for Life Insurance and Long Term Disability.
 Participants on COBRA do not receive a subsidy.
Page 15
COBRA Rates
State Retirees
Rates Effective
July 1, 2015 – June 30, 2016
Participant
Statewide PPO
Statewide HMO
Consumer Driven Health Plan
Hometown Health Plan and
Health Plan of Nevada
Participant Premium
Participant Premium
619.61
770.53
Participant + Spouse/DP
1,109.17
1,483.57
Participant + Child(ren)
808.15
1,099.33
1,300.27
1,812.37
Spouse/DP Only
619.61
770.53
Spouse/DP + Child(ren)
808.15
1,099.33
Participant + Family
 COBRA participants do not qualify for Life Insurance and Long Term Disability.
 Participants on COBRA do not receive a subsidy.
Page 16
COBRA Rates
Non-State Employees
Rates Effective
July 1, 2015 – June 30, 2016
Statewide PPO
Statewide HMO
Consumer Driven Health Plan
Hometown Health Plan and
Health Plan of Nevada
Participant Premium
Participant Premium
Participant
1,021.68
837.14
Participant + Spouse/DP
1,895.05
1,598.53
Participant + Child(ren)
1,780.02
1,219.46
Participant + Family
2,652.53
1,980.85
 COBRA participants do not qualify for Life Insurance and Long Term Disability.
 Participants on COBRA do not receive a subsidy.
Page 17
COBRA Rates
Non-State Retirees
Rates Effective
July 1, 2015 – June 30, 2016
Statewide PPO
Statewide HMO
Consumer Driven Health Plan
Hometown Health Plan and
Health Plan of Nevada
Participant Premium
Participant Premium
Participant
1,003.42
818.88
Participant + Spouse/DP
1,876.78
1,580.27
Participant + Child(ren)
1,761.75
1,201.19
Participant + Family
2,634.26
1,962.58
Spouse/DP Only
1,003.42
818.88
Spouse/DP + Child(ren)
1,761.75
1,201.19
 COBRA participants do not qualify for Life Insurance and Long Term Disability.
 Participants on COBRA do not receive a subsidy.
Page 18