1. finance
2. personal finance
3. insurance

2015
INSURANCE BENEFITS
SUMMARY
This document does not create a contract of employment. All benefits and an individual’s right to
them are subject to state regulations, University Policies and Procedures, the individual plan
documents, and the duly executed and recorded enrollment forms.
University of South Carolina
University of South Carolina
Division of Human Resources
Division of Human Resources
Summary of Benefits
This booklet provides a summary of the insurance/retirement benefits, privileges, and services for which you may be eligible as
a qualifying employee of the University of South Carolina. The University of South Carolina is a participating employer in South
Carolina state government benefit programs, administered by SC Public Employee Benefit Authority (PEBA). Whether you have
recently joined the University as a new employee or are a candidate for employment, we hope you find this information
helpful. If you would like additional information, please feel free to call the Benefits Office at (803) 777-6650 or visit the Human
Resources website at: http://hr.sc.edu.
More specific information about your benefits, paycheck, and personnel records may be accessed through the Visual
Information Processing system (VIP) at: http://vip.sc.edu , the PEBA Insurance Benefits division’s website at: www.eip.sc.gov,
and the PEBA Retirement Benefits’ website at: www.retirement.sc.gov.
Information for New Employees
Welcome to the University of South Carolina! This guide provides a summary of available State/University insurance and
retirement benefits which are applicable to the various employees groups as described below. To prepare you for making
enrollment choices, the Benefits Office has highlighted important information for your reference. If after review of this
material, you feel more information is needed, please contact the Benefits Office as soon as possible and well within 30 days
following your start date. Please pay particular attention to the information requested on page 15-as applicable to your
eligibility. If you are enrolling dependents, you will need to include this information with your insurance enrollment
documents. Your insurance cannot be activated without this information.
Eligibility for Full Benefit Offerings
Employees hired in a state-defined Full-Time Equivalent (FTE) position or a fully funded Research Grant/Time-Limited position
has an online resource which includes valuable information to assist with enrollment in insurance
(health/dental/vision/life/disability) and retirement benefits of their choice. Pension program participation is mandatory for
those employees employed in FTE positions. It is initiated via a welcome email with the link by the assigned Benefits Office
counselor to the employee upon receipt of the hiring paperwork from the employees’ Department. For your convenience, this
webpage may be accessed at: http://hr.sc.edu/benefits/benefits_orientation.html.
Affordable Care Act (ACA) Insurance Eligibility (Limited Insurance Offerings)
Employees initially hired with a scheduled work week of 30 hours or more in other capacities (temporary, temporary faculty
position, non-funded Research Grant/Time positions, etc.) are eligible for health, dental, and vision insurance according to
federal Affordable Care Act (ACA), SC Public Employee Benefit Authority (PEBA), and University of South Carolina guidelines.
Upon determination of eligibility by the Benefits Office, an email will be forwarded to the eligible employees which will include
the applicable online orientation link to review benefits. For a review of health, dental, and vision offerings, this may be
assessed at the link indicated above. Please note that life and disability insurance benefits information indicated via this link
will not be applicable for ACA employees.
Eligibility for Optional Pension Program Participation
New employees in temporary, temporary faculty position, non-funded Research Grant/Time positions are extended an
opportunity to participate in or opt out of pension program benefits. If they do not non-elect membership within 30 days of
their hire date, they are automatically enrolled in the South Carolina Retirement System (SCRS) program. There are certain
guidelines that may require participation and will be reviewed accordingly based on PEBA guidelines. Online pension
orientation for temporary employees may be assessed at: http://hr.sc.edu/benefits/temppensionorientation.html.
This document does not create a contract of employment. All benefits and an individual’s right to them are subject to state
regulations, University Policies and Procedures, the individual plan documents, and the duly executed and recorded
enrollment forms.
Most recent revision: 1/2015
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University of South Carolina
University of South Carolina
Division of Human Resources
Division of Human Resources
Table of Contents
General Information ............................................................................................. 3-7
Paydays ......................................................................................................... 3
Benefits Eligibility .......................................................................................... 3
Eligible Dependents ...................................................................................... 3
COBRA ........................................................................................................... 4
Effective Dates of Coverage .......................................................................... 4
Insurance Costs and Payroll Deductions ....................................................... 4
Enrollment Periods ....................................................................................... 5
Holidays and Leave ....................................................................................... 5-6
Other Privileges............................................................................................. 6-7
Insurance Coverage .............................................................................................. 7-13; 17
Comparison of Health Plans Offered for 2015 .............................................. 17
State Health Plans: Standard and Savings ..................................................... 7-8
Tricare Supplemental Plan ............................................................................ 9
Dental Insurance ........................................................................................... 9
Vision Care .................................................................................................... 9-10
Long Term Disability Plans…………………………………………………………………………..10
Life Plans ....................................................................................................... 10-11
State Optional Life Rate Chart for 2015 ........................................................ 18-20
MoneyPlu$ (Flexible Account Plans) ............................................................. 11-12
Making Insurance Changes ........................................................................... 12
Failure to Enroll or Update Coverage ............................................................ 12-13
Insurance Enrollment: Required Documentation ......................................... 13
Retirement Benefits and Offerings ....................................................................... 13-14
Other Supplemental Offerings .............................................................................. 14
USC Cancer Plan ............................................................................................ 14
USC Hospital Confinement Plan .................................................................... 14
Auto & Homeowners Insurance.................................................................... 14
Enrollment Worksheets ........................................................................................ 15-16
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University of South Carolina
University of South Carolina
Division of Human Resources
Division of Human Resources
Paydays
Employees are paid on the 15th and the last workday of each month. If these dates fall on the weekend or a holiday,
employees will be paid the business day preceding the weekend or holiday. Generally, time worked up to that date will be
included– with the exception of temporary employees who a paid on a 2 week lag. Employees are required to have their
paychecks direct deposited.
Benefits Eligibility
Full Benefit Offerings eligibility: To qualify for full benefit offerings under state and University insurance plans, you must be
employed in a state-defined FTE position working at least 20 hours a week. Research grant-funded and time-limited employees
who meet these requirements are eligible for the benefits, if funded and specified in their grant agreement. Faculty and staff
in Full-Time Equivalent (FTE) positions are required by state law to participate in a retirement program. In addition, those
employees in other position types who previously opted into the South Carolina Retirement System (SCRS) program and
continue to show established time within the SCRS program may be required to continue participation.
Affordable Care Act eligibility: Employees in other position types initially hired with a scheduled work week of 30 hours or
more in other capacities (temporary, temporary faculty position, non-funded Research Grant/Time positions, etc.) are eligible
to enroll in health, dental, dental plus, vision insurance, and the MoneyPlu$ pretax premium feature according to federal
Affordable Care Act (ACA), SC Public Employee Benefit Authority (PEBA), and University of South Carolina guidelines. Those
employees that are eligible for their own active coverage (whether they enroll or refuse their own coverage) will be required to
come off of their spouse’s coverage if they are enrolled under another PEBA participating entity. Additionally, Medicare eligible
PEBA retirees (whether they enroll or refuse their own coverage) will be required to refuse PEBA coverage. ALL Medicare
eligible employees/dependents: Please note that in the instance that Medicare eligible employees and/or dependent(s) are
extended rights to active group coverage- whether they accept or refuse Medicare will be secondary and active group coverage
will become primary.
According to ACA guidelines, employees initially hired with a scheduled work week of less than 30 hours per week will be
placed in a measurement period of one year, which begins the first of the month following the hire date. If it is determined at
the conclusion of that year that the employee qualified for benefits based on averaging at least 130 hours per month, they will
be extended insurance based on ACA guidelines. Those who qualify in this manner will be extended continued insurance for
one year (if employed) regardless of the scheduled number of work hours during that year.
Optional Pension Program Participation eligibility: New employees in temporary, temporary faculty position, non-funded
Research Grant/Time positions are extended an opportunity to participate in or opt out of pension program benefits. If nonelection of membership does not take place within 30 days of their hire date, they are automatically enrolled in the South
Carolina Retirement System (SCRS) program. There are certain guidelines that may require participation and will be reviewed
accordingly based on PEBA guidelines.
Eligible Dependents
You may cover either your lawful spouse, or a former spouse (if required by a divorce decree or court order), but not both.
However, if your spouse (or former spouse-by order) is an employee of a South Carolina state-covered entity or retiree, each of
you must carry your own insurance coverage (based on the insurance for which you qualify), and you may not duplicate
coverage for the same dependent children.
You may cover any of your children under the health, dental, or vision plans as long as s/he is under age 26 (with the exception
of incapacitated children). Incapacitated children may continue to be covered if s/he is an incapacitated unmarried child over
the age of 26 who is incapable of self-sustaining employment because of a disability and who is principally dependent on you
for support (incapacity must be established within 90 days prior to age 26; prior to age 19 for Dependent Life Child coverage).
PEBA incapacitation review process may take up to 30 days (longer with extenuating circumstances). For additional information
regarding what is needed, please speak with your assigned counselor. For all dependents, you must provide proof of
relationship, dates of birth, and social security numbers for your dependent spouse and children and this information is subject
to review, prior to approval of coverage.
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University of South Carolina
University of South Carolina
Division of Human Resources
Division of Human Resources
COBRA (Consolidated Omnibus Budget Reconciliation Act)
After you enroll in the health, dental, vision, or medical spending account plans (as applicable), you will receive a notice
advising you and/or your covered dependents of the right to keep this coverage in the event of certain qualifying
circumstances. A federal law known as Consolidated Omnibus Budget Reconciliation Act (COBRA) requires that this
information be provided to you and your covered family members when you enroll in the health, dental, vision, or medical
spending account plans (as applicable), and thereafter, each time we are aware of a change in your family status that affects
insurance eligibility. Please let your covered family members know so they may expect to receive this information in the event
they experience a qualifying event.
Coverage may be continued for a limited time under COBRA if you and/or your dependents lose coverage because:
· You are state-defined FTE position and working hours are reduced to less than 20 hours a week;
· You voluntarily quit work, are laid off, or fired (unless the firing is due to gross misconduct);
· You no longer qualify otherwise under insurance guidelines;
· You have separated or divorced spouse; or
· Your dependent child is no longer eligible for coverage.
These events should be reported within 60 days of occurrence. COBRA coverage will be offered and, if desired, must be
elected within 60 days of the insurance termination effective date. If elected, the COBRA coverage will be retroactive to the
insurance termination date. If COBRA is not reported and elected within 60 days of occurrence COBRA coverage will not be
extended. Rules and regulations governing continuation of coverage under COBRA are described in your Insurance Benefits
Guide, which is published annually by the SC PEBA Insurance Benefits division. This guide is mailed to your campus address
by the 2nd week in January of each year. It is also available on the Benefits website links.
Effective Dates of Coverage
As a new hire, the effective date of coverage for the various insurance plans for which you enroll is the first day of the month
following your date of hire, unless you begin work on the first workday of the month; in which case, you may choose an
effective date of the first of that month or the first of the following month*. (Persons whose eligibility has to be assessed over
a year for ACA purposes, upon becoming eligible, insurance will be effective the first of the month following the determination
of qualification). As applicable, the effective date for retirement program membership is your initial date of hire. Depending
on when your hiring paperwork is completed and forwarded to the Benefits Office, you may not have completed your
enrollment forms by the effective dates described above. However, provided insurance forms are completed and submitted
within 31 days of your start date (pension forms must be completed within 30 days of the date of hire), your coverage is
retroactive to the appropriate effective date. Please make a note that each month insurance premium deductions are
scheduled to be taken one month in advance and are retroactive to the effective date of coverage. *Note: Please notify the
Benefits Office immediately if you begin your employment in leave without pay status. For insurance purposes, the effective
date will be deferred until you actually start work, whereas pension membership will still be effective as of the date of hire.
Insurance Costs and Payroll Deductions
Costs: Rates for the health plans are provided on page 17. Rates for the dental and vision care plans are provided on pages
9-10. Optional and dependent life rates are provided on pages 18-19. Rates for other plans may be accessed via USC’s Benefits
Office online orientation resources.
Payroll Deductions: As stated previously, each month insurance premiums are scheduled to be deducted one month in advance
for the following month. Depending on when your coverage is effective and when the Payroll Office receives your enrollment
forms, the first paycheck following enrollment may include payroll deductions for up to two months of premiums. You should
always check your electronic pay stub after enrolling or making any insurance change to make sure the appropriate
premiums are being deducted. Please contact the Payroll Office at (803) 777-4227 with questions about your payroll
deductions.
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University of South Carolina
University of South Carolina
Division of Human Resources
Division of Human Resources
Enrollment Periods
Initial New Hire Enrollment: Within the 31-day period following your date of hire* (within 30 days of the hire date for the
pension program purposes), you may enroll in benefits described in this summary– according to eligibility, unless you are
transferring from another South Carolina state-covered entity. If you are transferring from another South Carolina statecovered entity, you are required to continue your same level and type of coverage in existence with the prior employer. The
Benefits Office encourages all employees to have paperwork completed and forwarded within 7 days of your hire date to allow
for timely processing. Transfer employees’ PEBA insurance/pension elections will not change from coverage opted with the
prior employer.
*Note: If you begin employment in leave without pay status, please notify the Benefits Office immediately as insurance
enrollment will be deferred until your actual start date (insurance enrollment must take place within 31 days of the actual
start date. However, pension program enrollment still needs to take place within 30 days of the date of hire).
Open Enrollment: The Open Enrollment period for the state insurance plans take place in October each year. You may make
specified benefit changes at that time. Insurance changes made during Open Enrollment will be effective the following January
1. Information will be available to you in September about changes that are occurring in the state insurance plans for the next
calendar year, and about the benefits changes that you may make during the enrollment period. It is important that you
anticipate this information, read it carefully, and make changes appropriate to your needs during the enrollment period. See
page 12 for additional information. Dental/Dental Plus coverage changes are offered as a part of a Special Enrollment which
occurs every other year in odd-numbered years. Please review information under “Making Insurance Changes” and “Failure
to Enroll or Update Coverage” sections. Optional Retirement Plan (ORP) enrollment is held January through March each year
for eligible ORP participants– with an effective date of the following April 1.
Holidays and Leave
Note: Only eligible employees are entitled to USC Holidays and Leave. ACA employees are not entitled to these benefits.
Holidays: There are 13 paid holidays. The holiday schedule is set each year to coincide with the academic schedule. The
holiday schedule for 2015 is provided below. The University’s holiday schedule does not mirror all holidays observed by other
state agencies. Dates with an asterisk (*) represent substituted days for these days.
New Year’s Day, Thursday, January 1, 2015
Martin Luther King, Jr. Day, Monday, January 19, 2015
Independence Day, Friday, July 3, 2015
Labor Day, Monday, September 7, 2015
Thanksgiving Day, Thursday, November 26, 2015
Day After Thanksgiving, Friday, November 27, 2015
December Holiday, Wednesday, December 23, 2015*
Christmas Eve, Thursday, December 24, 2015
Christmas Day, Friday, December 25, 2015
Day After Christmas, Monday, December 28, 2015
December Holiday, Tuesday, December 29, 2015*
December Holiday, Wednesday, December 30, 2015*
December Holiday, Thursday, December 31, 2015*
New Year’s Day, Friday, January 1, 2016
Sick Leave: If you work one-half the work week in a state defined Full-Time Equivalent (FTE) position, you will earn sick leave.
FTE employees earn at the rate of 1¼ days a month. Part-time FTE employees earn sick leave on a pro-rata basis. Employees
may accumulate up to a maximum of 195 days each year; however, no more than 180 days may be carried into a new calendar
year. Up to 10 days of available sick leave may be used each year for the illness of an immediate family member. Sick leave is
generally forfeited at separation from employment. However, it may be transferable upon transferring without a break in
service to another qualifying agency. Employees in a grant-funded or time-limited position may earn sick leave, if allowed by
the grant and USC guidelines. However, it may or may not be transferrable to other grant-funded or time-limited positions
within the University. Sick leave for these position types can’t be transferred to another qualifying agency.
Annual Leave: If you work one-half the work week in a leave-eligible position on a 12-month pay basis, you will earn annual
leave. Qualified FTE employees earn annual leave at the rate of 1¼ days a month for the first 10 years and an additional 1¼
days per year following the 10th year anniversary up through the 22nd year. Qualified part-time FTE employees earn annual
leave on a pro-rata basis. The maximum accumulation each year is 75 days; however, only 45 days may be carried over into a
new calendar year. At separation from employment, you will be paid a lump sum amount for unused annual leave, up to 45
days*. Upon transfer to another qualifying agency without a break in service, annual leave may be transferred. *Note: If
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University of South Carolina
University of South Carolina
Division of Human Resources
Division of Human Resources
allowed by the grant, employees in grant-funded and time-limited positions may be required under the grant to use accrued
annual leave prior to the expiration of the grant or separation from employment. If it is not used, it may be lost. In addition,
they may or may not be entitled to bonus annual leave accruals, but may or may not be able to transfer leave to another grantfunded or time-limited position within the University. Annual leave for these position types can’t be transferred to another
qualifying agency.
Family and Medical Leave Act: The Family and Medical Leave Act (FMLA) allows qualified employees to take up to 12 weeks of
unpaid leave per calendar year when they are unable to work because of their own serious health condition, the
birth/placement/adoption of a newborn child (within one year of birth), or to care for a spouse or qualified family member with
a serious health condition, or any qualifying exigency arising out of the fact that employee’s qualified family member is a
covered military member on “covered active duty.” FMLA may be allowed for a qualified caregiver for up to 26 weeks to care
for a seriously injured or ill service member. Any available annual or sick leave used in conjunction with approved FMLA, will
run concurrently with FMLA leave, pursuant to University Policies and Procedures.
Other Leave With Pay: Up to three consecutive workdays of leave with pay are allowed at the death of an immediate family
member, as outlined in HR Policy 1.09. Up to 15 workdays of leave with pay are allowed for annual training in the National
Guard or Armed Forces Reserves. Additional military leave may be granted during times of emergency. Leave with pay is also
provided when an employee is subpoenaed to serve as a juror or witness for court, for reasons not in relation to personal
litigation.
Leave Pool: Employees in state-defined FTE positions may voluntarily donate annual leave or sick leave to the University of
South Carolina’s leave pool. In catastrophic situations, employees who have no available leave may request leave from the pool
if the absence would result in at least 30 days in leave without pay status. The leave request is subject to approval by both the
Department and the Division of Human Resources.
Sabbatical Leave: Tenured professors or associate professors may be granted sabbatical leave by the president, based on
seniority, merit, and six or more years of service as a full-time faculty member (see the Faculty Manual).
Personal or Educational Leave Without Pay: Leave without pay may be granted when deemed to be in the best interest of the
University. Up to 10 days of personal leave without pay may be granted through your department. Requests for more than 10
days must be submitted through the department, with final approval made within the Division of Human Resources.
Other Privileges
Note: Some of the benefits outlined below may not be available to all categories of employees. Please contact the
administrator to determine if you are eligible.
Tuition Assistance Program: On a space availability basis, faculty (after one semester) and staff (after six months) may apply to
take one three-hour credit course (four hours in the case of a lab course) per academic term at no charge. Eligible research
grant-funded employees may apply for tuition assistance by completing the USC Tuition Assistance Application for research
grant employees, which includes a promissory note that must be completed.
Employee Assistance Program: This program offers assistance to eligible faculty and staff and their family members who may
be experiencing a range of life challenges such as child-rearing concerns, elder care issues, alcohol and drug-related problems,
abuse issues, marital difficulties, depression, anxiety, stress, financial problems, and legal issues. For assistance, contact Deer
Oaks Employee Assistance Program at 1-866-327-2400.
Visual Information System (VIP) for Faculty and Staff: When your hire documents and benefits enrollment forms have been
processed, you will be able to access information about your paycheck, benefits, leave status, and other personal information
online by using a personal identification number (PIN) that you select through the VIP system. VIP may be accessed at:
https://vip.sc.edu. For your first 30 days of employment, your PIN will be your birth month and date. You must change your
PIN to keep it active.
Dual Career Employment Services: When faculty and professional staff are relocating, it has become increasingly important to
assist with their spouse’s or partner’s career needs in addition to housing and other relocation concerns. Dual Career
Employment Services are provided through the Division of Human Resources’ Employment Office for spouses/partners of newly
recruited faculty and professional staff. For details on this service, call (803)777-3821, or visit the Human Resources’ website
at: http://hr.sc.edu/employ/dualcareer.html.
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University of South Carolina
University of South Carolina
Division of Human Resources
Division of Human Resources
Additional Privileges:
Reduced-Price Athletic Tickets
Carolina Collegiate Federal Credit Union
Professional Development Programs
U.S. Savings Bonds
Strom Thurmond Wellness & Fitness Center
USC Cultural Events Tickets
Blatt Physical Education Center
USC Bookstore Discount
Free Notary Services
Pre-Retirement Seminars
Child Development Center
You may learn more about some of these privileges by attending a University Orientation. For information on
attending a University Orientation session, please call (803) 777-6578.
Insurance Coverage
Health Insurance
You may choose from three health insurance plans. Outlined below are major features of these plans. The comparison chart
on page 17 provides a more detailed description of plan summaries and cost.
State Health Plans: The State Health Plan offers a choice between two different insurance plans, Standard Plan or Savings
Plan. These plans are self-insured and funded by premiums paid to the plan. Claims are processed by Blue Cross-Blue Shield of
South Carolina. Most medical services must be medically necessary in order to be covered, with the exception of the following
routine services: Pap smears, mammograms, Well-Child Care, colonoscopies, and the preventative worksite screening benefit.
The Savings Plan also covers a routine physical– later discussed in this section. Payment of these services is subject to program
plan guidelines. Both plans have an annual deductible that must be met before co-insurance benefits are paid. After the
deductible is met, you will pay part of the expenses until you meet an annual out-of-pocket maximum. After the out-of-pocket
maximum is met, you are covered for 100% of eligible charges for the remainder of the year (according to plan provisions and
guidelines).
Standard Plan Deductibles
$445 for individual coverage
$890 for family coverage
Savings Plan Deductibles
$3,600 for individual coverage
$7,200 for family coverage
Medi-Call (pre-certification requirement of the State Health Plans): Pre-certification is required within 48 hours for all hospital
admissions (inpatient/outpatient), all sclerotherapy, chemotherapy, radiation therapy, in vitro fertilization, GIFT, ZIFT, or any
other fertility procedure for a covered member, within first 3 months of pregnancy, when baby is born, if your baby has
complications at birth, before baby is given the drug Synagis outside the hospital nursery; any non-emergency surgical
procedure performed in a hospital, freestanding clinic, or ambulatory surgical center; hospitalization that exceeds the length of
stay limitation previously authorized by Medi-Call; extended care services (hospice or alternative treatment plan, home health
care, skilled nursing facility, long-term acute care facility, durable medical equipment); any medical service or procedure
involving inpatient rehabilitative services and related outpatient physical, speech, or occupational therapy, second surgical
opinion and extended care, and organ transplant, bone marrow transplant, or other stem cell rescue or tissue transplant for
which benefits are provided. Failure to obtain pre-certification in the above circumstances, or within 48 hours in an emergency,
will result in a $200 penalty for each admission, and the costs incurred during the hospitalization or treatment will not
contribute to the out-of-pocket maximums. It is your responsibility to ensure that the provider has pre-authorized the
services. Medi-Call may be contacted at (803) 699-3337 or (800) 925-9724 (nationwide and Canada).
Advanced Radiology (pre-certification requirement of the State Health Plans): If you or a covered dependent are scheduled to
receive CT, MRI, MRA, or PET scans from an out-of-network provider, you are responsible for ensuring that the provider
receives pre-authorization from National Imaging Associates (NIA). Otherwise, the provider will not be paid and you will be
responsible for the entire bill. NIA may be reached by calling (866) 500-7664.
Provider Networks: The State Health Plan has participating provider networks for hospitals, physicians, mental health and
substance abuse, pharmacies, ambulatory surgical centers, transplant centers, and mammography centers. The networks
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University of South Carolina
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Division of Human Resources
include most providers in South Carolina and some providers in other states. Participating providers have agreements with the
State Health Plan that determine how much they can charge State Health Plan members for services. You must use network
providers for Well-Child Care, routine mammograms, and prescriptions. There is no reimbursement for non-network providers
for these services. You have access to doctors and hospitals for medical benefits almost everywhere with the BlueCard
Program, administered by Blue Cross and Blue Shield of South Carolina. You may call (800)-810-BLUE (2583) for more
information.
Coordination of Benefits: The State Health and Dental Plans use the Birthday Rule for coordination of benefits. If a husband
and wife have two different employer group insurance plans and both cover their children, the parent whose birthday comes
first in the calendar year must file claims for the children under his or her insurance first, as the primary coverage.
1) Standard Plan: Under the Standard Plan, the family deductible is the same, regardless of the number of family members
covered. The maximum that any one family member can contribute toward the $890 family deductible is $445. The family
deductible may be met by any combination of two or more family members. Per-occurrence deductibles are applied to certain
services. The deductibles are as follows and do not apply toward the plan deductible or the out-of-pocket maximum: $12 pervisit deductible for each visit to a professional provider’s office; $95 per occurrence for outpatient hospital services (see the
Insurance Benefits Guide for exceptions); and $159 for each emergency room visit. The emergency room deductible is waived if
you are admitted to the hospital.
When the deductible is met, the plan pays at 80% of allowed charges for in-network providers and 60% for out-of-network
providers. For out-of-network providers, you are liable for 40% of allowable charge and any balance billed by the provider.
Under the Standard Plan, for in-network services there is a $2,540 maximum coinsurance for individual coverage or $5,080 for
family coverage, and for out-of-network services there is $5,080 maximum for individual coverage or $10,160 for family
coverage. The Standard Plan will then pay 100% of the allowable charges. Expenses paid for prescription drugs, deductibles,
and non-covered services are not credited toward your health coinsurance maximum. Also, penalties for not pre-certifying
certain services (as outlined on the prior page) do not count toward the coinsurance maximum.
The Standard Plan includes a prescription drug program that is not subject to the health deductible. This program is
administered by Catamaran and is easy and convenient to use. Participants simply show their Catamaran prescription card
when purchasing prescriptions from a participating pharmacy and pay a co-payment for up to a 31-day supply of $9 for generic
drugs, $38 for higher cost brand drugs, or $63 for highest cost brand drugs. If the price of your prescription is less than the copayment amount, you pay the lesser amount. You must use a participating pharmacy and show your Catamaran prescription
card when purchasing medications. Benefits are not payable if you use a non-participating pharmacy. However, if you incur
prescription drug expenses while traveling outside the United States, you will be able to file a claim for reimbursement of your
expenses that will be limited to the plan’s allowable charge less the co-payment. There is an annual prescription drug out-ofpocket maximum of $2,500 per person. When a participant has spent $2,500 in prescription drug co-payments, the plan will
cover that participant’s prescription drugs at no cost for the remainder of the year.
2) State Health Savings Plan: The annual deductible for individual coverage is $3,600 and $7,200 for family coverage. The total
amount of $7,200 has to be met before the insurance will begin paying the coinsurance percentage. There are no prescription
drug co-pays within this plan. The total allowable charge for drugs is paid by the participants and these amounts are included in
the deductible. This plan has no per-occurrence or per-visit deductibles. The State Health Savings Plan covers the following
preventative services: Well-Child Care, routine mammograms, colonoscopies, health screenings, an annual physical (may
include routine Pap), an annual flu shot, 24-hour access to a nurse care line, and a self-care guide.
If you are covered under the Savings Plan, you pay the full allowable charge for all services received and it is applied to your
deductible. After your annual deductible is met, the Savings Plan pays 80% of your covered medical, prescription drugs, and
mental health and substance abuse expenses, if you use network providers. You pay 20%. If you use out-of-network
providers, the Savings Plan pays 60% of your covered expenses and you pay 40% and any other balance billed.
In addition to the deductible, each year the coinsurance maximum for in-network coverage is $2,400 ($4,800 out-of-network)
for individual coverage or $4,800 ($9,600 out-of-network) for family coverage. The State Health Savings Plan will then pay
100% of allowable charges. Expenses paid for non-covered services, copayments, and penalties resulting from not calling MediCall, National Imaging Associates (NIA), or Companion Benefit Alternatives (CBA) do not count toward the annual deductible or
coinsurance maximum.
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University of South Carolina
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Division of Human Resources
3) Tricare Supplement Plan: The Tricare Supplement Plan is underwritten by Monumental Life Insurance Company and is
administered by Selman & Company/ Association and Society Insurance Corporation (ASI). The premiums may be pre-taxed
and are paid in full by the employee. Premiums are not subject to a tobacco surcharge. Basic life and basic long term disability
coverage do not accompany this coverage. Eligibility for coverage is extended to active and retired service members and their
spouses who are under the age of 65 years old, not eligible for Medicare, and registered with Defense Enrollment Eligibility
Reporting System (DEERS). Additionally, dependent children are eligible based on Tricare eligibility guidelines. Upon
termination of coverage, COBRA rights are not extended. Please see the 2015 Insurance Benefits Guide pages 91-93 for more
information regarding coverage details.
Dental Insurance
State Dental Plan: This plan provides minimal coverage and includes four classes of services. Class I (Preventive/Diagnostic)
pays 100% of the established fee schedule. Class II (Basic Services) and Class III (Prosthetics) have a combined annual
deductible of $25 for each covered person. Class II then pays 80% of the fee schedule, while Class III pays 50% of the fee
schedule. Class IV (Orthodontics) only covers dependent children under age 19, and covers 50% of the fee schedule up to a
lifetime maximum of $1,000. The maximum benefit per year for classes I, II, and III is $1,000 per covered person. Basic dental
coverage for the employee’s coverage is paid by the employer and is at no cost to the employee. While it does provide some
coverage, the coverage is minimal and in most instances, will not provide total coverage of claims. Changes to and from the
dental plans are only allowed during Special Enrollment periods occurring in October of odd-numbered years for an effective
date of January 1 of the following year. Please refer to the Insurance Benefits Guide for all exclusions.
Dental Plus: Provides a higher level of coverage for most of the services covered under the State Dental Plan. It is not an offset
program that pays what the State Dental Plan does not. Instead, it covers the same procedures and services (except
orthodontia) at the same percentage levels as the State Dental Plan, but has a higher fee schedule. Dental Plus premiums are
paid entirely by the employee. Subscribers must carry the same level of coverage for Dental Plus as the State Dental Plan. The
combined maximum per year for Dental Plus coverage is $2,000 per covered individual.
Dental and Dental Plus Premiums:
Semi-Monthly Rates for 12-month and 9-month Pay Basis for State Dental Plan
Employee Only
Employee/Spouse
Employee/Children
Full Family
12-month
9-month
12-month
9-month
12-month
9-month
12-month
9-month
$0
$12.29
$0
$3.82
$5.10
$6.86
$9.15
$10.67
Semi-Monthly Rates for 12-month and 9-month Pay Basis for Dental Plus Plan
$16.39
$24.83
$33.11
$28.63
$38.17
$37.11
$14.23
$49.48
Vision Care
The Vision Care Plan is administered by EyeMed and provides savings on eye care and eyewear. The plan provides coverage for
an annual comprehensive eye exam once a year, standard plastic lenses or contact lenses once a year, and frames once every
two years. For more details, please refer to the 2015 Insurance Benefits Guide pages 105-113.
Discounts on conventional contact lenses, additional eyeglasses, and more are offered through the plan. Co-pays are
required for some services and the plan provides coverage for out-of-network services. For more information and a list of
providers, view the State Vision Plan Schedule of Benefits Flyer or visit: http://www.eyemedvisioncare.com.
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Division of Human Resources
Division of Human Resources
Vision Care Premiums:
Semi-Monthly Rates for 12-month and 9-month Pay Basis for EYEMED Vision Plan
Employee Only
Employee/Spouse
Employee/Children
Full Family
12-month
9-month
12-month
9-month
12-month
9-month
12-month
9-month
$3.50
$4.67
$7.00
$9.33
$7.93
$9.99
$10.99
$14.65
Long Term Disability Plans
Note: ACA employees are not eligible for these benefits.
A pre-existing condition limitation applies to the Basic and Supplemental Long Term Disability Plans. Generally, a pre-existing
condition is a physical or mental condition for which you consulted a physician, received medical treatment or services, or took
prescribed drugs during the six-month period before coverage became effective. No benefits will be paid for a disability caused
or contributed to by a pre-existing condition unless: 1) on the date you become disabled you have been continuously covered
under the plan for at least 12 months or; 2) you have not been consulted by a physician, received medical treatment or
services, or taken prescribed medications during any 12 consecutive months between your date of disability and six months
before the date your coverage became effective.
Basic Long Term Disability Plan: Members of either one of the State Health Plans are covered for this benefit at no cost to the
member. Benefits under this Basic Long Term Disability Plan are not extended to Tricare Supplemental Plan subscribers. For
eligible employees, the plan pays up to 62.5% of the employee’s monthly base salary (up to a maximum of $800 a month)
following a 90-day waiting period, less any deductible income received or income the employee is eligible to receive from other
sources; benefits are not paid for an injury or sickness caused by a pre-existing condition until you have been insured for at
least 12 months or treatment free for 12 months immediately preceding the date of disability, whichever occurs sooner.
Supplemental Long Term Disability Plan: This optional disability income plan is also intended to provide income protection.
For those who are automatically enrolled under the Basic Long Term Disability Plan, this option supplements that coverage. For
those not enrolled under the Basic Long Term Disability Plan, this option may also be elected to supplement income. After a 90
or 180-day waiting period, the benefit pays up to 65% of the member’s monthly salary to a maximum of $8,000 per month, less
any disability benefits received from the basic disability plan and other sources; not to be less than $100 a month. The cost is
based on the employee’s salary and age. Benefits are not paid for an injury or sickness caused by a pre-existing condition until
the participant has been insured for at least 12 months or is treatment free for 12 months immediately preceding the date of
disability, whichever occurs sooner.
Life Plans
Note: ACA employees are not eligible for these benefits under group coverage.
State Group Life Plan: If you enroll in either of the State Health Plans, you will be covered for $3,000 in life insurance and
$3,000 in accidental death and dismemberment, at no cost to you. Enrollment in the Tricare Supplemental Plan does not
qualify for this benefit.
State Optional Life Plan: New employees can elect initial coverage (within 31 days of the start date) in $10,000 increments up
to three times their basic annual salary (up to a $500,000 maximum) without providing medical evidence of good health. This
figure will be rounded down to the nearest $10,000 increment. During initial enrollment, additional coverage above three
times your basic annual salary (up to $500,000) may be requested, provided that you show medical evidence of good health.
When medical evidence of good health is required, you must complete Minnesota Life’s Evidence of Insurability form. You do
not need to see a doctor to have this form completed. If coverage is approved, it will become effective the first of the month
following approval. Premiums on the first $50,000 of Optional Life coverage may be tax-sheltered if enrolled in the MoneyPlu$
premium pretax feature.
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Division of Human Resources
Division of Human Resources
Employees may enroll or make changes in the State Optional Life program in the event of a special eligibility situation.
Examples include birth, marriage, adoption, or foster child placement. Enrollment changes must be requested within 31 days of
the qualifying event.
The plan includes accidental death and dismemberment benefits equal to the face amount of the policy, a living benefit for
terminally ill members under age 60, and a seat belt provision of an additional 25% of the accidental death benefit when
applicable. It also includes day care, education, felonious assault, and repatriation benefits. Upon retiring, members under the
age of 75 may maintain a certain amount of insurance at group rates.
For coverage levels and costs, refer to the chart on pages 18-20. Note: Faculty on nine-month appointments should multiply
the monthly rates by 12, then divide the resulting annual rate by 18 pay periods to arrive at their specific pay period deduction.
Those paid on a twelve month basis should multiply the monthly rates by 12, then divide the annual rate by 24 pay periods to
arrive at their correct per pay period deduction.
Dependent Life Spouse: An employee may elect to cover their spouse with life coverage in increments of $10,000, up to 50% of
the employee’s Optional Life coverage or $100,000, whichever is less. However, an employee either not enrolled or enrolled
for up to $30,000 may still enroll in spouse coverage up to $20,000. Medical evidence of good health is required for initial
coverage greater than $20,000. Premiums are the same as Optional Life rates for employees and are based on the employee’s
age.
Dependent Life Child: An employee may elect to cover his/her dependent children up to age 25 (provided they are a full-time
student from age 19-24; if not, a benefit will be provided up to the last of the month following their 19th birthday) for $15,000.
Children may be enrolled in the Dependent Life program at any time during the year. The premium for coverage for children is
$1.10 per month, regardless of the number of children covered.
MoneyPlu$ (Flexible Benefits Features)
MoneyPlu$, a program administered by WageWorks, can help maximize your spendable income by allowing you to pay
certain insurance costs on a pretax basis. This means no state, federal, or Social Security taxes are withheld from dollars
included in the following MoneyPlu$ options:
Pretax Premiums feature: You may pay group insurance premiums on a pretax basis for your health, vision, dental, dental plus,
and up to the first $50,000 of State Optional Life Insurance coverage. Note: While the Pretax premium feature and the
Health Savings Account (for Savings Plan participant-described below) is available to ACA employees, ACA employees are not
eligible for enrollment in the other flexible spending accounts.
Flexible Spending Accounts
Medical Spending Account: You may enroll during Open Enrollment and must be employed for one year as of January 1
following an October enrollment period before you can enroll in a Medical Spending Account. You may direct pretax dollars to
be deposited into your account to pay for out-of-pocket medical expenses for anyone you claim on your income tax return.
Out-of-pocket expenses are the portion of expenses you are required to pay without any reimbursement by an insurance plan.
You can set aside up to $2,550 in a medical spending account each year. However, you must use the 2015 funds by the grace
period of March 15, 2016 and file claims by March 31, 2016 or you will lose it. Paper claims are filed to facilitate
reimbursement. For an additional cost, employees may request a WageWorks Visa card to access Medical Spending Account
funds to pay covered expenses. You must re-enroll each year in October for the following calendar year.
Dependent Care Spending Account: Depending on your tax filing status, you may set aside, on a pretax basis, up to $5,000 each
calendar year to pay dependent care expenses for children under age 13 or for mentally or physically disabled dependents of
any age. The benefit is limited to employees who must have dependent care to permit the employee and spouse (if married) to
work or attend school. The day care provider is required to provide a statement of costs. You may enroll upon initial hiring,
within 31 days of a qualifying event, or during Open Enrollment. You must re-enroll each year in October for the following
calendar year.
Limited-Use Medical Spending Account: If you are enrolled in a Health Savings Account (HSA), you are eligible to enroll in a
Limited-Use Medical Spending Account. This account may be used to pay expenses not covered by the Health Plan Savings Plan,
including non-covered prescription drugs, dental, and vision care.
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Division of Human Resources
Note: With the exception of the MoneyPlu$ pretax premium feature, you must re-enroll each year during the October
enrollment period. There is a “use it or lose it” rule for the Dependent Care and both Medical Spending accounts. At
termination of employment, claims may be submitted only for services incurred prior to termination, unless COBRA coverage
is opted for the accounts.
Health Savings Account (HSA)
This account in conjunction with the State Health Plan Savings Plan was designed to provide an economical insurance plan to
employees who are willing to take greater responsibility for their health care in an effort to reduce their insurance
premiums and save money for qualified medical expenses. An employee opting for this account must be covered under a high
deductible health insurance plan, such as the Savings Plan. The employee cannot be covered by any other health plan, including
Medicare. To contribute to an HSA through payroll deduction, the employee must enroll in the MoneyPlu$ HSA established
with Wells Fargo. Contributions are reported and administered by WageWorks.
The maximum contribution for a subscriber with single coverage is $3,350 and a subscriber with any other family member can
contribute up to $6,650. Subscribers age 55 and older may make “catch-up” contributions to an HSA in the amount of $1,000
for 2015. Contributions may be paid in lump sum or in equal payments during the year. Once a month, you may change the
amount of your MoneyPlu$ HSA payroll deduction. Employees will be provided one Wells Fargo Visa debit card to cover
expenses from the HSA. You may order additional cards or request a supply of checks by calling 1-866-884-7374. You may only
withdraw HSA funds that are actually in your account.
Making Insurance Changes
Open Enrollment: Open Enrollment is held in October of each year. Changes made during Open Enrollment are effective
January 1 the following year. During this time, you may change from one health plan to another, enroll yourself and/or eligible
dependents in a health plan, and/or drop health coverage for yourself and/or dependents *. *Note: A Special Enrollment period
will be held every other year in the odd-numbered years to enroll or drop dental coverage for yourself and/or dependents.
Changes to dental will not be made outside of this time period, unless there is an eligible qualifying event.
Coverage Changes/Qualifying Events: You may make certain changes throughout the year within 31 days of a qualifying event.
Qualifying events include: marriage, divorce, legal separation, birth, death, adoption, legal guardianship of a dependent child, a
child reaching age 26, or a spouse or child gaining or losing other insurance coverage. A spouse gaining or losing employment is
also a qualifying event for MoneyPlu$ changes.
Other Changes Permitted Throughout the Year: You may apply for the following changes or additions throughout the year
(subject to approval with medical evidence of good health): enroll in or increase Optional or Dependent Life coverage or enroll
in Supplemental Long Term Disability. To apply as a late entrant, you must complete a medical questionnaire that must be
approved by the insurance company.
Failure to Enroll or Update Coverage
It is important that you know the consequences of missing an enrollment or change opportunity. When you fail to enroll or
update coverage within 31 days of hire or a qualifying event, your options are restricted as follows:
Health, Vision and Dental Plans: Open Enrollment for the health, vision, and dental plans is held during October of each year.
During Open Enrollment, you may enroll or cancel coverage for yourself or dependents. You may not make these changes at
any other time, except when the change is made within 31 days of a qualifying event.
MoneyPlu$: Outside of initial enrollment, you may enroll in (or cancel) the insurance premium pretax feature only during an
Open Enrollment period. You must enroll in or change your amounts under the medical or dependent care spending account
features each year during Open Enrollment, or within 31 days of a qualifying event. Remember that if you do not re-enroll in
the spending accounts each year during the October enrollment, the accounts will not continue the following year.
Optional Life: If you do not enroll within 31 days of your hire date, you can enroll only within 31 days of a special eligibility
situation, with medical evidence of good health (or without medical evidence of good health during specified enrollment
periods). If you are not participating in the MoneyPlu$ pretax premium feature, you may apply as a late entrant at any time
during the year. In this event, you must complete a Notice of Election and a Personal Health Statement for review of medical
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Division of Human Resources
Division of Human Resources
evidence of good health and the insurance company must approve your application. Approved coverage will be effective the
first of the month following approval as long as you are actively at work that day as a full-time employee. A deferred effective
date provision applies if the employee is not actively at work on the effective date. Coverage opted during a qualified Open
Enrollment will be effective as of the following January 1.
Dependent Life: If you did not enroll eligible dependents within 31 days of your hire date or within 31 days of gaining a
dependent, you may apply as a late entrant. You must complete a medical questionnaire and the insurance company must
approve your application. You must list eligible dependents that you wish to be covered. You may drop Dependent Life
coverage at any time.
Insurance Enrollment: Required Documentation
The SC PEBA Insurance Benefits division requires documentation showing proof of relationship at the time of enrollment for
dependents of new hires and for dependents added during Open Enrollment or due to a special eligibility situation. Please refer
to page 15 for a list of acceptable documents for showing proof of relationship.
If married, you will need to provide the information listed below for your spouse. You will also need this information for your
beneficiaries and any dependents you wish to cover for health, vision, dental, or dependent life insurance.
Transfers from Other State Agencies: Please complete the Transfer Employee form which is provided on the Transfer
Employee Online Orientation webpage at: http://hr.sc.edu/benefits.html. Please attach a copy of your last pay stub and fax it
to the Benefits Office at (803) 777-1584. Please note that PEBA insurance/pension elections will not change from coverage
opted with the prior employer upon initial employment with the University.
*Required Information for Spouse, Dependents, or Beneficiaries:
Name/Social Security Number/ Date of Birth/ Relationship
You and your dependent’s coverage cannot be activated without this information. Please reference the following 2 pages to
review Enrollment Documentation needed for your dependents. Use the worksheet on page 16 as a guide to help in selecting
the plans in which you want to enroll.
Retirement Benefits and Offerings
Employees hired in permanent positions, are required by state law to participate in the SCRS, PORS (if applicable), or the State
Optional Retirement Program (State ORP). Additionally, the University also contributes to the federal Social Security program,
for which participation is required of all employees. Employees hired in research grant-funded positions are eligible for
benefits, including retirement, if allowed by the specifications of the grant.
South Carolina Retirement Systems (SCRS) and Police Officers Retirement Systems (PORS): The SCRS and the PORS are known
as defined benefit plans. Benefits at retirement are based on a formula containing the member’s average final compensation
(annual average of the 20 highest consecutive calendar quarters’ earnings-highest 12 quarters for those considered Class II
members and have established membership prior to July 1, 2012), age, and years of credited service. Members may purchase
credit for certain kinds of service such as active duty military, public service in other states, and civil service. Members of the
SCRS and PORS contribute on a pretax basis at the rate of 8% and 8.41% (respectively) of earnings. After eight years of earned
service (five years of earned service if you had covered service with another entity prior to July 1, 2012 and are considered a
Class II member), a member is vested and may leave contributions on file with the Retirement System at separation from
employment. Vested members may also file for a reduced monthly annuity upon reaching age 60 for the SCRS, or age 55 for the
PORS (a full annuity will be offered if one waits until the age of 65). As of July 1, 2015, the SCRS/PORS contribution rates are
scheduled to increase to 8.16% and 8.74% respectively.
State Optional Retirement Program (State ORP): The State ORP, a defined contribution plan, is an alternative to the South
Carolina Retirement System’s (SCRS) retirement plan. Employees eligible for State ORP participation may select funds from the
following carriers: MassMutual, MetLife, TIAA-CREF, or VALIC. Members contribute on a pretax basis, 8% of earnings. This
amount will increase to 8.16% on July 1, 2015. The amount of employer contributions to the employee’s ORP account for fiscal
year 2014-2015 is 5% of earnings. Employees may change investment providers during the annual Open Enrollment period,
which is January 1 to March 1. Changes made will have an April 1 effective date. During the State ORP Open Enrollment,
participants have a one-time opportunity to switch to the SCRS, if they have been enrolled in State ORP for at least 12 months
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Division of Human Resources
Division of Human Resources
but not more than 60 months by March 1 of the year in which they elect to switch retirement programs.
Incidental Death Benefits for SCRS, PORS, and State ORP plans: This benefit applies to members of the South Carolina
Retirement System, the State Optional Retirement Program, and the Police Officers Retirement System. At the death of a
contributing member who has at least 12 months of retirement service credit, a benefit equal to the member’s annual
budgeted base salary is paid to the beneficiary. Under the SCRS and the PORS, the beneficiary is also entitled to a refund of the
member’s contributions plus interest. If the member had 15 years of retirement service credit under SCRS and PORS programs,
the beneficiary may elect a lifetime annuity in lieu of a refund. Under the State ORP, the incidental death benefit is based on
the cash value of the account as of the date of death. The beneficiary may receive the cash value of the account through
annuities, lump-sum distributions, or periodic withdrawals.
SCRS Disability Retirement program: Members of the South Carolina Retirement System (SCRS) or Police Officers Retirement
System (PORS) who are disabled and have at least eight years of earned retirement service credit may apply for disability
retirement. If you have prior covered service established prior to July 1, 2012, you may be considered a Class II employee, for
which five years of earned service will meet eligibility for disability retirement. SCRS disability applications will require a
determination of disability by the Social Security Administration. If disability is approved, the employee will receive a monthly
benefit for life.
Deferred Compensation (401k/457) program and 403b plans: You may set aside additional funds toward retirement on a
pretax basis through the State Deferred Compensation Program. The program offers 457 and 401(k) plans. There are also a
number of 403(b) plans available through private insurance/investment companies. Note: Funds can be rolled over from these
plans to purchase eligible retirement service with the South Carolina Retirement System.
Other Supplemental Offerings
The following plans represent supplemental offerings outside of the State PEBA systems for which you may apply at any time,
subject to approval of medical of good health and pre-existing condition clauses:
USC Cancer Plan: According to plan guidelines administered by Colonial Life Insurance Company, this plan provides a cash
payment at the initial diagnosis of internal cancer and a daily benefit for hospital confinement, outpatient treatment, and
hospice care related to any type of cancer subject to the pre-existing conditions clause in the plan. Spouses and children also
may be covered. Applicable benefits are paid in addition to other insurance coverage you may have.
USC Hospital Confinement Plan: This plan, administered by Colonial Life Insurance Company, offers a choice of a $50 or $80
daily benefit, to be paid directly to the member when the member or a covered spouse or child is confined in a hospital.
Applicable benefits are paid in addition to other insurance plans you may have.
Auto and Homeowners Insurance Plans: Employees and members of their household may purchase automobile and
homeowners insurance at low competitive rates through the Travelers Insurance Company. USC employees may pay premiums
automatically through payroll deduction or regular monthly withdrawals from their checking or savings accounts. Free quotes
may be obtained by calling Travelers at 1-800-842-5936 or by visiting: http://www.travelers.com/personal/?sponsor=sc.
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Division of Human Resources
Division of Human Resources
Enrollment Documentation Worksheet
Following is a list of acceptable documentation to prove your relationship to family members you are attempting to add to
coverage. Please be sure to submit photocopies only as South Carolina PEBA divisions cannot return submitted documentation.
Legal Spouse:
· A copy of the marriage license or page 1 of your federal tax return.
Former Spouse:
· A copy of the divorce decree ordering the subscriber to cover the former spouse.
Common Law Spouse:
· A copy of the common law marriage affidavit.
Natural Child:
· A copy of the long-form birth certificate showing the subscriber as the parent.
Step Child:
· A copy of the long-form birth certificate showing the name of the natural parent, plus documentation that
the natural parent and the subscriber are married (see requirement for Legal Spouse or Common Law
Spouse in the list above).
Adopted Child:
· A copy of the court documentation verifying completed adoption, or
· A copy of a letter of placement from an adoption agency, an attorney, or the S.C. Department of Social
Services verifying that the adoption is in progress.
Foster Child:
· A copy of the court order or other legal document placing the child with the subscriber, who is a licensed
foster parent.
Other Children:
· For all other children for whom a subscriber has legal custody, a copy of the court order or other legal
document granting custody of the child/children to the subscriber. Documentation must verify the
subscriber has guardianship responsibility for the child/children, not merely financial responsibility.
Incapacitated Child:
· A copy of the Incapacitated Child Certification Form plus proof of relationship. See the appropriate child
type (natural, step, adopted, foster or other) in the list above for acceptable documentation to prove
the relationship.
If you do not have the required documentation to prove your relationship to a dependent, you may have to pay a fee to receive
a copy from the governmental agency that has the original. We encourage you to request your documentation as soon as
possible since this process may take several weeks and many agencies increase fees for expedited delivery. To obtain copies of
marriage licenses or birth certificates, visit the following websites:
· Marriage license/birth certificate: http://www.cdc.gov/nchs/w2w.htm
· Birth certificate (for children born in S.C.): www.scdhec.gov/administration/vr/index.htm.
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Division of Human Resources
Division of Human Resources
Health Insurance
Coverage Type
Cost
 State Savings Plan
 Employee Only
 Employee/Child(ren)
________
 State Standard Plan
 Employee/Spouse
 Full Family
________
Basic Dental:  Yes  No
 Employee Only
 Employee/Child(ren)
________
Dental Plus:  Yes  No
 Full Family
 Employee/Spouse
________
 Employee Only
 Employee/Child(ren)
________
 Full Family
 Employee/Spouse
________
 Tricare Supplement Plan
Dental Plan
Vision Plan
 Yes  No
MoneyPlu$
 MoneyPlu$ premium pretax feature
 Yes  No
 Dependent Care:
Amount________
________
 Health Savings Account1
Amount________
________
1Must
be enrolled in Savings Plan in order to elect.
Life Insurance
Face Amount
Cost
 State Group Life (Automatic if enrolled in one of State health plans)
$3,000
-0-
 Dependent Life/Spouse
____________
________
 Dependent Life/Child(ren)
____________
________
 State Optional Life
____________
________
Disability Insurance Plans
Waiver period
Cost
 State LTD Plan (Automatic if enrolled in one of the health plans)
90 day
-0-
 State Supplemental LTD
90 day
________
180 day
________
Other Insurance
Amount
Cost
 Cancer Plan
____________
________
 Hospital Confinement Plan
____________
________
Retirement Deduction
 S.C. Retirement System
________
 S.C. Police Officers Retirement System
________
 State Optional Retirement Program
 MetLife
 MassMutual
 TIAA-CREF
 VALIC
________
Direct Deposit: Direct deposit is required and can be done online through VIP (https://vip.sc.edu). For
assistance, talk with a Benefits counselor.
Income Tax Withholding
 Married
 Single
 Married, but withhold at single rate
Exemptions:
________
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Comparison of Health Plan Benefits Offered for 20151
This chart is for comparison purposes only. For more information on these plans, please refer to your 2014 Insurance Benefits Guide.
Plan
SHP Savings Plan
SHP Standard Plan2
Availability
Coverage worldwide
Coverage worldwide
Medicare Supplemental Plan2
Same as Medicare
Available to retirees and covered dependents/survivors
who are eligible for Medicare
Tobacco users will pay a $40- or $60-per-month surcharge in addition to their health premium.5
Active Employee
Monthly Premiums
Subscriber Only
Subscriber/Spouse
Subscriber/Children
Full Family
$ 9.70
$ 77.40
$ 20.48
$113.00
Refer to the “Premiums” page
of the PEBA Insurance Benefits website
for applicable rates.
$ 97.68
$253.36
$143.86
$306.56
Please note that premiums for optional employer groups, such as local subdivisions, may vary. To verify your rates, contact your benefits office.
Annual Deductible
Single
Family
Coinsurance
Coinsurance
Maximum
Single
Family
(no copayments)
$3,600
$7,2003
$445
$890
In-network
Plan pays 80%
You pay 20%
Out-of-network
Plan pays 60%
You pay 40%
In-network
Plan pays 80%
You pay 20%
Out-of-network
Plan pays 60%
You pay 40%
$2,400
$4,800
(excludes
deductible)
$4,800
$9,600
(excludes
deductible)
$2,540
$5,080
(excludes deductible and
copayments)
$ 5,080
$10,160
(excludes deductible and
copayments)
Chiropractic payments limited
to $500 a year, per person
Physicians Office
Visits
Pays Medicare Part A and Part B deductibles
Out-of-network
Plan pays 60%
You pay 40%
Hospitalization/
Emergency Care
No copayments
Prescription Drugs
Participating pharmacies and mail order only: You pay the State
Health Plan’s allowed amount until the annual deductible is met.
Afterward, the Plan will reimburse 80% of the allowed amount;
you pay 20% in coinsurance. When the coinsurance maximum is
reached, the Plan will reimburse 100% of the allowed amount.
None
Chiropractic payments limited
to $2,000 a year, per person
$12 copayment, then:
No copayments
In-network
Plan pays 80%
You pay 20%
Pays Part B coinsurance of 20%
In-network
Plan pays 80%
You pay 20%
Out-of-network
Plan pays 60%
You pay 40%
Outpatient facility services:
$95 copayment
Emergency care: $159 copayment
then:
In-network
Plan pays 80%
You pay 20%
Out-of-network
Plan pays 60%
You pay 40%
Participating pharmacies only (up to 31-day supply): $9 Tier 1
(generic-lowest cost alternative),
$38 Tier 2 (brand-higher cost alternative),
$63 Tier 3 (brand-highest cost alternative)
Mail order and Retail Maintenance Network
pharmacies (up to 90-day supply):
$22 Tier 1, $95 Tier 2, $158 Tier 3
Copay maximum: $2,500
Pays Part B coinsurance of 20%
For inpatient hospital stays, the Plan pays: Medicare deductible;
coinsurance for days 61-150; (Medicare benefits may end sooner
if the member has previously used any of his 60 lifetime reserve
days); 100% beyond 150 days (Medi-Call approval required)
For skilled nursing facility care, the Plan pays
coinsurance for days 21-100; 100% of approved days beyond
100 days, up to 60 days per year.
Participating pharmacies only (up to 31-day supply):
$9 Tier 1 (generic-lowest cost alternative),
$38 Tier 2 (brand-higher cost alternative),
$63 Tier 3 (brand-highest cost alternative)
Mail order and Retail Maintenance Network
pharmacies (up to 90-day supply):
$22 Tier 1, $95 Tier 2, $158 Tier 3
Copay max: $2,500
Premiums for subscribers of optional employer groups (such as cities, counties and other local subdivisions) may increase, decrease or remain the same, based on the group’s rating. If you are a subscriber of an experience-rated
group, your benefits office will announce next year’s rates.
Refer to your 2014 Insurance Benefits Guide for information on how this plan coordinates with Medicare.
3
If more than one family member is covered, no family member will receive benefits, other than preventive, until the $7,200 annual family deductible is met.
4
State Health Plan subscribers who use tobacco or cover dependents who use tobacco will pay a $40-per-month surcharge for subscriber-only coverage. The surcharge is $60 for other levels of coverage.
1
2
2015
Insurance Benefits Guide
Optional Life, Dependent Life–
Spouse Monthly Premiums
Optional Life premiums are determined by your age on the preceding December 31 and the amount of
insurance you select. Premiums for Dependent Life-Spouse coverage are the same as the Optional Life
premiums, which are based on the employee’s age. Premiums are the same for retirees, regardless of age
or effective date.
Monthly Premiums for Subscribers through Age 69*
Subscriber’s Age**
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
$ 0.52
$ 1.04
$ 1.56
$ 2.08
$ 2.60
$ 3.12
$ 3.64
$ 4.16
$ 4.68
$ 5.20
$ 5.72
$ 6.24
$ 6.76
$ 7.28
$ 7.80
$ 8.32
$ 8.84
$ 9.36
$ 9.88
$10.40
$10.92
$11.44
$11.96
$12.48
$13.00
$13.52
$14.04
$14.56
$15.08
$15.60
$16.12
$16.64
$17.16
$17.68
$18.20
$18.72
$19.24
$19.76
$20.28
$ 0.68
$ 1.36
$ 2.04
$ 2.72
$ 3.40
$ 4.08
$ 4.76
$ 5.44
$ 6.12
$ 6.80
$ 7.48
$ 8.16
$ 8.84
$ 9.52
$10.20
$10.88
$11.56
$12.24
$12.92
$13.60
$14.28
$14.96
$15.64
$16.32
$17.00
$17.68
$18.36
$19.04
$19.72
$20.40
$21.08
$21.76
$22.44
$23.12
$23.80
$24.48
$25.16
$25.84
$26.52
$ 0.76
$ 1.52
$ 2.28
$ 3.04
$ 3.80
$ 4.56
$ 5.32
$ 6.08
$ 6.84
$ 7.60
$ 8.36
$ 9.12
$ 9.88
$10.64
$11.40
$12.16
$12.92
$13.68
$14.44
$15.20
$15.96
$16.72
$17.48
$18.24
$19.00
$19.76
$20.52
$21.28
$22.04
$22.80
$23.56
$24.32
$25.08
$25.84
$26.60
$27.36
$28.12
$28.88
$29.64
$ 1.08
$ 2.16
$ 3.24
$ 4.32
$ 5.40
$ 6.48
$ 7.56
$ 8.64
$ 9.72
$10.80
$11.88
$12.96
$14.04
$15.12
$16.20
$17.28
$18.36
$19.44
$20.52
$21.60
$22.68
$23.76
$24.84
$25.92
$27.00
$28.08
$29.16
$30.24
$31.32
$32.40
$33.48
$34.56
$35.64
$36.72
$37.80
$38.88
$39.96
$41.04
$42.12
$ 1.70
$ 3.40
$ 5.10
$ 6.80
$ 8.50
$10.20
$11.90
$13.60
$15.30
$17.00
$18.70
$20.40
$22.10
$23.80
$25.50
$27.20
$28.90
$30.60
$32.30
$34.00
$35.70
$37.40
$39.10
$40.80
$42.50
$44.20
$45.90
$47.60
$49.30
$51.00
$52.70
$54.40
$56.10
$57.80
$59.50
$61.20
$62.90
$64.60
$66.30
$ 2.96
$ 5.92
$ 8.88
$ 11.84
$ 14.80
$ 17.76
$ 20.72
$ 23.68
$ 26.64
$ 29.60
$ 32.56
$ 35.52
$ 38.48
$ 41.44
$ 44.40
$ 47.36
$ 50.32
$ 53.28
$ 56.24
$ 59.20
$ 62.16
$ 65.12
$ 68.08
$ 71.04
$ 74.00
$ 76.96
$ 79.92
$ 82.88
$ 85.84
$ 88.80
$ 91.76
$ 94.72
$ 97.68
$100.64
$103.60
$106.56
$109.52
$112.48
$115.44
$ 5.48
$ 10.96
$ 16.44
$ 21.92
$ 27.40
$ 32.88
$ 38.36
$ 43.84
$ 49.32
$ 54.80
$ 60.28
$ 65.76
$ 71.24
$ 76.72
$ 82.20
$ 87.68
$ 93.16
$ 98.64
$104.12
$109.60
$115.08
$120.56
$126.04
$131.52
$137.00
$142.48
$147.96
$153.44
$158.92
$164.40
$169.88
$175.36
$180.84
$186.32
$191.80
$197.28
$202.76
$208.24
$213.72
$ 11.60
$ 23.20
$ 34.80
$ 46.40
$ 58.00
$ 69.60
$ 81.20
$ 92.80
$104.40
$116.00
$127.60
$139.20
$150.80
$162.40
$174.00
$185.60
$197.20
$208.80
$220.40
$232.00
$243.60
$255.20
$266.80
$278.40
$290.00
$301.60
$313.20
$324.80
$336.40
$348.00
$359.60
$371.20
$382.80
$394.40
$406.00
$417.60
$429.20
$440.80
$452.40
*Premium includes Accidental Death and Dismemberment coverage only for active employees and covered spouses of active employees.
**Premiums for the spouse’s coverage will be based on the active employee’s age. Spouse’s coverage cannot exceed 50 percent of
the active employee’s Optional Life coverage or $100,000, whichever is less.
www.eip.sc.gov
S.C. Public Employee Benefit Authority
225
Premiums
Coverage
$ 10,000
$ 20,000
$ 30,000
$ 40,000
$ 50,000
$ 60,000
$ 70,000
$ 80,000
$ 90,000
$100,000
$110,000
$120,000
$130,000
$140,000
$150,000
$160,000
$170,000
$180,000
$190,000
$200,000
$210,000
$220,000
$230,000
$240,000
$250,000
$260,000
$270,000
$280,000
$290,000
$300,000
$310,000
$320,000
$330,000
$340,000
$350,000
$360,000
$370,000
$380,000
$390,000
<35
Insurance Benefits Guide
2015
Subscriber’s Age**
Coverage
$400,000
$410,000
$420,000
$430,000
$440,000
$450,000
$460,000
$470,000
$480,000
$490,000
$500,000
<35
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
$20.80
$21.32
$21.84
$22.36
$22.88
$23.40
$23.92
$24.44
$24.96
$25.48
$26.00
$27.20
$27.88
$28.56
$29.24
$29.92
$30.60
$31.28
$31.96
$32.64
$33.32
$34.00
$30.40
$31.16
$31.92
$32.68
$33.44
$34.20
$34.96
$35.72
$36.48
$37.24
$38.00
$43.20
$44.28
$45.36
$46.44
$47.52
$48.60
$49.68
$50.76
$51.84
$52.92
$54.00
$68.00
$69.70
$71.40
$73.10
$74.80
$76.50
$78.20
$79.90
$81.60
$83.30
$85.00
$118.40
$121.36
$124.32
$127.28
$130.24
$133.20
$136.16
$139.12
$142.08
$145.04
$148.00
$219.20
$224.68
$230.16
$235.64
$241.12
$246.60
$252.08
$257.56
$263.04
$268.52
$274.00
$464.00
$475.60
$487.20
$498.80
$510.40
$522.00
$533.60
$545.20
$556.80
$568.40
$580.00
*Premium includes Accidental Death and Dismemberment coverage only for active employees and covered spouses of active employees.
**Premiums for the spouse’s coverage will be based on the active employee’s age. Spouse’s coverage cannot exceed 50 percent of
the active employee’s Optional Life coverage or $100,000, whichever is less.
Monthly Premiums for Subscribers Age 70 and Older*
(Retiree coverage ends at age 75)
Coverage
Premiums
$ 10,000
$ 20,000
$ 30,000
$ 40,000
$ 50,000
$ 60,000
$ 70,000
$ 80,000
$ 90,000
$100,000
$110,000
$120,000
$130,000
$140,000
$150,000
$160,000
$170,000
$180,000
$190,000
$200,000
$210,000
$220,000
$230,000
$240,000
$250,000
$260,000
$270,000
$280,000
$290,000
$300,000
$310,000
$320,000
$330,000
$340,000
226
Coverage
65%
$ 6,500
$ 13,000
$ 19,500
$ 26,000
$ 32,500
$ 39,000
$ 45,500
$ 52,000
$ 58,500
$ 65,000
$ 71,500
$ 78,000
$ 84,500
$ 91,000
$ 97,500
$104,000
$110,500
$117,000
$123,500
$130,000
$136,500
$143,000
$149,500
$156,000
$162,500
$169,000
$175,500
$182,000
$188,500
$195,000
$201,500
$208,000
$214,500
$221,000
Ages 70 - 74
$ 13.02
$ 26.04
$ 39.04
$ 52.06
$ 65.08
$ 78.08
$ 91.10
$104.10
$117.12
$130.14
$143.14
$156.16
$169.18
$182.18
$195.20
$208.22
$221.22
$234.24
$247.26
$260.26
$273.28
$286.30
$299.30
$312.32
$325.34
$338.34
$351.36
$364.36
$377.38
$390.40
$403.40
$416.42
$429.44
$442.44
Coverage
42%
$ 4,200
$ 8,400
$ 12,600
$ 16,800
$ 21,000
$ 25,200
$ 29,400
$ 33,600
$ 37,800
$ 42,000
$ 46,200
$ 50,400
$ 54,600
$ 58,800
$ 63,000
$ 67,200
$ 71,400
$ 75,600
$ 79,800
$ 84,000
$ 88,200
$ 92,400
$ 96,600
$100,800
$105,000
$109,200
$113,400
$117,600
$121,800
$126,000
$130,200
$134,400
$138,600
$142,800
Ages 75 - 79
$ 13.68
$ 27.36
$ 41.04
$ 54.70
$ 68.38
$ 82.06
$ 95.74
$109.40
$123.08
$136.76
$150.44
$164.10
$177.78
$191.46
$205.14
$218.80
$232.48
$246.16
$259.84
$273.50
$287.18
$300.86
$314.54
$328.20
$341.88
$355.56
$369.24
$382.92
$396.58
$410.26
$423.94
$437.62
$451.28
$464.96
S.C. Public Employee Benefit Authority
Coverage
31.7%
$ 3,170
$ 6,340
$ 9,510
$ 12,680
$ 15,850
$ 19,020
$ 22,190
$ 25,360
$ 28,530
$ 31,700
$ 34,870
$ 38,040
$ 41,210
$ 44,380
$ 47,550
$ 50,720
$ 53,890
$ 57,060
$ 60,230
$ 63,400
$ 66,570
$ 69,740
$ 72,910
$ 76,080
$ 79,250
$ 82,420
$ 85,590
$ 88,760
$ 91,930
$ 95,100
$ 98,270
$101,440
$104,610
$107,780
Ages 80+
$ 17.26
$ 34.50
$ 51.76
$ 69.00
$ 86.26
$103.52
$120.76
$138.02
$155.26
$172.52
$189.76
$207.02
$224.26
$241.52
$258.78
$276.02
$293.28
$310.52
$327.78
$345.02
$362.28
$379.54
$396.78
$414.04
$431.28
$448.54
$465.78
$483.04
$500.28
$517.54
$534.80
$552.04
$569.30
$586.54
www.eip.sc.gov
2015
Coverage
$350,000
$360,000
$370,000
$380,000
$390,000
$400,000
$410,000
$420,000
$430,000
$440,000
$450,000
$460,000
$470,000
$480,000
$490,000
$500,000
Insurance Benefits Guide
Coverage
65%
$227,500
$234,000
$240,500
$247,000
$253,500
$260,000
$266,500
$273,000
$279,500
$286,000
$292,500
$299,000
$305,500
$312,000
$318,500
$325,000
Ages 70 - 74
$455.46
$468.48
$481.48
$494.50
$507.52
$520.52
$533.54
$546.56
$559.56
$572.58
$585.60
$598.60
$611.62
$624.62
$637.64
$650.66
Coverage
42%
$147,000
$151,200
$155,400
$159,600
$163,800
$168,000
$172,200
$176,400
$180,600
$184,800
$189,000
$193,200
$197,400
$201,600
$205,800
$210,000
Ages 75 - 79
$478.64
$492.32
$505.98
$519.66
$533.34
$547.02
$560.68
$574.36
$588.04
$601.72
$615.38
$629.06
$642.74
$656.42
$670.08
$683.76
Coverage
31.7%
$110,950
$114,120
$117,290
$120,460
$123,630
$126,800
$129,970
$133,140
$136,310
$139,480
$142,650
$145,820
$148,990
$152,160
$155,330
$158,500
Ages 80+
$603.80
$621.04
$638.30
$655.54
$672.80
$690.06
$707.30
$724.56
$741.80
$759.06
$776.30
$793.56
$810.80
$828.06
$845.32
$862.56
*Premium includes Accidental Death and Dismemberment coverage only for active employees and covered spouses of active
employees.
Please note: For subscribers who retired on or after January 1, 1994, up to December 31, 1998, coverage
terminates at age 70, with an option to convert the coverage at that time.
Premiums
www.eip.sc.gov
S.C. Public Employee Benefit Authority
227