EMPLOYEE BENEFITS

POLICY & PROCEDURES MANUAL

CEO-RISK MANAGEMENT DIVISION

1010 10TH STREET, STE 5900, MODESTO CA 95354
(209) 525-5717
 EMPLOYEE BENEFITS POLICY & PROCEDURES MANUAL

Table of Contents

1. Employee Benefits Contact Information

2. Effective Dates of Coverage

3. Employee Benefits Eligibility Guidelines

-Dependent Eligibility Requirements
-Local Area Zip Code List

4. Health Insurance Enrollment Procedures

5. Life Events/Enrollment Changes

6. Medical Plan Descriptions

• What is a Health Savings Account (HSA)?

7. Dental Plan Descriptions

• Core Plan
• Buy Up Plan

8. Vision Plan Description

9. Basic and Supplemental Life Insurance

• Evidence of Insurability Form
• Life Insurance Policy

10. Health Insurance Premium Payment Procedures for Unpaid Leave of Absence

11. Termination of Health Insurance Benefits and COBRA Rights

12. Benefit Summaries

13. Mass Mutual Deferred Compensation Plan and Loan Program

14. Flexible Spending Accounts - Dependent Care or Health Reimbursement Account

15. Employee Assistance Program (EAP)

16. Management Disability Plans- Short Term and Long Term (STD, LTD)

17. Death of an Employee/Retiree

18. PARS – Public Agency Retirement System

19. Self Service Instructions

 EMPLOYEE BENEFITS
CONTACT INFO
VENDOR GROUP # PHONE NUMBER

STANISLAUS COUNTY
PARTNERS IN HEALTH
Providers and Referrals for SCPH
www.scpartnersinhealth.org CA000496 (877) 830-7470

CAPITOL ADMINISTRATORS
Claims and Eligibility for SCPH CA000496 (877) 789-8499

ANTHEM BLUE CROSS

www.anthem.com/ca 275366 (800) 888-8288

DELTA DENTAL
www.deltadentalins.com 3351 (800) 765-6003

VISION SERVICE PLAN

www.vsp.com 4450000102 (800) 877-7195

MASS MUTUAL DEFERRED COMP

www.retire.hartfordlife.com 150163 (800) 528-9009

WELLS FARGO
HEALTH BENEFIT SERVICES
www.wellsfargo.com/hsa Stanislaus County (866) 884-7374

WAGEWORKS
www.takecarewageworks.com 1428 (800) 950-0105

VOYA/RELIASTAR Policy #31640-7 #50 Contact Employee Benefits

HUMANA VOLUNTARY BENEFITS Stanislaus County (877) 378-1505

EAP- ComPsych- Guidance Resources

www.guidanceresouces.com
Web ID: MY5848i County of Stanislaus (877) 533-2363

PARS- Public Agency Retirement

Services- ARS Stanislaus County (800) 540-6369 Ext 130

CEO-RISK MANAGEMENT DIVISION- PHONE- 209-525-5717

EMPLOYEE BENEFITS
1010 10TH STREET SUITE 5900 E-FAX- 209-567-4367
MODESTO 95354
FAX- 209-525-5779
WEBSITE-
http://www.stancounty.com/riskmgmt/risk-eb-home-
main.shtm

EMAIL- [email protected]

2/15
 EMPLOYEE BENEFITS
EFFECTIVE DATES OF COVERAGE

NEW HIRES-

♦ Health Insurance benefits are effective the first of the month, following date of hire.

♦ Deductions will be taken, and credits will be given on the first paycheck the employee
receives in their first month of coverage, and semi-monthly thereafter.

♦ If there is a third paycheck in the month, no deductions or credits will appear.

♦ If the employee does not receive two paychecks in their first month of coverage, then
deductions and credits for benefits will be doubled on their first paycheck.

TERMINATIONS-

♦ Health Insurance benefits will terminate on the last day of the month of the event of
termination, retirement, unpaid absence or covered leave (FMLA, PDL, CFRA) exhausting.

♦ When terminating, the employee must work at least one full scheduled day in the month to
get coverage for that month.

♦ COBRA, if elected, will be effective the first of the month following date of termination.

LIFE EVENTS/ENROLLMENT CHANGES-

♦ All enrollment changes outside of open enrollment must be made within 30 days from the
date of the event.

♦ Eligibility and premium changes due to a marriage, divorce or over age dependent will be
effective the first of the month following the qualifying event date.

♦ Eligibility changes due to the birth of a baby are effective the date of birth, however change in
premium will take effect the first of the following month.

♦ Eligibility changes due to an adoption are effective the date the child was placed in the home
for adoption, however change in premium will take effect the first of the following month.

1/1/13
RETURNING FROM LEAVE OF ABSENCE/SUSPENSION-

♦ If health insurance premiums are being paid by the employee while on unpaid absence,
County paid benefits will resume the first of the month following your return to full-time
employment.

♦ If your health insurance was canceled due to non-payment of premiums while on an unpaid
absence, County paid benefits will resume the first of the month following your return to full-
time employment. There is also a possibility of an adjustment of premiums on your paycheck
when you return.

♦ If you are enrolled in a Flexible Spending Account, you are responsible for the admin fee
while on unpaid leave. If you fail to pay the admin fee while you are out, your paycheck will
be adjusted accordingly when you return to paid status. There will also be an adjustment to
your semi-monthly contribution to the FSA account in order to meet your Annual Pledge.

1/1/13
EMPLOYEE BENEFITS ELIGIBILITY GUIDELINES

-MEDICAL, DENTAL, VISION AND LIFE PLANS

STANISLAUS COUNTY PARTNERS IN HEALTH

ANTHEM BLUE CROSS
DELTA DENTAL CORE AND BUYUP PLANS
VISION SERVICE PLAN
VOYA RELIASTAR LIFE INSURANCE

Regular full-time employees as defined by their job description in a position that includes
insurance benefits, are eligible to enroll in Medical, Dental, Vision and Life coverage
along with their qualifying dependents. This coverage will take effect the first day of the
month following their date of hire or event.

• The County provides a semi-monthly contribution towards medical, dental and vision
insurance based on the employee's Standard Hours.

• A minimum of 30 hours worked per week is required to qualify for County insurance
benefits.

• All employees enrolled will have a share of cost deducted from their paycheck semi-
monthly.

o Regular full-time employees working 40 hours per week will receive an

employer contribution equal to:
EPO medical coverage is paid at 80% of the lowest cost EPO coverage level
HDHP medical coverage is paid at 95% of the lowest cost HDHP coverage level
Dental and Vision coverage is paid at 80%
Basic Life is paid at 100%
No employer contribution towards Supplemental Life

o Employees working a percentage/reduced schedule will have a lower

contribution toward health insurance benefits
35 - 39 hours per week = 90% of the employer contribution
30 - 34 hours per week = 75% of the employer contribution
Below 30 hours per week = 0% of the employer contribution (employee will be
offered COBRA to continue health coverage at their expense)

• Employer health insurance contributions will be reduced accordingly for regular full-
time employees who are paid less than 80 hours per 14 day period (employees using
DOC, ATO etc.) for 3 consecutive pay periods. Employee benefit eligibility will be
evaluated on a quarterly basis. If the employee's hours fall below 80 hours in 3
consecutive pay periods in a quarter, the employee's contributions will be adjusted
based on the quarterly average effective the first pay period of the following quarter.
Benefits will be restored at 100% effective the first pay period of the following quarter
in which the employee is paid an average of 80 hours in the quarter.

Revised 1/15
• Employees enrolled in a High Deductible Health Plan (HDHP) will also be enrolled in
a Health Savings Account (HSA). The County will fund the individual HSA account
in the following amounts:

o Employee Only - $1,200 annually

o Employee + 1 - $2,000 annually
o Family - $2,000 annually

The County will fund 6 months of the HSA account contribution in January for any
employee enrolling in an HSA plan. The remaining annual contribution will be
deposited semi-monthly over the last 6 months of the year. Employees are required to
pay any monthly account related fees on their individual Health Savings Account.

• Medical Plan Carrier is determined by physical address of the main subscriber. SCPH
is only available to local area residents and Anthem BlueCross is only available to out
of area residents. Please refer to the local area zip code list.

Revised 1/15
DEPENDENT ELIGIBILITY REQUIREMENTS

MEDICAL, DENTAL, VISION AND LIFE PLANS

STANISLAUS COUNTY PARTNERS IN HEALTH HDHP AND EPO PLANS

ANTHEM BLUE CROSS HDHP AND EPO PLANS
DELTA DENTAL CORE AND BUYUP PLANS
VISION SERVICE PLAN
VOYA RELIASTAR LIFE INSURANCE

1. Employee’s legal spouse. *Unless the spouse is a Stanislaus County employee.

The County does not allow dual coverage for employee spouses and/or dependents.

2. Child(ren) of the employee up to the age of 26 years including those child(ren) who
are adopted or there is legal guardianship. *Unless the dependent child is being
covered by another County employee (spouse or ex-spouse of employee, etc).

3. Employee’s CA Registered Domestic Partner as defined by California Secretary of

State under state law. If the employee and the employee’s partner are of the same
sex, or they are opposite sexes and one partner is at least 62 years old, then they are
eligible as long as they are registered as a domestic partnership with the Secretary
of State. The eligibility criteria for registration of a domestic partnership was set
by the California State Legislature and signed by the Governor in 1999. During the
legislative process, eligibility of opposite sex couples was limited to senior
citizens. Tax implications apply to cost of premiums for Domestic Partner health
insurance coverage. Please read details in Tab 4 Enrollment Procedures.

4. Child(ren) of the employee and/or their CA Registered Domestic Partner (see

above) up to the age of 26 years including those child(ren) who are adopted or
there is legal guardianship.

5. Dependents who exceed the age limit, may be eligible if they meet all the
following requirements: they are incapable of self-sustained employment because
of mental retardation or physical handicap that occurred prior to reaching the age
limit for Dependents and they receive all of their financial support and maintenance
from the employee or the employee’s Spouse/CA Registered Domestic Partner.
Proof of their incapacity and dependency will be required. Employee must request
enrollment in medical coverage by calling their medical insurance carrier prior to
the County's enrollment.

Revised 1/15
 Stanislaus County Partners in Health Service Area

County City Zip Codes

Stanislaus All All
Calaveras All All
Tuolumne All All
San Joaquin Escalon, Lathrop, Manteca, Ripon 95320, 95330, 95336, 95337, 95366
Page 1 of 2 Merced Delhi, Hilmar, Livingston 95315, 95324, 95334 As of 10/17/2014
 Stanislaus County Partners in Health Service Area
Complete Zip Code List

95221 95247 95310 95328 95353 95370

95222 95248 95313 95329 95354 95372
95223 95249 95314 95330 95355 95373
95224 95250 95315 95334 95356 95375
95225 95251 95316 95335 95357 95379
95226 95252 95319 95336 95358 95380
95228 95254 95320 95337 95360 95381
95229 95255 95321 95346 95361 95382
95232 95257 95323 95347 95363 95383
95233 95305 95324 95350 95364 95386
95245 95307 95326 95351 95366 95387
95246 95309 95327 95352 95367 95390
95368 95397

Page 2 of 2 As of 10/17/2014
HEALTH INSURANCE ENROLLMENT PROCEDURES

-MEDICAL, DENTAL AND VISION PLANS

STANISLAUS COUNTY PARTNERS IN HEALTH HDHP/EPO

ANTHEM BLUE CROSS HDHP/EPO
DELTA DENTAL CORE AND BUYUP PLANS
VISION SERVICE PLAN

Procedures to complete Health Insurance Enrollment for a new hire/rehire/part to full time:

♦ Forms are to be submitted electronically to [email protected].

♦ Coverage will be effective the first of the month following the employee’s event date.

♦ Complete the County Benefit Enrollment Form selecting the options pertaining to the
coverage level and plan choices along with dependent information. All dependent
information must be included (DOB, SSN, relationship, gender). Medical Plan carrier is
determined by physical address. Refer to the local area zip code list. SCPH is available to
local area residents and Anthem is available to out of area residents only.

♦ For enrollment of a spouse/domestic partner, submit a copy of the marriage/domestic

partnership certificate. For enrollment of a dependent child, submit a copy of the birth
certificate. If the dependent child is adopted or there is a legal custody situation, submit a
copy of the legal adoption and/or custody papers along with the birth certificate.

♦ If you choose the option of Waive for the medical plan option, indicate your other plan’s
information and provide proof of the coverage.

♦ If a new hire wants to waive their coverage or make changes to dependent enrollment after
paperwork has been submitted and processed:

• Waiving coverage or changes to dependent enrollment will be allowed up to 30 days

maximum from the date of hire and must be retroactive to the effective date.
Changing from one medical plan to another medical plan will not be allowed after the
first paycheck deduction has been processed.
• If employee has enrolled in a High Deductible Plan with a Health Savings Account that
has received contributions from the County and there is a change in contribution
amount, employee must agree to complete the necessary contribution correction form to
allow the County to retrieve funds deposited to the HSA.
• Employee acknowledges there may be a payroll deduction adjustment required to
process the retroactive change.

♦ For a Life Event enrollment change (not a new hire), refer to the Life Events Tab 5.

DOMESTIC PARTNER COVERAGE TAX IMPLICATIONS

Benefit coverage rendered under an employer group health plan to a Domestic Partner is
treated as federal taxable income to the employee. Therefore, Stanislaus County must tax the
employee on the value of the coverage (premium amount as if purchasing separately).
Revised 1/15
LIFE EVENTS/ ENROLLMENT CHANGES
MEDICAL, DENTAL AND VISION PLANS

STANISLAUS COUNTY PARTNERS IN HEALTH HDHP AND EPO PLANS

ANTHEM BLUE CROSS HDHP AND EPO PLANS
DELTA DENTAL CORE AND BUYUP PLANS
VISION SERVICE PLAN

Enrollment changes are only allowed during Open Enrollment or if the employee experiences a Life
Event. A Life Event may include Divorce, Marriage, Birth or Adoption. Adding or removing
dependents is the only change allowed. Medical Plan changes are only allowed during Open
Enrollment and are determined by the subscriber’s physical address. Exceptions to this rule are
listed below.

Self Service
If an employee needs to add or remove dependents due to a Life Event, log in to PeopleSoft Self
Service to enter the change. (Refer to Self Service instructions) Send backup documentation
electronically to Benefits (make sure name, emplid and reason for change is on the document).

Forms
If an employee does not have access to PeopleSoft Self Service, a County Benefit Enrollment Form
must be completed. Forms need to be submitted electronically via email or fax. Dependents
that become ineligible due to their age (26th birthday) will be automatically removed by employee
benefits at the end of the month following their birth date.

♦ All enrollment changes outside of open enrollment must be made within 30 days from the date
of the event.

♦ A copy of the marriage/domestic partnership/birth certificate or divorce/adoption judgment will

be required for this kind of change. If a new dependent is not added within 30 days, the employee
must wait until the next open enrollment period.

♦ Eligibility and premium changes due to a marriage, divorce or over age dependent will be
effective the first of the month following the qualifying event date.

♦ Eligibility changes due to the birth of a baby are effective the date of birth, however change in
premium will take affect the first of the following month.

♦ Eligibility changes due to an adoption are effective the date the child was placed in the home for
adoption, however change in premium will take effect the first of the following month.

♦ Please submit forms and/or proof of change documentation to Employee Benefits electronically via
scan and e-mail to [email protected] or via fax to 567-4367 or 525-5779.

Revised 1/15
EXCEPTIONS FOR MAKING PLAN CHANGES OUTSIDE OF OPEN ENROLLMENT

Loss of Coverage

In situations where a county employee has lost coverage while being covered under a plan other
than a Stanislaus County plan, the employee and dependents will be allowed to enroll into a county
plan. Applicable form must be completed and submitted to employee benefits electronically within
30 days of the loss of coverage. Proof is required.

Overlapping Open Enrollments

In situations where a County employee and his/her spouse who is employed by another entity have
different open enrollment periods, the County will allow the employee and dependents to
enroll/cancel during the non-county spouse’s open enrollment period. Proof of the conflicting open
enrollment period is required with the applicable county enrollment forms.

DENTAL PLAN

♦ Children not added at the time of birth may be enrolled during any open enrollment period or on
their 4th birthday.

♦ Anytime an employee has a break in coverage, coverage will be reduced to 70% upon their re-
enrollment. For example, an employee who did not pay premiums while on an unpaid Leave of
Absence or Military Leave.

DOMESTIC PARTNER COVERAGE TAX IMPLICATIONS

Benefit coverage rendered under an employer group health plan to a Domestic Partner is treated as
federal taxable income to the employee. Therefore, Stanislaus County must tax the employee on
the value of the coverage (premium amount as if purchasing separately).

Revised 1/15
 STANISLAUS COUNTY EPO MEDICAL BENEFITS SCHEDULE
2015

PARTICIPATING PROVIDERS NON-PARTICIPATING

PROVIDERS
No benefits will be paid for any member of a Family Unit until the Family Unit deductible has been met
regardless of the number of participants it takes to meet the family deductible.
COPAYMENTS: One copayment per provider or specialty group is charged per day.
Visits: If multiple visits occur on the same day, each visit counts toward the applicable benefit limit.
Urgent Care $20 Not Covered
Physician Visits $20 Not Covered
Specialist Visits $20 Not Covered
Outpatient Services/Office Visit $20 Not Covered
Outpatient Surgery $100 Not Covered
Emergency Room $75 $75
The Emergency room copayment is waived if the patient is admitted to the Hospital on an emergency
basis. The utilization review administrator, Health Care Strategies must be notified within 48 hours of the
admission, even if the patient is discharged within 24 hours of the admission.
MAXIMUM OUT-OF-POCKET AMOUNT, PER CALENDAR YEAR (CY)
Per Covered Person $1500 NA
Per Family Unit $3000 NA
The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at
which time the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year
unless stated otherwise.
The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%.
 Cost containment penalties
 Copayments applied to Acupuncture
 Copayments applied to Chiropractic Care
COVERED CHARGES
Hospital Services

Inpatient Hospital Includes room and 100% after $150 copayment at Not Covered
board for private and semi-private rooms; Hospital’s contracted rate
Acute Rehab, Inpatient Professional
Services, Medically Necessary Private
Duty Nursing, Ancillary Services, Supplies.
Intensive Care Unit 100% after $150 copayment at Not Covered
Hospital’s contracted rate
Outpatient Surgery Facility Performed in 100% after $100 copayment Not Covered
Outpatient Hospital or Ambulatory Surgery Facility’s contracted rate
Center.
Emergency Room Visit 100% after $75 copayment 100% after $75 copayment
(waived if admitted) (waived if admitted)
Urgent Care 100% after $20 copayment Not Covered
Skilled Nursing Facility 100% after $200 copayment at
facility’s contracted rate Not Covered
100 days maximum per CY
Physician Services

Office visits 100% after $20 copayment Not Covered

Specialist office visits 100% after $20 copayment Not Covered
Inpatient visits 100% Not Covered
Outpatient Surgery 100% after $100 copayment Not Covered
Inpatient Surgery 100% Not Covered
Allergy Office Visit 100% after $20 copayment Not Covered
Allergy testing 100% after $20 copayment Not Covered
Allergy Serum/Injections only 100% after $10 copayment Not Covered
Allergy Injection as part of the office visit 100% Not Covered
(includes serum).
Diagnostic Testing (X-ray, Lab) 100% after $10 copayment Not Covered
 PARTICIPATING PROVIDERS NON-PARTICIPATING
PROVIDERS
High-tech radiology 100% after $25 copayment Not Covered
Hearing Aid Services 100% Not Covered
(up to a maximum of $5,000 of benefits in
a Calendar Year) See coverage,
exclusions and limitations on plan
document
Infertility Services (Including hospital Not Covered Not Covered
charges, office visits, diagnostic lab & X-
ray, outpatient hospital or ambulatory
surgery center).
Infertility Drug Coverage Not Covered Not Covered
Home Health Care 100% Not Covered
100 visits maximum per CY
3 visits maximum per day
Infusion Services (Outpatient) Requires 100% after $10 copayment Not Covered
skilled or medical administration.
Home Infusion Includes Infusions and 100% Not Covered
Supplies.
Hospice Care 100% Not Covered
Respite Care 100% Not Covered
Up to 5 consecutive days for
each approved admission.
Injections and Immunizations Non-
routine, Includes Travel Immunizations.

Office Visit 100% after $20 copayment Not Covered

Provided during an Office Visit 100% after $20 copayment Not Covered
Injection only (Cost of administration and 100% after $10 copayment
materials or Office Visit Cost Share, Not Covered
whichever is less.

Ambulance Service Includes Ground and 100% after $50 copayment per 100% after $50 copayment per
Air Ambulance. trip trip
Nutritionist Consultations For diagnoses 100% after $15 copayment Not Covered
of diabetes and renal disease.
Health Education 100% Not Covered
Includes classes for Self management of
Asthma, Diabetes and Coronary Disease.
House Calls 100% Not Covered
Vision Exam (includes refraction) 100% after $10 copayment Not Covered
Hemodialysis

Nephrologist Visit - Routine 100% Not Covered

Nephrologist Visit - Non-Routine 100% after $20 copayment Not Covered
Cardiac Rehabilitation 100% after $20 copayment Not Covered
Respiratory/Pulmonary Therapy 100% after $20 copayment Not Covered
Chemotherapy/Radiation 100% Not Covered
Wig After Chemotherapy 100% Not Covered
Acupuncture (covered only for the 100% after $20 copayment Not Covered
treatment of nausea or chronic pain).
Occupational Therapy 100% after $20 copayment Not Covered
Speech Therapy 100% after $20 copayment Not Covered
Physical Therapy 100% after $20 copayment Not Covered
Biofeedback (Medical and Mental Health 100% after $20 copayment Not Covered
Services)
 PARTICIPATING PROVIDERS NON-PARTICIPATING
PROVIDERS
Jaw Joint/TMJ Not Covered

Office Visit 100% after $20 copayment

Outpatient Surgery 100% after $100 copayment

Inpatient Surgery 100% after $150 copayment

Durable Medical Equipment (including 100% after $20 copayment Not Covered
diabetic testing supplies).
Sexual Dysfunction 40% Not Covered
Limit:8 doses,30 days
Breast Pump and Supplies 100% Not Covered
Prosthetics /Orthotics Includes medically 100% Not Covered
necessary eyewear for diagnoses of
aniridia and aphakia; colostomy/ostomy
and urological supplies.
Spinal Manipulation Chiropractic (Self 100% after $15 copayment Not Covered
Referred Visits). 20 visits maximum per CY
Appliances limited to $50 per
CY.
Special Oral Foods – Amino Acid 100% Not Covered
modified products.
Family Planning

Consultations, Counseling or 100% Not Covered

Diaphragm fitting
Contraceptive devices/injections 100% Not Covered
Administered by a Physician.
Tubal Ligation 100% Not Covered
Elective Abortion Office Visit 100% after $20 copayment Not Covered
Outpatient Surgery 100% after $100 copayment Not Covered
Inpatient Hospital 100% after $200 copayment Not Covered
Pregnancy
(Including dependent daughters)
Office Visit to confirm pregnancy 100% after $20 copayment Not Covered

Pre-natal Care (does not include all 100% Not Covered

pregnancy-related issues) and one Post
Partum visit.
Delivery 100% after $200 copayment Not Covered
Mental Disorders

Inpatient 100% after $200 copayment Not Covered

Intensive Outpatient/ Partial 100% Not Covered
Hospitalization
Outpatient 100% after Not Covered
$20 copayment individual
therapy
$10 copayment group therapy
Substance Abuse

Transitional Residential Detox covered 100% after $50 copayment Not Covered
under medical benefits.
Intensive Outpatient/Partial 100% after $5 copayment per Not Covered
Hospitalization day
 PARTICIPATING PROVIDERS NON-PARTICIPATING
PROVIDERS
Outpatient 100% after Not Covered
$20 copayment individual
therapy
$5 copayment group therapy
Preventive Care

Routine Well Adult Care (Including Well 100% deductible waived Not Covered
Woman) Includes vision and hearing
screenings. See Vision Exams for
Refractions.
Routine Well Child Care Includes vision 100% deductible waived Not Covered
and hearing screenings.
Immunizations (preventive) Applies to 100% deductible waived Not Covered
Adults and Children
Preventive screenings as recommended 100% deductible waived Not Covered
by Centers for Disease Control and HRSA.

Routine Well Newborn Care 100% deductible waived Not Covered

For a complete listing of routine preventive services, go to:

https://www.healthcare.gov/what-are-my-preventive-care-benefits.

Preventive Lab and X-ray screenings not specifically listed under the Preventive Screenings section are
treated the same as non-preventive Lab and X-ray Services. Frequency and Age Limits managed by Network
Provider except where noted

As stated under the United States Preventive Services Task Force recommendations & HRSA (Health
Resources and Services Administration.

Note: Mammograms are allowed annually for ages 40 and over

Hearing Exams are allowed annually
Preventive Care services are not subject to the deductible
Bariatric Surgery

Office Visit 100% after $20 copayment Not Covered

Outpatient Surgery 100% after $125 copayment Not Covered
Inpatient Hospital 100% after $200 copayment Not Covered
Travel and Lodging for Bariatric Surgery
Includes coverage for recipient and companion/parent for transportation and lodging. Must travel more than
50 miles away from your home for surgery. Daily expenses for transportation and lodging are not covered.
Transportation Limits Maximum of $130 for each Not Covered
Coverage includes one pre-surgical visit, round-trip
actual surgery and initial post-surgical
follow-up visit for patient (maximum 3
trips); actual surgery and initial post-
surgical follow-up visit for companion
(maximum 2 trips).
Limits Lodging Up to $100 per day Not Covered
Coverage includes one hotel room, double
occupancy for patient/companion, up to 2
days per trip for one pre-surgical visit and
post-surgical follow-up visit; one hotel
room, double occupancy, for companion,
up to 4 days, for patient surgery.
 PARTICIPATING PROVIDERS NON-PARTICIPATING
PROVIDERS
Organ Transplants

Office Visit 100% after $20 copayment Not Covered

Outpatient Surgery 100% after $100 copayment Not Covered
Inpatient Hospital 100% after $200 copayment Not Covered
Travel and Lodging for Organ Transplants
Includes coverage for recipient, care-giver and donor for transportation, lodging and daily expenses. Daily
expenses include incidental expenses such as meals and does not include personal expenses.
Transportation Limits None Not Covered
Lodging Limits None Not Covered
Daily Expense Limits Reimbursement up to $50 per Not Covered
day per person
Other Services

Accidental Injury to Teeth Repair of Not Covered

sound and natural teeth directly related to
an accidental injury.

Office Visit 100% after $20 copayment Not Covered

Outpatient Surgery 100% after $20 copayment Not Covered
Inpatient Hospital 100% Not Covered
Blood and Blood Products 100% Not Covered
Growth Hormone =Formulary Generic/Brand Not Covered
Smoking Cessation (We do cover =Formulary Generic/Brand Not Covered
smoking cessation drugs at the generic or
brand cost share (as appropriate).
Effective 1/1/2012 participation in a
smoking cessation program is no longer
required for the Plan coverage of smoking
cessation drugs and OTC products.
However, Medical Groups may strongly
encourage or make a clinical decision to
require a Participant participate in a
behavioral modification program prior to
writing a prescription. This applies for all
HP products including Self-Funded
Accounts.)
Weight Loss Not Covered Not Covered
Vision Hardware – Frames, Eyeglass Not Covered Not Covered
Lenses and Contact Lenses.
 PRESCRIPTION DRUG BENEFIT SCHEDULE

PRESCRIPTION DRUG BENEFIT

PARTICIPATING NON-PARTICIPATING
Female Contaceptive Drugs
Generic and Single Source 100% copayment waived Not Covered
Brand Contraceptive Drugs
(30, 60, or 90 day supply)
Emergency Contraception* 100% copayment waived Not Covered

Pharmacy Option (up to 30 Day Supply)

Generic Drugs (also includes $10 copayment Not Covered
syringes for diabetics)
Formulary Brand Name $25 copayment Not Covered
Drugs (Prior Authorization
Required)
Pharmacy Option (31 to 60 Day Supply)
Generic Drugs (also includes $20 copayment Not Covered
syringes for diabetics)
Formulary Brand Name $50 copayment Not Covered
Drugs (Prior Authorization
Required)
Pharmacy Option (61 to 100 Day Supply)
Generic Drugs (also includes $30 copayment Not Covered
syringes for diabetics)
Formulary Brand Name $75 copayment Not Covered
Drugs (Prior Authorization
Required)
Mail Order Option (up to 30 Day Supply)
Generic Drugs (also include $10 copayment Not Covered
syringes for diabetics)
Formulary Brand Drugs (Prior $25 copayment Not Covered
Authorization Required)
Mail Order Option ( 31 to 100 Day Supply)
Generic Drugs (also include $20 copayment Not Covered
syringes for diabetic) (
Formulary Brand Drugs (Prior $50 copayment Not Covered
Authorization Required)
For items or injections dispensed by Pharmacy and requiring skilled administration in the
Physician's Office (Implantable contraceptives, administered meds, etc.) Office Visit Cost Share
for administration may apply.
* With prescription, no cost share. Without prescription, Participant pays retail cost
Refer to the Prescription Drug Section for details on the Prescription Drug benefit.

The following over-the-counter drugs are covered at 100% at a Participating Pharmacy when
prescribed by a physician for preventive services, including:
 Aspirin to reduce the risk of heart attack
 Oral Fluoride for children to reduce the risk of tooth decay
 Folic acid for women to reduce the risk of birth defects
 Iron supplements for children to reduce the risk of anemia
 Vitamin D
 Female contraceptives that are approved by the Food and Drug Administration (FDA) and are
generally available over-the-counter (spermicides, female condoms and sponges)
 STANISLAUS COUNTY HDHP MEDICAL BENEFITS SCHEDULE
2015

PARTICIPATING PROVIDERS NON-PARTICIPATING PROVIDERS

No benefits will be paid for any member of a Family Unit until the Family Unit deductible has been met regardless of the
number of participants it takes to meet the family deductible.
DEDUCTIBLE, PER CALENDAR YEAR (CY), applies to all services except preventative.
Per Covered Person $1250 N/A
Per Family Unit $2500 N/A
The Emergency room copayment is waived if the patient is admitted to the Hospital on an emergency basis. The
utilization review administrator, Health Care Strategies must be notified within 48 hours of the admission, even if the
patient is discharged within 24 hours of the admission.
COPAYMENTS: One copayment per provider or specialty group is charged per day.
Visits: If multiple visits occur on the same day, each visit counts toward the applicable benefit limit.
Office visits $20 N/A
Inpatient $150 N/A
Emergency Room visits $75 N/A
Urgent Care visits $20 N/A
MAXIMUM OUT-OF- POCKET, PER CALENDAR YEAR (CY)
Per Covered Person $3000 N/A
Per Family Unit $6000 N/A
The Plan will pay the designated percentage of Covered Charges until out-of-pocket amounts are reached, at which time
the Plan will pay 100% of the remainder of Covered Charges for the rest of the Calendar Year unless stated otherwise. All
Services except Preventive and other Services with a $0 Cost Share apply to the Out–of Pocket Maximum.
The following charges do not apply toward the out-of-pocket maximum and are never paid at 100%.
 Cost containment penalties
 Copayments applied to Acupuncture
 Copayment applied to Chiropractic Care
COVERED CHARGES
Hospital Services

Inpatient Hospital Includes room and board 100% after $150 copayment per Not Covered
for private and semi-private rooms; Acute admit and calendar year (CY)
Rehab, Inpatient Professional Services, deductible
Medically Necessary Private Duty Nursing, (only 1 copayment per Hospital
Ancillary Services, Supplies. admission will apply).

Intensive Care Unit 100% after $150 copayment per Not Covered
admit and CY deductible (only 1
copayment per Hospital admission
will apply).

Outpatient Surgery Facility 100% after $100 copayment and CY Not Covered
Performed in Outpatient Hospital or deductible
Ambulatory Surgery Center.

Emergency Room Visit 100% after $75 copayment (waived if 100% after $75 copayment and CY
admitted) and CY deductible deductible

Emergency Ambulance 100% after $50 copayment per trip 100% after $50 copayment per trip
Includes Ground and Air Ambulance and CY deductible and CY deductible

Urgent Care 100% after $20 copayment and CY Not Covered

deductible
 PARTICIPATING PROVIDERS NON-PARTICIPATING PROVIDERS
Reconstructive Surgery Includes
procedures to improve function and change
appearance for conditions due
to disease, trauma, congenital/developmental
anomalies, post-mastectomy (to produce
symmetrical appearance only) and Medically
Necessary surgery.

Office Visit 100% after $20 copayment and CY Not Covered

deductible
Outpatient Surgery 100% after $100 copayment and CY Not Covered
deductible
Inpatient Hospital 100% after $150 copayment and CY Not Covered
deductible

Skilled Nursing Facility 100% after $200 copayment per Not Covered
admit and CY deductible, 100- days
maximum per CY.

Physician Services

Office visits 100% after $20 copayment and CY Not Covered

deductible

Specialist office visits 100% after $20 copayment and CY Not Covered
deductible

Outpatient Surgery Performed in Outpatient 100% after $100 copayment and CY Not Covered
Hospital or Ambulatory Surgery Center. deductible

Allergy testing 100% after $20 copayment and CY Not Covered

deductible

Allergy Serum/Injections only 100% after $10 copayment and CY Not Covered
deductible

Diagnostic Testing (X-ray & Lab) 100% after $10 copayment and CY Not Covered
deductible

Hearing Aid Services 100% after CY deductible Not Covered

(up to a maximum of $5,000 of benefits in a
Calendar Year) See coverage, exclusions and
limitations on plan document
High-tech radiology 100% after $25 copayment and CY Not Covered
deductible

Infertility Services (including hospital Not Covered Not Covered

charges, office visits, diagnostic lab & X-ray,
outpatient hospital or ambulatory surgery
center).
Infertility Drug Coverage Not Covered Not Covered
Home Health Care 100% after CY deductible Not Covered
100 visits maximum per CY
3 visits maximum per day.
 PARTICIPATING PROVIDERS NON-PARTICIPATING PROVIDERS
Infusion Services (Outpatient) 100% after $10 copayment and CY Not Covered
deductible
Home Infusion 100% after CY deductible Not Covered

Hospice Care 100% after CY deductible Not Covered

Respite Care 100% after CY deductible Not Covered

Up to 5 consecutive days for each
approved admission.
Injections and Immunizations Non-routine,
includes travel immunizations
Office Visit 100% after $20 copayment and Not Covered
CY deductible
Provided during an office visit 100% after $20 copayment and Not Covered
CY deductible
Injection Only (Materials and 100% after $10 copayment and CY Not Covered
administrations) deductible

Nutritionist Consultations For diagnoses of 100% after $15 copayment and CY Not Covered
diabetes & renal disease. deductible.

Health Education Includes classes for Self 100% deductible waived Not Covered
management of Asthma, Diabetes and
Coronary Disease.

House Calls 100% after CY deductible Not Covered

Vision Exam (includes refraction) 100% after $10 copayment and CY Not Covered
deductible
Hemodialysis

Nephrologist visit - Routine 100% after CY deductible Not Covered

Nephrologist visit – Non - Routine 100% after $20 copayment and CY Not Covered
deductible

Cardiac Rehabilitation 100% after $20 copayment and CY Not Covered

deductible

Respiratory/Pulmonary Therapy 100% after $20 copayment and CY Not Covered

deductible
Chemotherapy/Radiation 100% after CY deductible Not Covered

Wig After Chemotherapy 80% after CY deductible Not Covered

Acupuncture 100% after $20 copayment and CY Not Covered

(covered only for the treatment of nausea or deductible
chronic pain)
Occupational Therapy No visit maximum 100% after $20 copayment and CY Not Covered
deductible

Speech Therapy No visit maximum 100% after $20 copayment and CY Not Covered
deductible
 PARTICIPATING PROVIDERS NON-PARTICIPATING PROVIDERS
Physical Therapy No visit maximum 100% after $20 copayment and CY Not Covered
deductible

Biofeedback Includes Medical and Mental 100% after $20 copayment and CY Not Covered
Health Services deductible
Jaw Joint/TMJ

Office Visit 100% after $20 copayment and CY Not Covered

deductible
Outpatient surgery 100% after $100 copayment and CY Not Covered
deductible
Inpatient surgery 100% after $150 copayment and CY Not Covered
deductible
Durable Medical Equipment 100% after $20 copayment and CY Not Covered
(including diabetic testing supplies) deductible
Sexual Dysfunction Device 40% after CY deductible Not Covered
Limit: 8 doses,30 days
Breast Pump and Supplies 100% deductible waived Not Covered
Prosthetics/Orthotics 100% after CY deductible Not Covered
Includes medically necessary eyewear for
diagnoses of aniridia and aphakia;
colostomy/ostomy and urological supplies.
Spinal Manipulation Chiropractic (Self 100% after $15 copayment and CY Not Covered
Referred Visits) deductible (20 visit maximum per
CY)
Appliances limited to $50 per CY
deductible waived.
Special Oral Foods – Amino Acid modified 100% after CY deductible Not Covered
products
Family Planning

Consultations or Diaphragm Fitting 100% deductible waived Not Covered

Contraceptive devices/injections 100% deductible waived Not Covered

administered by a Physician
Tubal Ligation 100% deductible waived Not Covered

Elective Abortion – Office 100% after $20 copayment and CY Not Covered
deductible
Elective Abortion – Outpatient Surgery 100% after $100 copayment and CY Not Covered
deductible
Elective Abortion – Inpatient Hospital 100% after $200 copayment and CY Not Covered
deductible
Pregnancy
(Including dependent daughters)
Office Visit to confirm pregnancy 100% after $20 copayment and CY Not Covered
deductible
Pre-natal Care (does not include all 100% deductible waived Not Covered
pregnancy-related issues) and one Post
Partum visit
Delivery Hospital Inpatient 100% after $200 admission Not Covered
Includes contracted Birthing Center if copayment and CY deductible
available
 PARTICIPATING PROVIDERS NON-PARTICIPATING PROVIDERS
Mental Disorders

Inpatient 100% after $200 copayment per Not Covered

admission and CY deductible
Intensive Outpatient/Partial 100% after CY deductible Not Covered
Hospitalization
Outpatient 100% after $20 copayment for Not Covered
individual therapy/ $10 copayment
for group therapy and CY deductible
Substance Abuse

Transitional Residential Detox covered 100% after $50 copayment per Not Covered
under medical benefits admission and CY deductible
Intensive Outpatient/ Partial Hospitalization 100% after $5 copayment per day Not Covered
Includes all services provided during the day and CY deductible
Outpatient 100% after $20 copayment for ind. Not Covered
therapy/ $5 copayment for group
therapy and CY deductible
Preventive Care

Routine Well Adult Care (Including Well 100% deductible waived Not Covered
Woman) Includes vision and hearing
screenings. See Vision Exams for
Refractions.
Routine Well Child Care Includes vision and 100% deductible waived Not Covered
hearing screenings.

Immunizations (preventive) Applies to 100% deductible waived Not Covered

Adults and Children
Preventive screenings as recommended by 100% deductible waived Not Covered
Centers for Disease Control and HRSA.

Routine Well Newborn Care 100% after CY deductible Not Covered

For a complete listing of routine preventive services, go to:

https://www.healthcare.gov/what-are-my-preventive-care-benefits.

Preventive Lab and X-ray screenings not specifically listed under the Preventive Screenings section are treated the same
as non-preventive Lab and X-ray Services. Frequency and Age Limits managed by Network Provider except where noted

As stated under the United States Preventive Services Task Force recommendations & HRSA (Health Resources and
Services Administration.

Note: Mammograms are allowed annually for ages 40 and over

Hearing Exams are allowed annually
Preventive Care services are not subject to the deductible
Bariatric Surgery

Office Visit 100% after $20 copayment and CY Not Covered

deductible
Outpatient Surgery 100% after $125 copayment per Not Covered
procedure and CY deductible
Inpatient Hospital 100% after $200 copayment per Not Covered
admit and CY deductible
 PARTICIPATING PROVIDERS NON-PARTICIPATING PROVIDERS
Travel and Lodging for Bariatric Surgery
Includes coverage for recipient and companion/parent for transportation and lodging. Must travel more than 50 miles away
from your home for surgery. Daily expenses for transportation and lodging are not covered.
Transportation Limits Maximum of $130 for each round-trip Not Covered
Coverage includes one pre-surgical visit,
actual surgery and initial post-surgical follow-
up visit for patient (maximum 3 trips); actual
surgery and initial post-surgical follow-up visit
for companion (maximum 2 trips).
Limits Lodging Up to $100 per day Not Covered
Coverage includes one hotel room, double
occupancy for patient/companion, up to 2
days per trip for one pre-surgical visit and
post-surgical follow-up visit; one hotel room,
double occupancy, for companion, up to 4
days, for patient surgery.
Organ Transplants

Office Visit 100% after $20 copayment and CY Not Covered

deductible
Outpatient Surgery 100% after $100 copayment per Not Covered
procedure and CY deductible
Inpatient Hospital 100% after $200 copayment per Not Covered
admit and CY deductible
Travel and Lodging for Organ Transplants
Includes coverage for recipient, care-giver and donor for transportation, lodging and daily expenses. Daily expenses
include incidental expenses such as meals and does not include personal expenses.
Transportation Limits None NA
Lodging Limits None NA
Daily Expense Limits Reimbursement up to $50 per day NA
per person
Other Services

Accidental Injury to Teeth Repair of sound

and natural teeth directly related to an
accidental injury.
Office Visit Not Covered Not Covered
Outpatient Surgery Not Covered Not Covered
Inpatient Hospital Not Covered Not Covered

Blood and Blood Products 100% after deductible Not Covered

Growth Hormone =Formulary Generic/Brand Not Covered
Smoking Cessation =Formulary Generic/Brand Not Covered
Weight Loss Not Covered Not Covered
Items or Injections requiring skilled 100% after CY deductible Not Covered
administration in the Physician's Office and
dispensed by Pharmacy.
Vision Hardware - Frames, Eyeglass Not Covered Not Covered
Lenses and Contact Lenses
For items or injections dispensed by Pharmacy and requiring skilled administration in the Physician's Office (Implantable
contraceptives, administered meds, etc.) Office Visit Cost Share for administration may apply.
 PRESCRIPTION DRUG BENEFIT SCHEDULE

PRESCRIPTION DRUG BENEFIT

PARTICIPATING NON-PARTICIPATING

Female Contaceptive Drugs

Generic and Single Source 100% - deductible waived Not Covered
Brand Contraceptive Drugs (30,
60, or 90 Day Supply)
Emergency Contraception* 100% - deductible waived Not Covered

Pharmacy Option (up to 30 Day Supply)

Generic Drugs (includes syringes $10 copayment after CY Not Covered
for diabetics) deductible
Formulary Brand Name Drugs $25 copayment after CY Not Covered
(Prior Authorization Required) deductible
Pharmacy Option (31 to 60 Day Supply)
Generic Drugs (also includes $20 copayment after CY Not Covered
syringes for diabetics) deductible

Formulary Brand Name Drugs $50 copayment after CY Not Covered

(Prior Authorization Required) deductible
Pharmacy Option (61 to 100 Day Supply)
Generic Drugs (also includes $30 copayment after CY Not Covered
syringes for diabetics) deductible

Formulary Brand Name Drugs $75 copayment after CY Not Covered

(Prior deductible
Authorization Required)
Mail Order Option (up to 30 Day Supply)
Generic Drugs $10 copayment after CY Not Covered
deductible

Formulary Brand Name Drugs $25 copayment after CY Not Covered

(Prior Authorization Required) deductible
Mail Order Option (31 to 100 Day Supply)
Generic Drugs $20 copayment after CY Not Covered
deductible

Formulary Brand Name Drugs $50 copayment after CY Not Covered

(Prior Authorization Required) deductible
* With prescription, no cost share. Without prescription, Participant pays retail cost
Refer to the Prescription Drug Section for details on the Prescription Drug benefit
The following over-the-counter drugs are covered at 100% at a Participating Pharmacy
when prescribed by a physician for preventive services, including:
 Aspirin to reduce the risk of heart attack
 Oral Fluoride for children to reduce the risk of tooth decay
 Folic acid for women to reduce the risk of birth defects
 Iron supplements for children to reduce the risk of anemia
 Vitamin D
 Female contraceptives that are approved by the Food and Drug Administration (FDA)
and are generally available over-the-counter (spermicides, female condoms and
sponges)
Health Savings Account (HSA)- 2015
Frequently Asked Questions

What is a Health Savings Account?

An HSA is a bank account with money used to pay health care costs. Participants enroll in a relatively
inexpensive high deductible insurance plan. Then, a tax-deductible savings account is opened to cover
current and future medical expenses. The money deposited, as well as the earnings, is tax-deferred.

Once funds are deposited into the HSA, the account can be used to pay for qualified medical expenses
tax-free, even if you no longer have HDHP coverage or you leave County employment. The funds in
your account roll over automatically each year and remain indefinitely until used. There is no time limit
on using the funds.

Why a High Deductible Plan?

To get the benefits of an HSA, the law requires that the savings account be combined with a High
Deductible Health Plan. High Deductible Health Insurance costs less than traditional low deductible or
EPO/HMO coverage, because the insurance company does not have to process and pay claims for
routine, low-dollar medical care.

How does a Health Savings Account Work?

You obtain coverage under a qualified high deductible health insurance plan. You are then allowed to
deposit voluntary and/or employer contributions up to the IRS limits of $3,350 for singles or $6,650 for
families into your Health Savings Account for 2015. For calendar year 2015, the County is contributing
funds based on coverage level for qualified individuals, $1,200 for single employees and $2,000 for
Employee +1 and Family coverage. Half of the deductible will be deposited into your account on
January 2, 2015, the remaining half will be deposited on a semi-monthly basis beginning July 8, 2015.
Employees can also add voluntary contributions to their HSA in addition to the County contributions,
however the combination of employee and County contributions cannot exceed the IRS limits.

You can use the savings account to pay for your lower-dollar medical expenses, or those that are not
covered by the health plan. Once you meet the deductible, the health insurance covers your medical
expenses as defined in the policy.

What if you meet your deductible before the HSA account is fully funded by the
County?
Most medical providers will allow you to make payments for services that may exceed your available
funds. If you are required to pay for any qualifying expenses with personal funds outside of your HSA,
you can withdraw available funds from your HSA to reimburse yourself as those funds become
available. There is no time limit for when you can reimburse yourself for your health care expenses.
You should keep legible receipts of your medical expenses, and records of when you do reimburse
yourself.

When you are paying for your medical expenses from your HSA account, how does
your insurance company know when you have paid up to your deductible?
If you use an in-network provider, they can file your claim for you. This is the smart way to work
things, as it will ensure that you receive the company's discounted price, instead of having to pay the full
price.
With a high-deductible health plan, before I meet my deductible, will I have to pay
full price for doctor visits, or will I receive a discount?
Visits to a doctor in your network will be re-priced according to the discount negotiated by the qualified
high deductible plan, before you are billed. This can mean substantial discounts in what you pay for
your health care, even before you meet your deductible.

With a high-deductible health plan, before I meet my deductible, will I be able to

purchase prescriptions anywhere, or must I use a participating pharmacy?
On Anthem Blue Cross and SCPH's deductible plans, you may purchase your prescriptions anywhere
you like including online, and it will go towards your deductible. However, you may have to file a
claim with the prescription vendor in order to have the expense applied to your deductible.

Other than the County’s contribution, how can I make voluntary contributions to
the HSA?
You may sign up at Open Enrollment for a semi-monthly payroll contribution. If you need to change or
stop your semi-monthly contribution, you may do so by completing a change form and e-mailing it to
County Benefits. You may also deposit contributions directly to the HSA bank account at any time
throughout the year or all at once at the beginning of the year by going into a Wells Fargo bank.

You may fund your HSA with a one-time rollover from your IRA. If you can afford to fully fund your
HSA without using a rollover from your IRA, you will get a full tax-deduction for your HSA
contribution. However, if you do not have enough money available to fully fund your account, moving
money from your IRA to your HSA is a smart move. It will protect this money from ever being taxed if
it is used to pay qualified medical expenses.

Can I as the employee be enrolled with another medical insurance plan and also be
enrolled on the County's High Deductible Plan with the HSA account?
No. Employees that have other coverage are not eligible for the HDHP with HSA.

Can my spouse be enrolled with another medical insurance plan and also be
enrolled on my County High Deductible Plan with the HSA account?
Yes, but only if the spouse has outside coverage and is not a County employee. The County will not
allow dual coverage for two married County employees.

Can my children be enrolled with another medical insurance plan and also be
enrolled in the County’s High Deductible Plan with the HSA account?
Yes. Due to Health Care Reform, children up to age 26 may be enrolled on any of the County’s
medical, dental and vision plans. However, children must be considered an IRS dependent to qualify for
the Health Savings Account funds.
For what purpose can HSA funds be used?
The funds belong to you. If funds are withdrawn for reasons other than to pay for qualified medical
expenses by someone under age 65, the amount withdrawn is taxable and subject to a 20% penalty by
the IRS. After age 65, there is no penalty for non-qualified withdrawals but amounts are taxable.

Funds used to pay for the following are tax-free and penalty-free:
♦ Qualified medical expenses as defined under Section 213 of the IRS Code (See IRS Publication 502:
Medical and Dental Expenses).
♦ COBRA insurance, qualified long-term care expenses and Health insurance premiums for
individuals receiving unemployment compensation.
♦ Medicare and retiree health insurance premiums, but not Medicare Supplement premiums.

Funds may be used for eligible expenses for your spouse or dependents, even if they are not covered by
the HDHP. But keep in mind, those expenses will not go towards your annual deductible or out-of-
pocket maximum.

It is your responsibility to keep track of your own qualified-medical expenses. Individual contributions
and taxable distributions should be reported on form 1040.

Important: In order for dependents to be eligible to use HSA funds they must qualify as an IRS
dependent based on the quidelines. For IRS dependent eligibility, refer to page 12 of the IRS
pub.501 located on the Employee Benefits website under Forms or www.IRS.gov.

What happens at age 65?

When you turn 65 you become eligible for Medicare. If you enroll in Medicare Part A or Part B, you
are no longer eligible for coverage under a high-deductible health plan. You may still use tax-free HSA
funds to pay for qualified medical expenses, Medicare Part D premiums, and retiree health insurance
premiums. You are also entitled to take out any amount from your account for any reason, penalty free
(though you must pay income taxes on the withdrawals at that time). There are no requirements laid out
in the law at the present time indicating when you must start taking distributions.

What happens to my HSA if I die?

Your HSA will be treated as your surviving spouse’s HSA, but only if your spouse is the named
beneficiary. If there is no surviving spouse or your spouse is not the beneficiary, then the savings
account will cease to be an HSA and will be included in the federal gross income of your estate or
named beneficiary.

What are the guidelines around rolling over an IRA into an HSA?
• The IRA transfer is a one time event.
• The transfer amount applies to the HSA annual contribution.
• The IRA transfer must be directly from the IRA to the HSA.
What happens to employees with chronic or catastrophic illnesses or a major
accident?
• The Traditional health coverage portion of the plan, which works a lot like current plans, will
begin once the deductible has been satisfied.
• The Out-of-Pocket Maximum provides a “safety umbrella” from the costs associated with
chronic or catastrophic illnesses.

What is the most I will ever pay in a calendar year if I’m enrolled in the HDHP
program?
Your HDHPs include an annual Out-of-Pocket Maximum. Money you spend from your HSA, out-of-
pocket expenses, and any coinsurance you pay all count toward this annual limit. HSA expenses outside
of your medical plan (dental, eye glasses, etc.) do not count toward your annual medical plan deductible
or maximum medical out-of-pocket expenses.

Out-of-Pocket Maximums
$3,000 Individual
$6,000 Family

What happens if I am enrolled in a HDHP HSA and I leave County employment?

You may choose to continue your HDHP coverage by enrolling in COBRA. You will keep what is
currently in your Health Savings Account and may use those funds to even pay your COBRA premiums,
however you will not receive any future employer contributions.

As long as you remain enrolled in the HDHP via COBRA, you may continue to voluntarily contribute to
your HSA. If you choose not to enroll in COBRA, you will no longer be able to contribute to your
HSA, however the funds belong to you.

I have a Domestic Partner on my HDHP. Can I use the money in my HSA for my
domestic partner's medical expenses?
Domestic partners are eligible for the HDHP however, the law states that money in an HSA can only be
used for yourself, your spouse and your tax dependents. If your domestic partner meets the IRS
qualifications to be considered a tax dependent under Code section 152, you can legally use your HSA
funds for his/her medical expenses. If they do not meet this qualification, you can not. You should seek
advice from a qualified tax consultant.

Revised 10/28/2014
 Plan Benefit Highlights for: County of Stanislaus (Core Plan)
Group No: 03351 Effective Date: 01/01/2015
In this incentive plan, Delta Dental pays 70% of the PPO contract allowance for covered diagnostic, preventive
and basic services and 70% of the PPO contract allowance for major services during the first year of eligibility.
The coinsurance percentage will increase by 10% each year (to a maximum of 100%) for each enrollee if that
person visits the dentist at least once during the year. If an enrollee does not use the plan during the calendar
year, the percentage will be reduced by 10% (the percentage will never drop below 70%). If an enrollee becomes
ineligible for benefits and later regains eligibility, the percentage will drop back to 70%.

Eligibility Primary enrollee, spouse (includes domestic partner coverage) and eligible
dependent children to the end of the month dependent turns age 26
Deductibles PPO-Dentists: None
Non-PPO-Dentists: $10 per person each calendar year
PPO-Dentists: N/A
Deductible waved for D & P?
Non-PPO-Dentists: Yes
Maximums $1,500 per person each calendar year

Waiting Period(s) Basic Benefits Major Benefits Prosthodontics

None None None

Benefits and Delta Dental PPO dentists** Non-PPO dentists**

Covered Services* In-PPO Network Out-of-PPO Network

Diagnostic & Preventive

Services (D & P) 70 - 100 % 70 - 100 %
Exams, cleanings and x-rays
Basic Services
Fillings, simple tooth extractions and 70 - 100 % 70 - 100 %
sealants
Endodontics (root canals) 70 - 100 % 70 - 100 %
Covered Under Basic Services
Periodontics (gum treatment) 70 - 100 % 70 - 100 %
Covered Under Basic Services
Oral Surgery 70 - 100 % 70 - 100 %
Covered Under Basic Services
Major Services
Crowns, inlays, onlays and cast 70 - 100 % 70 - 100 %
restorations
Prosthodontics 50 % 50 %
Bridges, dentures and implants
Dental Accident Benefits 100%
(included in calendar year maximum)
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.
Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist’s
submitted fees.
** Reimbursement is based on PPO contracted fees for PPO dentists, PPO contracted fees for Premier dentists
and PPO contracted fees for non-Delta Dental dentists.
Delta Dental of California Customer Service Claims Address
100 First St. 800-765-6003 P.O. Box 997330
San Francisco, CA 94105 Sacramento, CA 95899-7330
deltadentalins.com
This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or
Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your
plan, please consult your company’s benefits representative.
HLT_PPO_INCEN_DDC (Rev. 10/22/2014)
 County of Stanislaus
Plan Benefit Highlights for:
(Buy-Up Plan, Actives)
Group No: 03351 - 00003 Effective Date: 1/1/2015
In this incentive plan, Delta Dental pays 70% of the PPO contract allowance for covered diagnostic, preventive
and basic services and 70% of the PPO contract allowance for major services during the first year of eligibility.
The coinsurance percentage will increase by 10% each year (to a maximum of 100%) for each enrollee if that
person visits the dentist at least once during the year. If an enrollee does not use the plan during the calendar
year, the percentage will be reduced by 10% (the percentage will never drop below 70%). If an enrollee
becomes ineligible for benefits and later regains eligibility, the percentage will drop back to 70%.
This plan has a 3 year minimum enrollment requirement.

Eligibility Primary enrollee, spouse (includes domestic partner) and eligible dependent
children to the end of the month dependent turns age 26

Deductibles PPO Dentists: None

Non-PPO Dentists: $10 per person each calendar year
Deductibles waived for Diagnostic PPO Dentists; N/A
& Preventive (D & P)? Non-PPO Dentists: Yes
Maximums $2,000 per person each calendar year
Basic Services Major Services Prosthodontics Orthodontics
Waiting Period(s) None None None
None

Benefits and Delta Dental PPO dentists** Non-PPO dentists**

Covered Services* In-PPO Network Out-of-PPO Network

Diagnostic & Preventive

Services (D & P) 70-100 % 70-100 %
Exams, cleanings and x-rays
Basic Services
Fillings, simple tooth extractions and 70-100 % 70-100 %
sealants
Endodontics (root canals) 70-100 % 70-100 %
Covered Under Basic Services
Periodontics (gum treatment) 70-100 % 70-100 %
Covered Under Basic Services
Oral Surgery 70-100 % 70-100 %
Covered Under Basic Services
Major Services
Crowns, inlays, onlays and cast 70-100 % 70-100 %
restorations
Prosthodontics 50 % 50 %
Bridges, dentures and implants
Orthodontic Benefits 50 % 50 %
Dependent children
Orthodontic Maximums $ 2,000 Lifetime $ 2,000 Lifetime
(Not included in the calendar year maximum) (Not included in the calendar year maximum)

Dental Accident Benefits 100 %

(Included in the calendar year maximum)
* Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.
Reimbursement is based on Delta Dental contract allowances and not necessarily each dentist’s actual fees.
** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier
dentists and program allowance for non-Delta Dental dentists.
Delta Dental of California Customer Service Claims Address
100 First St. 800-765-6003 P.O. Box 997330
San Francisco, CA 94105 Sacramento, CA 95899-7330
deltadentalins.com
This benefit information is not intended or designed to replace or serve as the plan’s Evidence of Coverage or
Summary Plan Description. If you have specific questions regarding the benefits, limitations or exclusions for your
plan, please consult your company’s benefits representative.
HLT_PPO_INCEN_DDC (Rev. 10/16/2014)
 Benefit Description Copay
Your Coverage with a VSP Provider
• Focuses on your eyes and overall
WellVision $10 for exam
wellness
Exam and glasses
• Every 12 months

Your Vision Benefits Summary Prescription Glasses

Get the best in eyecare and eyewear with • $150 allowance for a wide selection of
frames
COUNTY OF STANISLAUS and VSP® Vision • $170 allowance for featured frame
Care. Frame
brands (see 'Extra Savings' below) Combined
• 20% savings on the amount over your with exam
allowance
Using your VSP
VSP benefit
benefit is
is easy.
easy. • $80 allowance at Costco® Optical
• Every 24 months
• Register at vsp.com.
Once your plan is effective, review your benefit information. • Single vision, lined bifocal, and lined
trifocal lenses Combined
• Find an eyecare provider who’s right for you. Lenses • Polycarbonate lenses for dependent with exam
The decision is yours to make—choose a VSP doctor, a children
• Every 12 months
participating retail chain, or any out-of-network provider.
To find a VSP provider, visit vsp.com or call 800.877.7195. • Standard progressive lenses $55
• Premium progressive lenses $95 - $105
• At your appointment, tell them you have VSP. There’s Lens • Custom progressive lenses $150 - $175
no ID card necessary. If you’d like a card as a reference, Enhancements • Average savings of 20-25% on other lens
enhancements
you can print one on vsp.com.
• Every 12 months
That’s it! We’ll handle the rest—there are no claim forms
to complete when you see a VSP provider. • $150 allowance for contacts; copay
Contacts does not apply
(instead of • Contact lens exam (fitting and Up to $60
glasses) evaluation)
Choice in Eyewear • Every 12 months
From classic styles to the latest designer frames, you'll find
hundreds of options. Choose from featured frame brands like Additional
• Diabetic Eyecare Plus Program
Coverage
Anne Klein, bebe®, Calvin Klein, Flexon®, Lacoste, Nike, Nine
West, and more1. Visit vsp.com to find a VSP provider who Glasses and Sunglasses
carries these brands. • Extra $20 to spend on featured frame brands. Go to
vsp.com/specialoffers for details.
Plan Information • 20% savings on additional glasses and sunglasses,
including lens enhancements, from any VSP provider
VSP Provider Network: VSP Choice within 12 months of your last WellVision Exam.
Extra
Diabetic Eyecare Plus: $20 Copay Retinal Screening
Savings
• No more than a $39 copay on routine retinal screening
as an enhancement to a WellVision Exam
Automatically get an extra $20 to spend when you choose
Laser Vision Correction
a featured frame brand like Anne Klein, bebe®, Calvin
• Average 15% off the regular price or 5% off the
Klein, Flexon®, Lacoste, Nike, Nine West, and more. Visit promotional price; discounts only available from
vsp.com/specialoffers for details. contracted facilities

Your Coverage with Out-of-Network Providers

Visit vsp.com for details, if you plan to see a provider other than a
VSP network provider
Exam...............................................up to $45 Lined Trifocal Lenses............up to $65
Frame.............................................up to $70 Progressive Lenses................up to $50
Single Vision Lenses.............up to $30 Contacts.......................................up to $105
Lined Bifocal Lenses.............up to $50

Coverage with a participating retail chain may be different. Once your benefit is
effective, visit vsp.com for details.
Coverage information is subject to change. In the event of a conflict between this information and
your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable
laws, benefits may vary by location.

Visit vsp.com or call 800.877.7195

for more details on your vision 1
Brands/Promotion subject to change.
coverage and exclusive savings ©2014 Vision Service Plan. All rights reserved.
VSP, VSP Vision care for life, and WellVision Exam are registered trademarks
and promotions for VSP members. of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc.
All other brands are trademarks or registered trademarks of their respective owners.
BASIC AND SUPPLEMENTAL LIFE INSURANCE INFORMATION

VOYA / RELIASTAR EMPLOYEE LIFE BASIC TERM INSURANCE

Regular full-time employees as defined by their job description in a position that includes
life insurance benefits, are automatically enrolled in Basic Life Insurance coverage. This
coverage will take effect the first day of the month following their date of hire or event.
The amount of Basic Life Insurance provided depends on the employee's classification:

• Regular/Confidential $10,000 Basic

• Management/Dept Head $30,000 Basic + $30,000 AD&D
• Attorney $50,000 Basic + $50,000 AD&D

VOYA / RELIASTAR SUPPLEMENTAL LIFE AND AD&D INSURANCE

The County provides voluntary employee, spousal and child Supplemental Life Insurance
coverage in addition to what is provided by the employee Basic Life plan. The coverage
options and premiums are listed on the County Benefit Enrollment form and in the
Benefit Guide. Coverage will take effect the first day of the month following date of hire
or underwriting approval date.

• Employees may elect to enroll in additional Supplemental Life Insurance for the
employee, spouse and/or children as a new hire or make changes during the
annual Open Enrollment period only. Once enrolled, there will be a semi-
monthly after-tax paycheck deduction that includes the premium and
administration fee. Note: In order to enroll in the spousal or child
supplemental life plans, the employee must be enrolled in an employee
supplemental life plan for at least the same coverage or greater.

• If a new employee elects employee Supplemental Life Insurance in excess of

$100,000, they must complete an Evidence of Insurability Form and fax directly
to ReliaStar. The employee will be enrolled in $100,000 and charged the
applicable premium until approved by underwriting. At that time the employee
will be enrolled in the additional amount in excess of $100,000 and the new
applicable premium will be charged.

• Any new or increase in coverage of any Supplemental Life Insurance policies

during the annual Open Enrollment require completion of an Evidence of
Insurability Form and the form must be faxed to ReliaStar by the employee. The
employee will not be enrolled until approved by underwriting. At that time the
employee will be enrolled in the new approved amount of coverage and the
applicable premium and admin fee will be charged.

• If an employee allows their Supplemental Life insurance to lapse for 30 days or

more due to an unpaid leave of absence or reduction in hours, the employee will
need to re-apply and be approved by ReliaStar underwriting.

1/15
GENERAL INFORMATION

• Every regular full-time employee must designate a Primary Beneficiary for their
Basic and Supplemental Life Insurance by completing the applicable area on the
County Benefit Enrollment Form.

• There is also a space to designate a Contingent Beneficiary. This type of

beneficiary is a back up to the Primary.

• If a minor child is designated as a beneficiary and the employee passes away, the
Life Insurance proceeds will be put into a transition account until the child
reaches the age of 18.

• If employees need to make changes to their beneficiary after the initial

enrollment, log in to PeopleSoft Self Service and make the change at any time.
Please refer to the Self Service instructions under Tab 20. If there is no
PeopleSoft access available, complete the County Benefit Enrollment Form and
send electronically to Employee Benefits via fax 567-4367.

• The employee is the beneficiary for the spouse and child supplemental life
policies.

• The Life Insurance Policy is located in this manual as well as the Employee
Benefits website.

1/15
   
     
       
        
   
Use this form to apply for insurance coverage in addition to coverage you may already have through this plan.
Group Number  Account Number  Employer Name   
Location I
Structure    Option 2 II
Structure Option 3 III
Structure Option 4 IV
Structure
A. EMPLOYEE INFORMATION
Employee Name Gender: Male Female
SSN Personal Email Address Birth Date
Address City State ZIP
Home Phone ( ) Cell Phone ( )
Hire Date Salary $ Occupation
Primary Health Practitioner Practitioner Phone ( )
Practitioner Address City State ZIP

B. INSURANCE DETAILS (Complete this table based only on the coverage you have through this plan.)
Are you completing this form due to a Family Status Change (Marriage, Divorce, Birth, Adoption, etc.)? Yes No
(A) (B) (C) (A) – (B) – (C) = Amount
Coverage Type Total Amount Desired Current Amount Guaranteed Issue Amount To Be Underwritten

Employee Supplemental Life $ $ $ $

Spouse Supplemental Life $ $ $ $

Children Supplemental Life (per child) $ $ $ $

C. SPOUSE INFORMATION
Spouse Name Gender: Male Female
SSN Personal Email Address Birth Date
Home Phone ( ) Cell Phone ( )
Same Primary Health Practitioner as Employee (See information above.)
Primary Health Practitioner Practitioner Phone ( )
Practitioner Address City State ZIP

D. CHILD INFORMATION (Availability of Child coverage is dependent on plan rules and may also be dependent on approved
employee coverage. If more than 3 children, list information on additional sheet.)
Name Birth Date Gender Relationship
Male Female
Male Female
Male Female
Dependent Children Health Questions (Answer these questions only if applying for dependent child(ren) coverage.)
1. Within the past 5 years, have any dependent children been treated for or diagnosed with a mental or nervous disorder (excluding
ADHD), diabetes, heart disorder, cancer, asthma (requiring hospitalization within the last 2 years), or chemical abuse? . . . . . . . . Yes No
2. Do any dependent children have cerebral palsy, cystic fibrosis, muscular dystrophy, developmental disorder (including Autism and
Down’s Syndrome)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
For each “Yes” answer, provide name(s) of child(ren) and details.


             
Employee Name SSN (Last 4 digits only.)

E. EMPLOYEE AND SPOUSE HEALTH QUESTIONS (Must be answered for coverage that is not Guaranteed Issue.)
Employee (EE) Spouse (SP)
Yes No Yes No
1. Within the last 5 years have you been treated for or been diagnosed by a member of the medical profession or health

2. Within the last 5 years have you been treated for, any of the following: insulin dependent diabetes, heart attack,
coronary bypass/angioplasty, heart valve repair/replacement, stroke, metastatic cancer, emphysema or been an organ
transplant recipient?
---
Complete for EE and SP. > 3. Employee: Height ft. in. Weight lbs. Spouse: Height ft. in. Weight lbs.
4. In the past 5 years have you been diagnosed or treated by a health practitioner, or taken medication for any of the following:
a. Any disease or abnormality of the heart or blood vessels (excluding controlled high blood pressure), or any heart
rhythm abnormality?
b. Any disease of the lung (excluding asthma), liver (excluding hepatitis A), pancreas or intestine?
c. Non-insulin dependent diabetes, impaired glucose tolerance, or pre-diabetes?
d. Cancer or tumor, rheumatoid arthritis, connective tissue disease, neurological disease (excluding headaches),
autoimmune disease or any disease of the blood cells or serum including, but not limited to, anemia, polycythemia, or
bleeding or clotting disorder?
e. Depression, psychosis, suicide attempt, drug or alcohol abuse or addiction?
f. Polycystic kidney disease or kidney failure?
5. Within the last 5 years have you been diagnosed or treated by a physician or other health practitioner for:
a. Chest pain, heart trouble or circulatory condition?
b. Anemia or leukemia?
c. Sleep apnea, asthma or other respiratory disease?
d. Colitis, Crohn’s disease, ulcerative colitis or any other intestinal disease?
e. Stomach disease?
f. Brain or seizure disorder?
g. Mental or nervous disorder?
h. Arthritis, paralysis or any muscle weakness impacting your ability to perform daily activities?
i. Abnormal urine specimen or urinary tract disorder?
j. Prostate or other reproductive organ disorder?
6. Are you pregnant? Due Date Pre-pregnancy weight lbs
7. Are you currently taking any medication prescribed or provided by a physician or other health practitioner for any
disorder, condition, or disease not shown above?
8. Within the last 5 years have you received medical treatment or counseling for the use of alcohol or prescribed or non-
prescribed drugs, or been advised by a health practitioner to discontinue the use of such substances?

For every “Yes” answer, to any question in the previous section, give details below. Please attach a separate sheet if additional space is needed.
Recovered?
Applicant
Question
Number

Date Health Practitioner Name, Full

Fully

Condition Description of Address (Street, City, State, ZIP),

Description of Condition Began Treatment Received Phone
EE Yes
SP No
EE Yes
SP No
EE Yes
SP No
EE Yes
SP No


             
Employee Name SSN (Last 4 digits only.)

F. AUTHORIZATION AND ACKNOWLEDGMENT (Please read and sign below)

For underwriting and claim purposes, I give my permission to any physician or other medical practitioner, hospital, clinic, rehabilitation facility, insurance
or reinsuring company, MIB, Inc. (MIB), any consumer reporting agency to give ReliaStar Life Insurance Company (ReliaStar Life) or its authorized
representative (including any consumer reporting agency) acting on its behalf ALL INFORMATION on my behalf (except as limited below). This includes but
may not be limited to: (a) findings on medical care, psychiatric or psychological care or examination, or surgery, as they apply to me; and (b) any non-medical
information as it applies to me. I give my permission to ReliaStar Life to obtain consumer or investigative consumer reports about me.
I give my permission to ReliaStar Life and other insurance companies affiliated with ReliaStar Life to obtain any and all medical record information for
the purposes described in this form. I know that my medical records, including any alcohol or drug abuse information, may be protected by Federal
Regulations–42 CFR Part 2. I may revoke this permission as it applies to any information protected by 42 CFR Part 2 at any time, but not to the extent
action has been taken in reliance on it. I specifically consent to the re-disclosure of medical record information as set forth in this form. In connection with
any application for life insurance, or other insurance transaction that I may have with ReliaStar Life or any of its affiliated companies, I understand that I may
request that this information not be communicated to companies affiliated with ReliaStar Life.
I authorize ReliaStar Life, or its reinsurers, to disclose personal health information about me to MIB, Inc. in the form of a brief coded report for participation
in MIB’s fraud prevention and detection programs.
I understand that my further written consent will be required before any information described above is given, sold, transferred, or, in any way, relayed to
another party not before specified. My further consent must be provided on a form that states the new use of the information or why another party needs it.
I know that I have a right to receive a copy of this form. I certify that I have, will print, or will otherwise have access to a copy of all pages of this Evidence
Form to keep for my records. A photocopy of this form will be as valid as the original. This form will be valid for 24 months from the latest date shown below.
I acknowledge that I have been given ReliaStar Life’s: Consumer Privacy Notice and Insurance Information Practices Notice.

IMPORTANT! Please carefully read the next section. Then sign and date below.
I declare that all of the statements and answers, as they pertain to me and to my child(ren), if applicable, on all pages of this Evidence Form are complete
and true to the best of my knowledge and belief.
I realize that any misrepresentation or omission regarding the presence of any pre-existing impairments and/or diseases may result in the
requested coverage or benefits provided by such coverage being contested. I understand that any claim incurred prior to the approval of this
Evidence Form by ReliaStar Life Insurance Company’s Home Office will not be valid.

Employee Signature Date

Spouse Signature Date

Submit your EOI form directly to the insurer for fast and confidential handling via one of
the methods below:

Fax to: 1-612-467-8721

Or

Mail to: ReliaStar Life Insurance Company, PO Box 20, Mail Stop 4-S, Minneapolis, MN 55440


             
   
   
     
        
      

                      
                          
       
  
                         
                          
            
   
 
             
              
                           
                            
                  
           
           
   
                        
                         
                       
                       
                     
                          
                     
                             
                        
                            
                         
                          
                           
 
                
   
                         
                   
                             
                    
  
                            
                  
                               
                            
                      
   
                           
                       
                            
                             
                           
                      
                   
       
 

 


  

  

   

 

                                               

                                              

                                            

                                            

                                                  
                                
                                          
                            
                                          
                     

                                              

                                              

                                             

                                                   

             
               
   
  
  
   
          
           
            
          
   
  
     
   
    
   

 



    
  
              
                
                 
              


   

                    
    
                  
                
                
                
        
                
                
              





   

        

    
    
   

     



   

     

       

  

               
           
       
  
    
    
 
   
   
   
   
   
   
   
   

            
  
                  
               
       
        

    
    
   
   
   

   

               
                
     


   

   

                
                  
               
                  
          

     

   
            
      
 

     

        
       

               
       

              
 

     

              
            
 
             
        
  
              
 

         
                 
                
        
                 
               
           
                
         
               
                  
                
               

                


  


                   
     
          
     
    
              
                  

    
         
     
                    
                
        
                
              

       

                 
               
                   

                  
      
                   
          
                
  
         
                 
        
                 
         
                 
                 
                  
     
             
                
              
   
      
             
  
                   
  
          
                
         
                 
   


  

      

                 
               
                 
     
  
                
                
 
                 
           
           


              
            
                
       
                
     
              
        
            
        

                  
     
                
               
       
             
            
               
        

                 
                   
 


  

           
          
          
       

            
          
         

             
       
                  
               
                 
  
                
                
             
             
  
                
   
    
          
        
                   
                 
        
               

                 

                 
              
            
                  
       
       
                  
    
                  
                   
                   
    
               

                
                   
    
  
          
           
      
                 
         
     


  

    

           
                  
                
      
              
        
      
                 
                   

  
             
                   
                 

   
                
          
  
              
              
          
               

            
           

                 
               
                 
                  
                
       
           
           
        
               
                    
    
            

              


              
             
        
              
              
              
     


  

  

                 
                  
            
               
                 
               
      

                  
           
               
                 

                 
     
         
                 
  
                    
                

  
                
              
        
         
      

                   
 
     
     
  
  
           
 
              
                  
              

      
               
               
                
                 
   
             
              
            


  

      

                 
      
        
                 
 
      
                 
           

               
 
    
      
            
                   
       
               
                  
                 
                
              
                 
   
    
           
        
              
      

                  
   
           
          
     

                  
         
               
  
                  
               
                 
            
           

         

        
        
               
         


  

  

               
         
      
                
                
                
                   
        
               
                  
               
             
               
                  
       
         
               
                
                 
                 
        
              
    
 
                
                 
      
                   

                
     
       
       
              

   

               
              
              
    
  
              
               
            
                

               
      
                 
    
                 
              
     
                 
  


  

                     
 
             
        
              
             
             
               

     
                   
    
            
           
        

                  
                 
                    
          

   

     

             
         
          
              
               
      
         
            
   
    
    
                 
                 
                 
   
              
                
                   
                
       
                    
             
   
      
            
       

      

                  
    
                  



  

                 
                 
                
                 
           
              
   
                  
       
  
                 
    
       
            

                   
       

     

           
  
     
            
  
     
              
              
               
         
                   
               

       
 
                  
                 
 

      

       

  
      
     
                 
         
               
                


  

 
                
                    
               
                
               
           
               
  

   

       

  
      
      
              
 
                  
          

   

       

  
     
      
  
                   
                   
                  
                 
   
                 
               

   

        

  
      
      
                  
  
  
                 
          
     
             
             


  

   

        

    
    
     
            
  
                
      
                  

                
    
                
      

      

        

  
    
     
            
  
                 
             
     
           
         
                  
    
                  
          

      

        

  
      
                  
         
                 
             
              
                 

   
                    
                 
      
                 
     


  

   

         

  
    
     
    
                
         
    
               

             
              
            
            
             
            
               
              
  
                
                
   
                
                 
                

                
 
                  
 
               
        

                   
 
       
  
      
                 
        
              
        
        

                
                 
                   
                 

   

     

             
         


  

          

              
               
      
         
            
   
    
    
                 
                 
                 
   
              
                
                   
                
       
                    
             
   
      
              
       

      

                
       
               
        
                 
                
  
                
                 
           
           
                
          
  
                 
      
       
            

                  
           
               
            


  

     

           
   
     
            
   
     
              
              
              
            
                   
             
    
 
                  
                
               
                 


      

       

   
      
     
              
              
         
 
                
                
                
                
               
                
    
           
              
       
              
                  
 

   

       

   
      
      
              


  

 
               
                 
               
          

   

       

   
     
         
  
               
              
     
             
             

   

        

     
    
     
          
  
                 
               

      

       

     
       
      
              

       
    
                
         
    
               

             
              
            
              
           
                
 
               
              
 


  

 
                
                
   
  
                 

               
               
    
               
  
                 
         
     
       
               
      
      
     
         
            
          
        
            
  
                
                
                  
                  
                 
                
                 
                
                
                 
 
   
       
       
   
             
                
               
            
             



  

   

                
                  
                
  
                 
                
      
                
                 
        
 
                 
  
               
                
               
               
            

                  



  

  
                
           
               
 
          
                    

 
                
     
                 
                


  

  

                
               
                 
               
 
        
        
      
                

     
               
                
 
                   
                 
      
               

  
             
                
                 
  

               
                 
              
              
             


 

        

                 
                
      
 
     
            
                  
                
     
 
   
     
       

      

           
              
          
          
                  
   
              
                

                
              
                  
            
             
           
            
         
     
             
                 
  
 
  
   
     

           
    
  
          
 

              
           
             
      


 

                 
                
      
                
               
                
 
            


   
 HEALTH INSURANCE PREMIUM PAYMENT
PROCEDURES FOR UNPAID ABSENCES
UNPAID LOA/SUSPENSION/FMLA-

Employees are responsible for the full month’s payment of their health insurance premiums, on
the first day of the month following the qualifying event date. These are examples of a
qualifying event:

♦ Unpaid Leave of Absence (Personal, Administrative, etc) and does not receive a paycheck.

♦ Any type of covered leave time exhausts (FMLA, PDL, CFRA) and does not receive a
paycheck.

♦ Any time in which an employee continuously works a reduced schedule (less than 30 hrs per
week). Note: The first day of the reduced schedule is the qualifying event.

PREMIUM PAYMENT PROCEDURES-

♦ Employees are responsible for the total of all Health Insurance premiums effective the first of
the month following the unpaid absence or approved FMLA expiration date. Whichever date
is later. If the employee is covered under FMLA or on a work Suspension and they do not
receive a paycheck, the County portion of benefit premiums is paid. If the County pays for
it’s portion of benefits at anytime, the employee must pay all out of pocket share of cost*
premiums for that paycheck. Note: If the employee is covered by a protected leave, benefits
are only paid on their behalf if the out of pocket share of cost has been paid.

If the unpaid LOA begins and ends within the same calendar month, and a paycheck is
missed, the employee is responsible for any out of pocket share of cost only.

♦ The County does not prorate coverage for a month. Payments for Health Insurance
premiums are due the first of the month. While the employee is on an unpaid absence and
fails to make payments in a timely manner, their benefits will be canceled at the end of the
month. (Refer to Effective Dates of Coverage Tab 2) Re-instatement of benefits will occur
the first of the month following the return to full time status date. However, if an employee
allows their Supplemental Life insurance to lapse for 30 days or more, the employee will
need to re-apply to ReliaStar underwriting by completing an Evidence of Insurability form.

♦ If you are enrolled in a Flexible Spending Account, you are responsible for the admin fee
while on unpaid absence. If you fail to pay the admin fee while you are out, your paycheck
will be adjusted accordingly when you return to paid status. There will also be an adjustment
to your semi-monthly contribution to the FSA account in order to meet your Annual Pledge.

*Out of pocket share of cost pertains to the employee’s portion of the premiums for Medical, Supplemental Life
Insurance or FSA Fee.

Cash is not accepted. Check or money order only, made payable to: Stanislaus County Risk Mgmt
and mailed to: CEO-Risk Management Division 1010 10th Street, Suite 5900, Modesto, Ca 95354.
Revised 01/04/13
 EMPLOYEE BENEFITS
TERMINATION OF HEALTH INSURANCE

TERMINATIONS-

 Health Insurance benefits will terminate on the last day of the month following the event of
termination (retirement, unpaid absence or FMLA exhausting). Note: employee’s last day
worked must be in the month of coverage.

Ex: Last day worked is April 1st, date of termination is April 2nd, therefore coverage ends
April 30th. Or, last day worked March 31st, termination is April 1st, therefore coverage
ends April 1st.

 When terminating employment, the County offers employees and their families covered by
health insurance, the opportunity to elect a continuation of coverage called COBRA.

 Federal COBRA law provides terminated/retired employees 18 months of continuation

coverage at 102% of the County paid premium.
 Federal COBRA law provides 36 months of continuation coverage at 102% of the
County paid premium for dependents that lose coverage under an active employees plan.
 Until COBRA is elected and the first payment is received by Employee Benefits, all
insurance options will be canceled. When payment is received, elected options are
reinstated retroactive to the date of termination of active coverage.
 If a terminated/retired employee is interested in receiving Life Insurance conversion or
continuation information, contact Employee Benefits within 30 days of termination.

For more information regarding continuation coverage, please refer to the following
COBRA Rights Notice.

LEAVE OF ABSENCE-

 If your health insurance was canceled due to non-payment of premiums while on an unpaid
absence, County paid benefits will resume the first of the month following your return to full-
time employment. There is also a possibility of an adjustment of premiums on your paycheck
when you return.

 If you are enrolled in a Flexible Spending Account, you are responsible for the admin fee
while on unpaid leave. If you fail to pay the admin fee while you are on leave, your
paycheck will be adjusted accordingly when you return to paid status. There will also be an
adjustment to your semi-monthly contribution to the FSA account in order to meet your
Annual Pledge.

01/04/11
 CHIEF EXECUTIVE OFFICE
Risk Management Division
Employee Benefits
1010 10TH Street, Suite 5900, Modesto, CA 95354
Phone: 209.525.5717 Fax: 209.567.4367

Important Health Benefit Continuation Information

1. If your, or your dependent’s, County health benefit coverage has ended due to:
a. Termination
b. Retirement
c. Reduction in hours
d. Loss of eligibility

• Federal COBRA law provides 18 months of continuation coverage at 102% of the County paid
premium.
• For dependents that lose coverage under an active employees plan, the law provides 36 months
of COBRA coverage.

2. Please review your options below:

• Employees and/or dependents not covered by any other health plan:

o COBRA- Option to continue with current County Medical, Dental and/or Vision coverage.
Must pay monthly premiums by check or money order to County Risk Management.

o Health Insurance Marketplace- Health insurance options, that may cost less than COBRA,
are available through the Marketplace. Contact Alliant 800-444-1188 for assistance with
your options or visit www.healthcare.gov.

o County Early Retiree Medical- Medical insurance options available for early retirees (pre-65
or non-Medicare), through County Risk Management, after COBRA expires. Members may
be able to have monthly premium deducted from StanCERA retirement check or pay
monthly premium to County Risk Management.

o RESCO- Dental and Vision insurance options are available for retirees after COBRA expires.
Contact RESCO’s benefits administrator, PGA at (800) 511-9065.

• Retired employees and their dependents age 65+ or on Medicare, are not eligible for COBRA
medical coverage or County Early Retiree medical coverage. RESCO offers Medicare plan
supplements as well as Dental and Vision insurance. Contact RESCO’s benefits administrator,
PGA, for your options (800) 511-9065.

3. If you are continuing enrollment in Stanislaus County’s medical coverage, you must stay with the
same medical plan for the remainder of the current plan year. Medical plan changes are only allowed
during the annual open enrollment period, which take effect January 1 of the new plan year.

4. Complete the Stanislaus County COBRA or Early Retiree Enrollment Form and return to Employee
Benefits. Pre-printed COBRA Enrollment Form will not be available until after last day of employment.
Coverage will be reinstated retroactively if necessary, but not until full payment is received.
5. Make checks payable to: Stanislaus County Risk Management, 1010 10th Street, Suite 5900, Modesto,
CA 95354. The County does not offer ACH or automatic deduction. We recommend you speak with
your banking institution to see if they can set your payment up on automatic bill pay. We do not
accept cash. Monthly premiums may be paid in advance, but no more than one month prior to due
date.

6. Monthly premiums are due on the 1st day of each month. Stanislaus County does allow a 30 day grace
period. However, benefit eligibility for participants who do not pay their insurance premiums by the
first day of each month, will be placed on a coverage hold until payment is received or the expiration
of the 30-day grace period, whichever is earlier. If payments are not received in our office by the 30th
day, your coverage will be permanently terminated.

7. If you were enrolled in the County’s voluntary supplemental life insurance while employed, you may
convert to an individual policy directly with ReliaStar ING. Your life insurance conversion form and
proof of enrollment are enclosed. You have 30 days to enroll.

8. If you were enrolled in Humana’s voluntary Whole Life insurance or Critical Illness coverage while
employed with the County, you may convert to an individual policy with Humana. Please contact
Humana at (877) 378-1505 to convert your policy within 30 days.

Please review the following pages, Important Information About Your COBRA Continuation Rights, and
consider your options carefully before you make your decision to elect continuation coverage.

Go to our website at the link below to review detailed information regarding your health plan options:
http://www.stancounty.com/riskmgmt/risk-eb-home-main.shtm.

If you have additional questions, please call Employee Benefits at (209) 525-5717 or email us at
[email protected].

Revised 1/14
 Important Information
About Your COBRA Continuation Coverage Rights

This notice contains important information about your right to continue your health care coverage in the Stanislaus
County group health plan (the Plan), as well as other health coverage options that may be available to you,
including coverage through the Health Insurance Marketplace. You may be able to get coverage through the
Health Insurance Marketplace that costs less than COBRA continuation coverage. Please read the information
contained in this notice very carefully before you make your decision.

What is COBRA continuation coverage?

Federal law requires that most group health plans (including this Plan) give employees and their families the
opportunity to continue their health care coverage when there is a “qualifying event” that would result in a loss of
coverage under an employer’s plan. Depending on the type of qualifying event, “qualified beneficiaries” can
include the employee (or retired employee) covered under the group health plan, the covered employee’s spouse,
and the dependent children of the covered employee.

COBRA continuation coverage is the same coverage that the Plan gives to other participants or beneficiaries under
the Plan who are not receiving continuation coverage. Each qualified beneficiary who elects continuation coverage
will have the same rights under the Plan as other participants or beneficiaries covered under the Plan, including
open enrollment and special enrollment rights.

Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other more affordable coverage options
for you and your family through the Health Insurance Marketplace or other group health plan coverage options
(such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less
than COBRA continuation coverage.

When you lose job-based health coverage, it’s important that you choose carefully between COBRA continuation
coverage and other coverage options, because once you’ve made your choice, it can be difficult or impossible to
switch to another coverage option.

What is the Health Insurance Marketplace?

The Marketplace offers “one-stop shopping” to find and compare private health insurance options. In the
Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums and cost-sharing
reductions (amounts that lower your out-of-pocket costs for deductibles, coinsurance, and copayments) right
away, and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a
decision to enroll. You can access the Marketplace for your state at www.HealthCare.gov or to compare your
options, contact Alliant at 800-444-1188.

Coverage through the Health Insurance Marketplace may cost less than COBRA continuation coverage. Being
offered COBRA continuation coverage won’t limit your eligibility for coverage or for a tax credit through the
Marketplace.
When can I enroll in Marketplace coverage?

You always have 60 days from the time you lose your job-based coverage to enroll in the Marketplace. That is
because losing your job-based health coverage is a “special enrollment” event. After 60 days your special
enrollment period will end and you may not be able to enroll, so you should take action right away. In addition,
during an “open enrollment” period, anyone can enroll in Marketplace coverage.

To find out more about enrolling in the Marketplace, such as when the next open enrollment period will be and
what you need to know about qualifying events and special enrollment periods, visit www.HealthCare.gov.

If I sign up for COBRA continuation coverage, can I switch to coverage in the Marketplace? What if I
choose Marketplace coverage and want to switch back to COBRA continuation coverage?

If you sign up for COBRA continuation coverage, you can switch to a Marketplace plan during a Marketplace open
enrollment period. You can also terminate your COBRA continuation coverage early and switch to a Marketplace
plan if you have another qualifying event such as marriage or birth of a child through something called a “special
enrollment period.” But be careful - if you terminate your COBRA continuation coverage early without another
qualifying event, you’ll have to wait to enroll in Marketplace coverage until the next open enrollment period, and
could end up without any health coverage in the interim.

Once you’ve exhausted your COBRA continuation coverage and the coverage expires, you’ll be eligible to enroll in
Marketplace coverage through a special enrollment period, even if Marketplace open enrollment has ended.

If you sign up for Marketplace coverage instead of COBRA continuation coverage, you cannot switch to COBRA
continuation coverage under any circumstances.

How long will continuation coverage last?

In the case of a loss of coverage due to end of employment or reduction in hours of employment, coverage
generally may be continued for up to a total of 18 months. In the case of losses of coverage due to an employee’s
death, divorce or legal separation, the employee’s becoming entitled to Medicare benefits or a dependent child
ceasing to be a dependent under the terms of the plan, coverage may be continued for up to a total of 36 months.
When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the
employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA
continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of
Medicare entitlement. This notice shows the maximum period of continuation coverage available to the qualified
beneficiaries.

Continuation coverage will be terminated before the end of the maximum period if:

• any required premium is not paid in full on time,

• a qualified beneficiary becomes covered, after electing continuation coverage, under another group health
plan that does not impose any pre-existing condition exclusion for a pre-existing condition of the qualified
beneficiary (note: there are limitations on plans’ imposing a preexisting condition exclusion and such
exclusions will become prohibited beginning in 2014 under the Affordable Care Act),
• a qualified beneficiary becomes entitled to Medicare benefits (under Part A, Part B, or both) after electing
continuation coverage, or
• the employer ceases to provide any group health plan for its employees.

Continuation coverage may also be terminated for any reason the Plan would terminate coverage, for a participant
or beneficiary not receiving continuation coverage (such as fraud).
How can you extend the length of COBRA continuation coverage?

If you elect continuation coverage, an extension of the maximum period of coverage may be available if a qualified
beneficiary is disabled or a second qualifying event occurs. You must notify the Plan Administrator of a disability or
a second qualifying event in order to extend the period of continuation coverage. Failure to provide notice and
proof of a disability or second qualifying event may affect the right to extend the period of continuation coverage.

Disability

An 11-month extension of coverage may be available if any of the qualified beneficiaries is determined by the
Social Security Administration (SSA) to be disabled. The disability has to have started at some time before the 60th
day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation
coverage. Each qualified beneficiary who has elected continuation coverage will be entitled to the 11-month
disability extension if one of them qualifies. If the qualified beneficiary is determined by SSA to no longer be
disabled, you must notify the Plan of that fact within 30 days after SSA’s determination.

Second Qualifying Event

An 18-month extension of coverage will be available to spouses and dependent children who elect continuation
coverage if a second qualifying event occurs during the first 18 months of continuation coverage. The maximum
amount of continuation coverage available when a second qualifying event occurs is 36 months. Such second
qualifying events may include the death of a covered employee, divorce or separation from the covered employee,
the covered employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both), or a dependent
child’s ceasing to be eligible for coverage as a dependent under the Plan. These events can be a second qualifying
event only if they would have caused the qualified beneficiary to lose coverage under the Plan if the first qualifying
event had not occurred. You must notify the Plan within 60 days after a second qualifying event occurs if you want
to extend your continuation coverage.

How can you elect continuation coverage?

To elect COBRA continuation coverage, you must complete the COBRA Election Form and submit with payment
according to the directions on the form. Each qualified beneficiary has a separate right to elect continuation
coverage. For example, the employee’s spouse may elect continuation coverage even if the employee does not.
Continuation coverage may be elected for only one, several, or for all dependent children who are qualified
beneficiaries. A parent may elect to continue coverage on behalf of any dependent children. The employee or the
employee's spouse can elect continuation coverage on behalf of all of the qualified beneficiaries.

When and how must payment for COBRA continuation coverage be made?

Each qualified beneficiary is required to pay the entire cost of continuation coverage and may not exceed 102
percent (or, in the case of an extension of continuation coverage due to a disability, 150 percent) of the cost to the
group health plan (including both employer and employee contributions) for coverage of a similarly situated plan
participant or beneficiary who is not receiving continuation coverage. The required payment for each continuation
coverage period for each option is described in this notice. The premium payments for the “initial premium
months” must be paid for you (the employee) and for any spouse or dependent child by the 45th day after electing
continuation coverage. The initial premium months are the months that end on or before the 45th day after the
election of continuation coverage is made.

Once continuation coverage is elected, the right to continue coverage is subject to timely payment of the required
COBRA premiums. Coverage will not be effective for any initial premium month until that month’s premium is paid
within the 45-day period after the election of continuation coverage is made.
Monthly Premium Payments

All other premiums payments for health insurance coverage under COBRA are due on the 1st day of each month of
coverage. Monthly premiums may be paid in advance, but no more than one month prior to the due date.
COBRA regulations allow an additional 30-day grace period to make a payment for insurance coverage before
terminating COBRA eligibility. However, COBRA participants are encouraged to pay monthly insurance premiums
by the 1st day of each month to avoid any delay in claim payments or benefits eligibility. If payment is not received
by the 1st day of the month, COBRA coverage will be placed on hold for non-payment and claims for services
rendered during the 30 day grace period will be denied until such time premiums are received. If premiums are
received after the first of the month, but prior to the end of the grace period, coverage will be fully reinstated
retroactive to the beginning of the month.

For more information

This notice does not fully describe continuation coverage or other rights under the Plan. More information about
continuation coverage and your rights under the Plan is available in your summary plan description or from the
Plan Administrator.

For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and
Accountability Act (HIPAA), the Patient Protection and Affordable Care Act (PPACA) and other laws affecting group
health plans, visit the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) website at
www.dol.gov/ebsa or call their toll-free number at 1-866-444-3272.

Keep Your Plan Informed of Address Changes

In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the
addresses of you or any of your family members. You should also keep a copy, for your records, of any notices you
send to the Plan Administrator.

Plan Administrator

The Employer is the Plan Administrator. All notices, payments and other communications regarding the Plan and
COBRA must be directed to the following:

CEO-Risk Management Division

Employee Benefits
1010 10th Street, Suite 5900
Modesto, CA 95354
209-525-5717
[email protected]

Revised 5/7/2014
 STANISLAUS COUNTY
PERSONNEL MANUAL
REGULAR FULL-TIME/REPRESENTED EMPLOYEES
2015 BENEFIT PACKAGE

TYPE SEMI-MONTHLY PREMIUMS DESCRIPTION SUBJECT TO TAXES

MEDICAL HDHP WITH HSA Employee/dependent HDHP coverage paid Premium

INSURANCE at 95%. Federal/State—No
Employee Only $302.74 Employee/dependent EPO coverage paid at FICA/Medicare—No
Employee+1 $605.48 80%. Retirement Contributable—No
STANISLAUS COUNTY Family $817.41
PARTNERS IN HEALTH Waive
EPO Employee share will be deducted
(SCPH) semimonthly before tax from paycheck. Federal/State—Yes
OR Employee Only $361.99 FICA/Medicare—Yes
ANTHEM BLUECROSS Employee + 1 $723.98
$23.75 semimonthly medical waive credit Retirement Contributable—Yes
Family $977.38
provided with proof of other coverage.
Medical Plan Carrier is based on
employee’s zipcode. Health Savings Account (HSA) is
See Employee Benefit Guide for Employees working a benefitted percentage
funded by the County, $1,200 single
zipcode list. schedule will have a reduced employer
& $2,000 family per year.
contribution toward health insurance
benefits.
30-34 hrs/wk = 75% of the employer
contribution
35-39 hr/wk = 90% of the employer
contribution

DENTAL CORE PLAN Employee/dependent Dental coverage paid Premium

INSURANCE Employee Only $17.21 at 80% of the Core Plan. Federal/State—No
Employee + 1 $34.42 FICA/Medicare—No
Family $58.97 Employees working a benefitted percentage Retirement Contributable—No
DELTA DENTAL schedule will have a reduced contribution
BUYUP PLAN toward health insurance benefits.
Employee Only $23.94
Employee + 1 $47.88
Family $82.03

VISION CHOICE PLAN Employee/dependent Vision coverage paid Premium

INSURANCE Employee Only $4.15 Federal/State—No
Employee + 1 $8.03 at 80%.
FICA/Medicare—No
Family $11.33 Employees working a benefitted percentage Retirement Contributable—No
VSP schedule will have a reduced contribution
toward health insurance benefits.

SUPPLEMENTAL Opt. 1 - $20,000 - $ 2.25 EE and SP This is a voluntary benefit offered to Premium
EMPLOYEE AND SPOUSAL Opt. 2 - $30,000 - $ 3.38 EE and SP employees with two options available for Federal/State—Yes
TERM AD&D LIFE Opt. 3 - $50,000 - $ 5.63 EE Only spouses. All premiums will be deducted FICA/Medicare—Yes
INSURANCE AND CHILD Opt. 4 - $100,000- $11.25 EE Only semimonthly after tax from employees Retirement Contributable—No
TERM LIFE INSURANCE Opt. 5 - $150,000- $16.88 EE Only paycheck.
Opt. 6 - $200,000- $22.50 EE Only
VOYA/RELIASTAR Opt. 7 - $250,000- $28.13 EE Only
Opt. 8 - $300,000- $33.75 EE Only

Opt. 1 - $10,000 - $ 1.25 CH Only

BASIC TERM LIFE Regular Employee Basic Term Life County pays 100% of Basic Term and Basic Premium
INSURANCE $10,000 - $.43 Term AD&D Life insurance premiums. Federal/State—No
Attorneys Basic Term Life and AD&D FICA/Medicare—No
VOYA/RELIASTAR $50,000 - $2.63 Retirement Contributable—No

ACCIDENT AND CRITICAL See Employee Benefit Guide for Rates. These are voluntary benefits offered to Premium
ILLNESS INSURANCE employees and their dependents. All Federal/State—Yes
premiums will be deducted semimonthly FICA/Medicare—Yes
VOYA/RELIASTAR after tax from paycheck. Retirement Contributable—No

Personnel Manual/Other Benefits—Tab 12 Page 1

Revised 1/15
TYPE BIWEEKLY DESCRIPTION SUBJECT TO TAXES

VACATION ACCRUAL 3.08 hours first 2 years. 80 hours—2 weeks annually Taxed when time is used.
Federal/State—Yes
FICA/Medicare—Yes
4.62 hours biweekly beginning 3rd -10th Retirement Contributable—Yes
120 hours—3 weeks annually
year.

6.16 hours biweekly beginning 11th-20th 160 hours—4 weeks annually

year.

200 hours—5 weeks annually

7.70 hours biweekly beginning at 21+
years.

Prorated if work less than 80 hours

base. Maximum depends on Bargaining
Units. MOU provisions apply as
appropriate.

VACATION FLOATS .62—Posted as part of per pay period 16 hours total annually—additional Taxed when time is used. See
vacation accrual. vacation included in biweekly accruals. vacation accrual.
Federal/State—Yes
FICA/Medicare—Yes
Retirement Contributable—Yes

ANNUAL VACATION CASH Cash out per fiscal year contingent upon Federal/State—Yes
OUT ALLOWANCE departmental budget/approval. FICA/Medicare—Yes
Retirement Contributable—Yes

See MOU provisions for cash-out amounts.

TERM VACATION CASH Balance of hours paid at termination. Federal/State—Yes

OUT FICA/Medicare—Yes
Retirement Contributable—No

SICK LEAVE ACCRUAL Prorated if work less than 80 hours 96.20 annually. Taxed when time is used.
base. Federal/State—Yes
FICA/Medicare—Yes
3.7 per pay period. Retirement Contributable—Yes

TERM SICK LEAVE CASH Please check applicable MOU for cash-out Federal/State—Yes
OUT provisions. FICA/Medicare—Yes
Retirement Contributable—No

911 employees, please refer to your MOU.

Personnel Manual/Other Benefits—Tab 12 Page 2

Revised 1/15
 STANISLAUS COUNTY
PERSONNEL MANUAL
CONFIDENTIAL EMPLOYEES
2015 BENEFIT PACKAGE

TYPE SEMI-MONTHLY PREMIUMS DESCRIPTION SUBJECT TO TAXES

MEDICAL HDHP WITH HSA Employee/dependent HDHP coverage paid Premium

INSURANCE at 95%. Federal/State—No
Employee Only $302.74 Employee/dependent EPO coverage paid at FICA/Medicare—No
Employee+1 $605.48 80%. Retirement Contributable—No
STANISLAUS COUNTY Family $817.41
PARTNERS IN HEALTH Waive
EPO Employee share will be deducted
(SCPH) semimonthly before tax from paycheck. Federal/State—Yes
OR Employee Only $361.99 FICA/Medicare—Yes
ANTHEM BLUECROSS Employee + 1 $723.98
$75.00 semimonthly medical waive credit Retirement Contributable—Yes
Family $977.38
provided with proof of other coverage.
Medical Plan Carrier is based on
employee’s zipcode. Health Savings Account (HSA) is
See Employee Benefit Guide for Employees working a benefitted percentage
funded by the County, $1,200 single
zipcode list. schedule will have a reduced employer
& $2,000 family per year.
contribution toward health insurance
benefits.
30-34 hrs/wk = 75% of the employer
contribution
35-39 hr/wk = 90% of the employer
contribution.

DENTAL CORE PLAN Employee/dependent Dental coverage paid Premium

INSURANCE Employee Only $17.21 at 80% of the Core Plan. Federal/State—No
Employee + 1 $34.42 FICA/Medicare—No
Family $58.97 Employees working a benefitted percentage Retirement Contributable—No
DELTA DENTAL schedule will have a reduced contribution
BUYUP PLAN toward health insurance benefits.
Employee Only $23.94
Employee + 1 $47.88
Family $82.03

VISION CHOICE PLAN Employee/dependent Vision coverage paid Premium

INSURANCE Employee Only $4.15 Federal/State—No
Employee + 1 $8.03 at 80%.
FICA/Medicare—No
Family $11.33 Employees working a benefitted percentage Retirement Contributable—No
VSP schedule will have a reduced contribution
toward health insurance benefits.

SUPPLEMENTAL Opt. 1 - $20,000 - $ 2.25 EE and SP This is a voluntary benefit offered to Premium
EMPLOYEE AND SPOUSAL Opt. 2 - $30,000 - $ 3.38 EE and SP employees with two options available for Federal/State—Yes
TERM AD&D LIFE Opt. 3 - $50,000 - $ 5.63 EE Only spouses. All premiums will be deducted FICA/Medicare—Yes
INSURANCE AND CHILD Opt. 4 - $100,000- $11.25 EE Only semimonthly after tax from employees Retirement Contributable—No
TERM LIFE INSURANCE Opt. 5 - $150,000- $16.88 EE Only paycheck.
Opt. 6 - $200,000- $22.50 EE Only
VOYA/RELIASTAR Opt. 7 - $250,000- $28.13 EE Only
Opt. 8 - $300,000- $33.75 EE Only

Opt. 1 - $10,000 - $ 1.25 CH Only

BASIC TERM LIFE Regular Employee Basic Term Life County pays 100% of Basic Term and Basic Premium
INSURANCE $10,000 - $.43 Term AD&D Life insurance premiums. Federal/State—No
Attorneys Basic Term Life and AD&D FICA/Medicare—No
VOYA/RELIASTAR $50,000 - $2.63 Retirement Contributable—No

ACCIDENT AND CRITICAL See Employee Benefit Guide for Rates. These are voluntary benefits offered to Premium
ILLNESS INSURANCE employees and their dependents. All Federal/State—Yes
premiums will be deducted semimonthly FICA/Medicare—Yes
VOYA/RELIASTAR after tax from paycheck. Retirement Contributable—No

Personnel Manual/Other Benefits—Tab 12 Page 3

Revised 1/15
TYPE BIWEEKLY DESCRIPTION SUBJECT TO TAXES

VACATION ACCRUAL 3.08 hours first 2 years. 80 hours—2 weeks annually Taxed when time is used.
Federal/State—Yes
FICA/Medicare—Yes
4.62 hours biweekly beginning 3rd -10th Retirement Contributable—Yes
120 hours—3 weeks annually
year.

6.16 hours biweekly beginning 11th-20th 160 hours—4 weeks annually

year.

200 hours—5 weeks annually

7.70 hours biweekly beginning at 21+
years.
Prorated if work less than 80 hours
base. Maximum depends on Bargaining
Units.

VACATION FLOATS .62—Posted as part of per pay period 16 hours total annually—additional Taxed when time is used. See
vacation accrual. vacation included in biweekly accruals. vacation accrual.
Federal/State—Yes
FICA/Medicare—Yes
Retirement Contributable—Yes

ANNUAL VACATION CASH Cash out per fiscal year contingent upon Federal/State—Yes
OUT ALLOWANCE departmental budget/approval. FICA/Medicare—Yes
Retirement Contributable—Yes
40 hours with 100 hours minimum balance.
60 hours with 200 hours minimum balance.

TERM VACATION CASH Balance of hours paid at termination. Federal/State—Yes

OUT FICA/Medicare—Yes
Retirement Contributable—No

SICK LEAVE ACCRUAL Prorated if work less than 80 hours 96.20 annually. Taxed when time is used.
base. Federal/State—Yes
FICA/Medicare—Yes
3.7 per pay period. Retirement Contributable—Yes

TERM SICK LEAVE CASH 0% = 0-6 years of service. Federal/State—Yes

OUT 25% = 6+ years of service. FICA/Medicare—Yes
50%= Upon retirement (service or Retirement Contributable—No
disability) or death up to 600 hours or
individual maximum set in 11/9/94 and
1/18/95. Employees receive hour for hour
retirement service credit for any sick leave
above 600 hours or their personal maximum
amount.

DEFERRED 1.0% of base wages. County pays 1.0% of employee’s base Federal/State—No
COMPENSATION wages to designated deferred compensation FICA/Medicare—No
plan. Retirement Contributable—Yes

PROFESSIONAL $200 annually. Reimbursement for professional educational Reimbursement can be either:
DEVELOPMENT expenses, licenses and purchase of Taxable
(Currently suspended.) computers and related equipment. Depends Federal/State—Yes
on items purchased for reimbursement. FICA/Medicare—Yes
Contingent upon use of the benefit. This Retirement Contributable—No
benefit is prorated during the first year of
Non-Taxable
employment and upon retirement. Federal/State—No
FICA/Medicare—No
Retirement Contributable—No

Personnel Manual/Other Benefits—Tab 12 Page 4

Revised 1/15
 STANISLAUS COUNTY
PERSONNEL MANUAL
MANAGEMENT EMPLOYEES
2015 BENEFIT PACKAGE

TYPE SEMI-MONTHLY PREMIUMS DESCRIPTION SUBJECT TO TAXES

MEDICAL HDHP WITH HSA Employee/dependent HDHP coverage paid Premium

INSURANCE at 95%. Federal/State—No
Employee Only $302.74 Employee/dependent EPO coverage paid at FICA/Medicare—No
Employee+1 $605.48 80%. Retirement Contributable—No
STANISLAUS COUNTY Family $817.41
PARTNERS IN HEALTH Waive
EPO Employee share will be deducted
(SCPH) semimonthly before tax from paycheck. Federal/State—Yes
OR Employee Only $361.99 FICA/Medicare—Yes
ANTHEM BLUECROSS Employee + 1 $723.98
$75.00 semimonthly medical waive credit Retirement Contributable—Yes
Family $977.38
provided with proof of other coverage.
Medical Plan Carrier is based on
employee’s zipcode. Health Savings Account (HSA) is
See Employee Benefit Guide for Employees working a benefitted percentage
funded by the County, $1,200 single
zipcode list. schedule will have a reduced employer
& $2,000 family per year.
contribution toward health insurance
benefits.
30-34 hrs/wk = 75% of the employer
contribution
35-39 hr/wk = 90% of the employer
contribution.

DENTAL CORE PLAN Employee/dependent Dental coverage paid Premium

INSURANCE Employee Only $17.21 at 80% of the Core Plan. Federal/State—No
Employee + 1 $34.42 FICA/Medicare—No
Family $58.97 Employees working a benefitted percentage Retirement Contributable—No
DELTA DENTAL schedule will have a reduced contribution
BUYUP PLAN toward health insurance benefits.
Employee Only $23.94
Employee + 1 $47.88
Family $82.03

VISION CHOICE PLAN Employee/dependent Vision coverage paid Premium

INSURANCE Employee Only $4.15 Federal/State—No
Employee + 1 $8.03 at 80%.
FICA/Medicare—No
Family $11.33 Employees working a benefitted percentage Retirement Contributable—No
VSP schedule will have a reduced contribution
toward health insurance benefits.

SUPPLEMENTAL Opt. 1 - $20,000 - $ 2.25 EE and SP This is a voluntary benefit offered to Premium
EMPLOYEE AND SPOUSAL Opt. 2 - $30,000 - $ 3.38 EE and SP employees with two options available for Federal/State—Yes
TERM AD&D LIFE Opt. 3 - $50,000 - $ 5.63 EE Only spouses. All premiums will be deducted FICA/Medicare—Yes
INSURANCE AND CHILD Opt. 4 - $100,000- $11.25 EE Only semimonthly after tax from employees Retirement Contributable—No
TERM LIFE INSURANCE Opt. 5 - $150,000- $16.88 EE Only paycheck.
Opt. 6 - $200,000- $22.50 EE Only
VOYA/RELIASTAR Opt. 7 - $250,000- $28.13 EE Only
Opt. 8 - $300,000- $33.75 EE Only

Opt. 1 - $10,000 - $ 1.25 CH Only

BASIC TERM AD&D $30,000 - $1.58 County pays 100% of Basic Term Life and Premium
LIFE INSURANCE AD&D insurance premiums. Federal/State—No
FICA/Medicare—No
VOYA/RELIASTAR Retirement Contributable—No

ACCIDENT AND CRITICAL See Employee Benefit Guide for These are voluntary benefits offered to Premium
ILLNESS INSURANCE Rates. employees and their dependents. All Federal/State—Yes
premiums will be deducted semimonthly FICA/Medicare—Yes
VOYA/RELIASTAR after tax from paycheck. Retirement Contributable—No

Personnel Manual/Other Benefits—Tab 12 Page 5

Revised 1/15
TYPE BIWEEKLY DESCRIPTION SUBJECT TO TAXES

VACATION ACCRUAL 3.08 hours first 2 years. Taxed when time is used.
80 hours—2 weeks annually
4.62 hours biweekly beginning 3rd-10th Federal/State—Yes
year. 120 hours—3 weeks annually FICA/Medicare—Yes
6.16 hours biweekly beginning 11th- Retirement Contributable—Yes
160 hours—4 weeks annually
20th year.
7.70 hours biweekly beginning at 21+ 200 hours—5 weeks annually
years.
Prorated if work less than 80 hours
base. Maximum of 800 hours plus
one year accruals.
Taxed when time is used.
VACATION FLOATS 1.24—Posted as part of per pay period 32 hours total annually—additional Federal/State—Yes
vacation accrual. vacation. Included in biweekly accruals. FICA/Medicare—Yes
Retirement Contributable—Yes

ANNUAL VACATION CASH Twice in any 12 month period contingent Federal/State—Yes

OUT ALLOWANCE upon departmental budget/approval and FICA/Medicare—Yes
Ventura limitation. Retirement Contributable—Yes

TERM VACATION CASH Balance of hours paid at termination. Federal/State—Yes

OUT FICA/Medicare—Yes
Retirement Contributable—No

MANAGEMENT LEAVE 40 hours per year, no carry over, no cash Federal/State—Yes

out. Use it or lose it. FICA/Medicare—Yes
Retirement Contributable—Yes

SICK LEAVE ACCRUAL 96.20 hours annually. Credited January 1 Taxed when time is used.
annually. Current year’s accruals will be Federal/State—Yes
prorated upon termination, resignation or FICA/Medicare—Yes
retirement. Prorated for new Manager. Retirement Contributable—Yes
0% = Less than one year of service. Federal/State—Yes
TERM SICK LEAVE CASH 25% = Over one year of service. FICA/Medicare—Yes
OUT 75%= Upon retirement (service or Retirement Contributable—No
disability) or death up to 600 hours or
individual maximum set in 11/9/94 and
1/18/95. Employees receive hour for hour
retirement service credit for any sick leave
above 600 hours or their personal maximum
amount.
Taxed when time is used.
SICK LEAVE CONVERSION Convert sick leave to vacation time at open Federal/State—Yes
enrollment. Rate=40%. Remaining sick FICA/Medicare—Yes
leave balance=500 hours. Retirement Contributable—Yes
County pays 1.5% of employee’s base Federal/State—No
DEFERRED 1.5% of base wages. wages to designated deferred compensation FICA/Medicare—No
COMPENSATION plan. Retirement Contributable—Yes

Reimbursement for professional educational Reimbursement can be either:

PROFESSIONAL $700 annually. expenses, licenses and purchase of Taxable
DEVELOPMENT computers and related equipment. Depends Federal/State—Yes
(Currently suspended.) on items purchased for reimbursement. FICA/Medicare—Yes
Contingent upon use of the benefit. This Retirement Contributable—No
benefit is prorated during the first year of Non-Taxable
Federal/State—No
employment and upon retirement. FICA/Medicare—No
Retirement Contributable—No
Waiting period—30 days. On day 31 Federal/State—Yes
SHORT TERM DISABILITY receive 50% biweekly salary for eleven FICA/Medicare—Yes
months when completely disabled. Retirement Contributable—Yes
Premium
LONG TERM DISABILITY 60% to a maximum of $6,000 per month. Federal/State—No
Waiting period—365 days. FICA/Medicare—Yes
Retirement Contributable—No
$46.15 or $92.30 per pay period, plus
CAR ALLOWANCE mileage. Based on Department Head $1,200 or $2,400 annually based on Federal/State—Yes
discretion. determination of Department Head. FICA/Medicare—Yes
Retirement Contributable—Yes
Recruited from out-of-County up to
MOVING ALLOWANCE $2,500. Paid by the Department. See Personnel Policy. Tab 12. See IRS publication 521.

Management Lieutenants, please refer to your MOU.

Personnel Manual/Other Benefits—Tab 12 Page 6

Revised 1/15
 STANISLAUS COUNTY
PERSONNEL MANUAL
MANAGEMENT ATTORNEY EMPLOYEES
2015 BENEFIT PACKAGE

TYPE SEMI-MONTHLY PREMIUMS DESCRIPTION SUBJECT TO TAXES

MEDICAL HDHP WITH HSA Employee/dependent HDHP coverage paid Premium

INSURANCE at 95%. Federal/State—No
Employee Only $302.74 Employee/dependent EPO coverage paid at FICA/Medicare—No
Employee+1 $605.48 80%. Retirement Contributable—No
STANISLAUS COUNTY Family $817.41
PARTNERS IN HEALTH Waive
EPO Employee share will be deducted
(SCPH) semimonthly before tax from paycheck. Federal/State—Yes
OR Employee Only $361.99 FICA/Medicare—Yes
ANTHEM BLUECROSS Employee + 1 $723.98
$75.00 semimonthly medical waive credit Retirement Contributable—Yes
Family $977.38
provided with proof of other coverage.
Medical Plan Carrier is based on
employee’s zipcode. Health Savings Account (HSA) is
See Employee Benefit Guide for Employees working a benefitted percentage
funded by the County, $1,200 single
zipcode list. schedule will have a reduced employer
& $2,000 family per year.
contribution toward health insurance
benefits.
30-34 hrs/wk = 75% of the employer
contribution
35-39 hr/wk = 90% of the employer
contribution.

DENTAL CORE PLAN Employee/dependent Dental coverage paid Premium

INSURANCE Employee Only $17.21 at 80% of the Core Plan. Federal/State—No
Employee + 1 $34.42 FICA/Medicare—No
Family $58.97 Employees working a benefitted percentage Retirement Contributable—No
DELTA DENTAL schedule will have a reduced contribution
BUYUP PLAN toward health insurance benefits.
Employee Only $23.94
Employee + 1 $47.88
Family $82.03

VISION CHOICE PLAN Employee/dependent Vision coverage paid Premium

INSURANCE Employee Only $4.15 Federal/State—No
Employee + 1 $8.03 at 80%.
FICA/Medicare—No
Family $11.33 Employees working a benefitted percentage Retirement Contributable—No
VSP schedule will have a reduced contribution
toward health insurance benefits.

SUPPLEMENTAL Opt. 1 - $20,000 - $ 2.25 EE and SP This is a voluntary benefit offered to Premium
EMPLOYEE AND SPOUSAL Opt. 2 - $30,000 - $ 3.38 EE and SP employees with two options available for Federal/State—Yes
TERM AD&D LIFE Opt. 3 - $50,000 - $ 5.63 EE Only spouses. All premiums will be deducted FICA/Medicare—Yes
INSURANCE AND CHILD Opt. 4 - $100,000- $11.25 EE Only semimonthly after tax from employees Retirement Contributable—No
TERM LIFE INSURANCE Opt. 5 - $150,000- $16.88 EE Only paycheck.
Opt. 6 - $200,000- $22.50 EE Only
VOYA/RELIASTAR Opt. 7 - $250,000- $28.13 EE Only
Opt. 8 - $300,000- $33.75 EE Only

Opt. 1 - $10,000 - $ 1.25 CH Only

BASIC TERM AD&D $30,000 - $1.58 County pays 100% of Basic Term Life and Premium
LIFE INSURANCE AD&D insurance premiums. Federal/State—No
FICA/Medicare—No
VOYA/RELIASTAR Retirement Contributable—No

ACCIDENT AND CRITICAL See Employee Benefit Guide for These are voluntary benefits offered to Premium
ILLNESS INSURANCE Rates. employees and their dependents. All Federal/State—Yes
premiums will be deducted semimonthly FICA/Medicare—Yes
VOYA/RELIASTAR after tax from paycheck. Retirement Contributable—No

Personnel Manual/Other Benefits—Tab 12 Page 7

Revised 1/15
TYPE BIWEEKLY DESCRIPTION SUBJECT TO TAXES
3.08 hours first 2 years. 80 hours—2 weeks annually
VACATION ACCRUAL Taxed when time is used.
4.62 hours biweekly beginning 3rd-10th 120 hours—3 weeks annually Federal/State—Yes
year. FICA/Medicare—Yes
160 hours—4 weeks annually
6.16 hours biweekly beginning 11th- Retirement Contributable—Yes
20th year. 200 hours—5 weeks annually
7.70 hours biweekly beginning at 21+
years.
Prorated if work less than 80 hours
base. Maximum of 800 hours plus
one year accruals.
Taxed when time is used.
VACATION FLOATS 1.24—Posted as part of per pay period 32 hours total annually—additional Federal/State—Yes
vacation accrual. vacation. Included in biweekly accruals. FICA/Medicare—Yes
Retirement Contributable—Yes
ANNUAL VACATION CASH Twice in any 12 month period contingent Federal/State—Yes
OUT ALLOWANCE upon departmental budget/approval and FICA/Medicare—Yes
Ventura limitation. Retirement Contributable—Yes
TERM VACATION CASH Balance of hours paid at termination. Federal/State—Yes
OUT FICA/Medicare—Yes
Retirement Contributable—No
MANAGEMENT LEAVE 60 hours per year, no carry over, no cash Federal/State—Yes
out. Use it or lose it. FICA/Medicare—Yes
Retirement Contributable—Yes
SICK LEAVE ACCRUAL 96.20 hours annually. Credited January 1 Taxed when time is used.
annually. Current year’s accruals will be Federal/State—Yes
prorated upon termination, resignation or FICA/Medicare—Yes
retirement. Prorated for new Manager. Retirement Contributable—Yes
TERM SICK LEAVE CASH 0% = Less than one year of service. Federal/State—Yes
OUT 25% = Over one year of service. FICA/Medicare—Yes
75% = Upon retirement (service or Retirement Contributable—No
disability) or death up to 600 hours or
individual maximum set in 11/9/94 and
1/18/95. Employees receive hour for hour
retirement service credit for any sick leave
above 600 hours or their personal maximum
amount.
SICK LEAVE CONVERSION Convert sick leave to vacation time at open Taxed when time is used.
enrollment. Rate=40%. Remaining sick Federal/State—Yes
leave balance=500 hours. FICA/Medicare—Yes
Retirement Contributable—Yes
DEFERRED
COMPENSATION 1.5% of base wages. County pays 1.5% of employee’s base Federal/State—No
wages to designated deferred compensation FICA/Medicare—No
plan. Retirement Contributable—Yes
PROFESSIONAL Reimbursement for professional educational Reimbursement can be either:
DEVELOPMENT $700 annually. expenses, licenses and purchase of Taxable
computers and related equipment. Depends Federal/State—Yes
(Currently suspended.) on items purchased for reimbursement. FICA/Medicare—Yes
Contingent upon use of the benefit. This Retirement Contributable—No
benefit is prorated during the first year of Non-Taxable
Federal/State—No
employment and upon retirement. FICA/Medicare—No
Retirement Contributable—No
BAR DUES Applicable rate. Paid annually by the Department. Not applicable.
SHORT TERM DISABILITY Waiting period—30 days. On day 31 Federal/State—Yes
receive 50% biweekly salary for eleven FICA/Medicare—Yes
months when completely disabled. Retirement Contributable—Yes
LONG TERM DISABILITY 60% to a maximum of $6,000 per month. Premium
Waiting period—365 days. Federal/State—No
FICA/Medicare—Yes
Retirement Contributable—No
CAR ALLOWANCE $46.15 or $92.30 per pay period, plus $1,200 or $2,400 based on determination of Federal/State—Yes
mileage. Based on Department Head Department Head. FICA/Medicare—Yes
discretion. Retirement Contributable—Yes
MOVING ALLOWANCE Recruited from out-of-County up to
$2,500. Paid by the Department. See Personnel Policy. Tab 12. See IRS publication 521.

Personnel Manual/Other Benefits—Tab 12 Page 8

Revised 1/15
 STANISLAUS COUNTY
PERSONNEL MANUAL
DEPARTMENT HEADS
2015 BENEFIT PACKAGE

TYPE SEMI-MONTHLY PREMIUMS DESCRIPTION SUBJECT TO TAXES

MEDICAL HDHP WITH HSA Employee/dependent HDHP coverage paid Premium

INSURANCE at 95%. Federal/State—No
Employee Only $302.74 Employee/dependent EPO coverage paid at FICA/Medicare—No
Employee+1 $605.48 80%. Retirement Contributable—No
STANISLAUS COUNTY Family $817.41
PARTNERS IN HEALTH Waive
EPO Employee share will be deducted
(SCPH) semimonthly before tax from paycheck. Federal/State—Yes
OR Employee Only $361.99 FICA/Medicare—Yes
ANTHEM BLUECROSS Employee + 1 $723.98
$75.00 semimonthly medical waive credit Retirement Contributable—Yes
Family $977.38
provided with proof of other coverage.
Medical Plan Carrier is based on
employee’s zipcode. Health Savings Account (HSA) is
See Employee Benefit Guide for Employees working a benefitted percentage
funded by the County, $1,200 single
zipcode list. schedule will have a reduced employer
& $2,000 family per year.
contribution toward health insurance
benefits.
30-34 hrs/wk = 75% of the employer
contribution
35-39 hr/wk = 90% of the employer
contribution.

DENTAL CORE PLAN Employee/dependent Dental coverage paid Premium

INSURANCE Employee Only $17.21 at 80% of the Core Plan. Federal/State—No
Employee + 1 $34.42 FICA/Medicare—No
Family $58.97 Employees working a benefitted percentage Retirement Contributable—No
DELTA DENTAL schedule will have a reduced contribution
BUYUP PLAN toward health insurance benefits.
Employee Only $23.94
Employee + 1 $47.88
Family $82.03

VISION CHOICE PLAN Employee/dependent Vision coverage paid Premium

INSURANCE Employee Only $4.15 Federal/State—No
Employee + 1 $8.03 at 80%.
FICA/Medicare—No
Family $11.33 Employees working a benefitted percentage Retirement Contributable—No
VSP schedule will have a reduced contribution
toward health insurance benefits.

SUPPLEMENTAL Opt. 1 - $20,000 - $ 2.25 EE and SP This is a voluntary benefit offered to Premium
EMPLOYEE AND SPOUSAL Opt. 2 - $30,000 - $ 3.38 EE and SP employees with two options available for Federal/State—Yes
TERM AD&D LIFE Opt. 3 - $50,000 - $ 5.63 EE Only spouses. All premiums will be deducted FICA/Medicare—Yes
INSURANCE AND CHILD Opt. 4 - $100,000- $11.25 EE Only semimonthly after tax from employees Retirement Contributable—No
TERM LIFE INSURANCE Opt. 5 - $150,000- $16.88 EE Only paycheck.
Opt. 6 - $200,000- $22.50 EE Only
VOYA/RELIASTAR Opt. 7 - $250,000- $28.13 EE Only
Opt. 8 - $300,000- $33.75 EE Only

Opt. 1 - $10,000 - $ 1.25 CH Only

BASIC TERM AD&D $30,000 - $1.58 County pays 100% of Basic Term Life and Premium
LIFE INSURANCE AD&D insurance premiums. Federal/State—No
FICA/Medicare—No
VOYA/RELIASTAR Retirement Contributable—No

ACCIDENT AND CRITICAL See Employee Benefit Guide for These are voluntary benefits offered to Premium
ILLNESS INSURANCE Rates. employees and their dependents. All Federal/State—Yes
premiums will be deducted semimonthly FICA/Medicare—Yes
VOYA/RELIASTAR after tax from paycheck. Retirement Contributable—No

Personnel Manual/Other Benefits—Tab 12 Page 9

Revised 1/15
TYPE BIWEEKLY DESCRIPTION SUBJECT TO TAXES
4.62 hours biweekly first year. 120 hours—3 weeks annually Taxed when time is used.
VACATION ACCRUAL Federal/State—Yes
6.16 hours biweekly beginning 2nd- 160 hours—4 weeks annually FICA/Medicare—Yes
20th year. Retirement Contributable—Yes
200 hours—5 weeks annually
7.70 hours biweekly beginning at 21+
years.
Prorated if work less than 80 hours
base. Maximum of 800 hours plus
one year accruals or their actual
balance on 12/15/95 if more than 800
hours.
Taxed when time is used.
VACATION FLOATS 1.24—Posted as part of per pay period 32 hours total annually—additional Federal/State—Yes
vacation accrual. vacation. Included in biweekly accruals. FICA/Medicare—Yes
Retirement Contributable—Yes
ANNUAL VACATION CASH Twice in any 12 month period contingent Federal/State—Yes
OUT ALLOWANCE upon departmental budget/approval and FICA/Medicare—Yes
Ventura limitation. Retirement Contributable—Yes
TERM VACATION CASH Balance of hours paid at termination. Federal/State—Yes
OUT FICA/Medicare—Yes
Retirement Contributable—No
MANAGEMENT LEAVE 40 hours per year, no carry over, no cash Federal/State—Yes
out. Use it or lose it. FICA/Medicare—Yes
Retirement Contributable—Yes

SICK LEAVE ACCRUAL 96.20 hours annually. Credited January 1 Taxed when time is used.
annually. Current year’s accruals will be Federal/State—Yes
prorated upon termination, resignation or FICA/Medicare—Yes
retirement. Prorated for new Department Retirement Contributable—Yes
Head.
0% = Less than one year of service.
TERM SICK LEAVE CASH 25% = Over one year of service. Federal/State—Yes
OUT 75% = Upon retirement (service or FICA/Medicare—Yes
disability) or death up to 600 hours or Retirement Contributable—No
individual maximum set in 11/9/94 and
1/18/95. Employees receive hour for hour
retirement service credit for any sick leave
above 600 hours or their personal maximum
amount.
Convert sick leave to vacation time at open Taxed when time is used.
SICK LEAVE CONVERSION enrollment. Rate=40%. Remaining sick Federal/State—Yes
leave balance=500 hours. FICA/Medicare—Yes
Retirement Contributable—Yes

DEFERRED 2.0% of base wages. County pays 2.0% of employee’s base Federal/State—No
COMPENSATION wages to designated deferred compensation FICA/Medicare—No
plan. Retirement Contributable—Yes
Reimbursement for professional educational Reimbursement can be either:
PROFESSIONAL $900 annually. expenses, licenses and purchase of Taxable
DEVELOPMENT computers and related equipment. Depends Federal/State—Yes
(Currently suspended.) on items purchased for reimbursement. FICA/Medicare—Yes
Contingent upon use of the benefit. This Retirement Contributable—No
benefit is prorated during the first year of Non-Taxable
Federal/State—No
employment and upon retirement. FICA/Medicare—No
Retirement Contributable—No

SHORT TERM DISABILITY Waiting period—30 days. On day 31 Federal/State—Yes

receive 50% biweekly salary for eleven FICA/Medicare—Yes
months when completely disabled. Retirement Contributable—Yes
Premium
LONG TERM DISABILITY 60% to a maximum of $6,000 per month. Federal/State—No
Waiting period—365 days. FICA/Medicare—Yes
Retirement Contributable—No

CAR ALLOWANCE $184.62 per pay period, plus mileage. $4,800 annually. Federal/State—Yes
FICA/Medicare—Yes
Retirement Contributable—Yes
MOVING ALLOWANCE Recruited from out-of-County up to
$3,000. Paid by the Department. See Personnel Policy. Tab 12. See IRS publication 521.

Personnel Manual/Other Benefits—Tab 12 Page 10

Revised 1/15
 STANISLAUS COUNTY
PERSONNEL MANUAL
BOARD MEMBERS AND OTHER ELECTED OFFICIALS
2015 BENEFIT PACKAGE

TYPE SEMI-MONTHLY PREMIUMS DESCRIPTION SUBJECT TO TAXES

MEDICAL HDHP WITH HSA Employee/dependent HDHP coverage Premium

INSURANCE paid at 95%. Federal/State—No
Employee Only $302.74 Employee/dependent EPO coverage FICA/Medicare—No
Employee+1 $605.48 paid at 80%. Retirement Contributable—No
STANISLAUS COUNTY Family $817.41
PARTNERS IN HEALTH Waive
EPO Employee share will be deducted
(SCPH) semimonthly before tax from paycheck. Federal/State—Yes
OR Employee Only $361.99 FICA/Medicare—Yes
ANTHEM BLUECROSS Employee + 1 $723.98
$75.00 semimonthly medical waive Retirement Contributable—Yes
Family $977.38
credit provided with proof of other
Medical Plan Carrier is based on coverage.
employee’s zipcode. Health Savings Account (HSA) is
See Employee Benefit Guide for funded by the County, $1,200 single
zipcode list. & $2,000 family per year.

DENTAL CORE PLAN Employee/dependent Dental coverage Premium

INSURANCE Employee Only $17.21 paid at 80% of the Core Plan. Federal/State—No
Employee + 1 $34.42 FICA/Medicare—No
Family $58.97 Employees working a benefitted Retirement Contributable—No
DELTA DENTAL percentage schedule will have a
BUYUP PLAN reduced contribution toward health
Employee Only $23.94 insurance benefits.
Employee + 1 $47.88
Family $82.03

VISION CHOICE PLAN Employee/dependent Vision coverage Premium

INSURANCE Employee Only $4.15 Federal/State—No
Employee + 1 $8.03 paid at 80%.
FICA/Medicare—No
Family $11.33 Employees working a benefitted Retirement Contributable—No
VSP percentage schedule will have a
reduced contribution toward health
insurance benefits.

SUPPLEMENTAL Opt. 1 - $20,000 - $ 2.25 EE and SP This is a voluntary benefit offered to Premium
EMPLOYEE AND SPOUSAL Opt. 2 - $30,000 - $ 3.38 EE and SP employees with two options available Federal/State—Yes
TERM AD&D LIFE Opt. 3 - $50,000 - $ 5.63 EE Only for spouses. All premiums will be FICA/Medicare—Yes
INSURANCE AND CHILD Opt. 4 - $100,000- $11.25 EE Only deducted semimonthly after tax from Retirement Contributable—No
TERM LIFE INSURANCE Opt. 5 - $150,000- $16.88 EE Only employees paycheck.
Opt. 6 - $200,000- $22.50 EE Only
VOYA/RELIASTAR Opt. 7 - $250,000- $28.13 EE Only
Opt. 8 - $300,000- $33.75 EE Only

Opt. 1 - $10,000 - $ 1.25 CH Only

BASIC TERM AD&D $30,000 - $1.58 County pays 100% of Basic Term Life Premium
LIFE INSURANCE and AD&D insurance premiums. Federal/State—No
FICA/Medicare—No
VOYA/RELIASTAR Retirement Contributable—No

ACCIDENT AND CRITICAL See Employee Benefit Guide for These are voluntary benefits offered to Premium
ILLNESS INSURANCE Rates. employees and their dependents. All Federal/State—Yes
premiums will be deducted FICA/Medicare—Yes
VOYA/RELIASTAR semimonthly after tax from paycheck. Retirement Contributable—No

Personnel Manual/Other Benefits—Tab 12 Page 11

Revised 1/15
TYPE BIWEEKLY DESCRIPTION SUBJECT TO TAXES

VACATION ACCRUAL Not applicable.

VACATION FLOATS Not applicable.

ANNUAL VACATION CASH Not applicable.

OUT ALLOWANCE

TERM VACATION CASH Not applicable.

OUT

MANAGEMENT LEAVE Not applicable.

SICK LEAVE ACCRUAL Not applicable.

TERM SICK LEAVE CASH Not applicable.

OUT

SICK LEAVE CONVERSION Not applicable.

DEFERRED 2.0% of base wages. County pays 2.0% of employee’s base Federal/State—No
COMPENSATION wages to designated deferred FICA/Medicare—No
compensation plan. Retirement Contributable—Yes

PROFESSIONAL $900 annually. Reimbursement for professional Reimbursement can be either:

DEVELOPMENT educational expenses, licenses and Taxable
(Currently suspended.) purchase of computers and related Federal/State—Yes
equipment. Depends on items FICA/Medicare—Yes
purchased for reimbursement. Retirement Contributable—No
Contingent upon use of the benefit. Non-Taxable
Federal/State—No
This benefit is prorated during the first FICA/Medicare—No
year of employment and upon Retirement Contributable—No
retirement.

SHORT TERM DISABILITY Not applicable.

Premium
LONG TERM DISABILITY 60% to a maximum of $6,000 per Federal/State—No
month. Waiting period—365 days. FICA/Medicare—Yes
Retirement Contributable—No

CAR ALLOWANCE $184.62 per pay period, plus mileage. $4,800 annually. Federal/State—Yes
FICA/Medicare—Yes
Retirement Contributable—Yes

MOVING ALLOWANCE Not applicable.

See Tab 23 for an explanation of Retirement Benefits.

Personnel Manual/Other Benefits—Tab 12 Page 12

Revised 1/15
DEFERRED COMPENSATION

Mass Mutual Deferred Compensation Plan (Formerly The Hartford)

GENERAL INFORMATION

Employees have the option to participate in a County Sponsored Deferred Compensation

Plan through Mass Mutual. Voluntary Contributions are optional by completing an
enrollment form at any time during the year. Deductions may be taken up to 26 pay
periods per year. Employees may increase/decrease or stop their contributions at any
time by using eBenefits Self Service. If Self Service is unavailable, employees must
complete the Contribution Change Form and submit electronically.

The Enrollment form must be submitted to Employee Benefits for enrollment processing
and signature by the Plan Sponsor/Administrator. If you are making an Investment
Change or a Withdrawal after termination, contact Mass Mutual.

All newly Hired or Promoted Management, Confidential Employees, and Attorneys must
complete a Deferred Compensation Enrollment Form as the County contributes a
percentage of their salary as a benefit.

Deferred Compensation Pre-retirement Catch Up Contribution

If an employee wishes to utilize the catch up provision, by deferring amounts that were
not deferred under the plan limitations during taxable years that the plan was available to
them, they will need to complete a Contribution Change form and a Pre-retirement
Catch-Up Notification form. Pre-retirement Catchup Provision only available during the
three years prior to, but not including, the year the participant will reach normal
retirement age. These forms are located on Employee Benefits website.
Additional amount available to participants age 50 and older, not to be used concurrently with the
Pre-Retirement Catchup Provision.

Investment Election Change/Transfer-Deferred Compensation/Withdrawals after

Termination

This option must be done by contacting Mass Mutual at (800) 528-9009, or by accessing
their web site @ www.retire.hartfordlife.com.

Withdrawals

Employees are eligible to withdraw their funds from Hartford only after they terminate
employment. However, if an employee is experiencing a financial hardship they may
qualify for a Hardship Withdrawal and must contact Mass Mutual to obtain information
and forms.

05/13
 Deferred Compensation Loan Process

1. Participant will call Mass Mutual’s customer service at (800) 528-9009 and
request a loan quote/loan data to be faxed or emailed directly to the
participant.
(Mass Mutual will verify participant’s account balance and loan amount
available, interest rate, repayment amount & schedule.)

2. Participant completes loan application and sends back to Mass Mutual for
processing. Do not send application to Employee Benefits.

3. Mass Mutual will send the loan check within approximately 7 working days
to participant’s address on Loan Application and notify Employee Benefits.

4. Employee Benefits will setup payroll loan deduction to be deducted

bi-weekly from the participant’s payroll check.

EARLY PAYOFF OF YOUR LOAN

If you decide to pay off your Deferred Compensation Loan early, you must
contact Mass Mutual for assistance. Participants will be able to send a check
directly to Mass Mutual or go online through their website and payoff the
loan. You will need to call Mass Mutual or go online for the current payoff
amount of the loan.

If you have any questions about the above process, please call Mass Mutual at
(800) 528-9009 or go online to https://retire.hartfordlife.com.

Rev. 05/13
 THE HARTFORD GROUP RETIREMENT PROGRAMS
LOAN PROGRAM FAST FACTS
The following information is intended to serve as a quick reference on the features of The Hartford’s
Government Market loan program available for 457(b) plans.

FEATURES

Loan Types / Loan Terms • General Purpose Loan: 1 - 5 years

• Primary Residence Loan: 1 - 20 years
Loan Minimum • $1,000
Loan Maximum The loan may not exceed:
• 50% when added to the outstanding balance of all other retirement plans
sponsored by the employer and the participant’s vested account value (excluding
Self Directed Brokerage Account “SDBA” balance) or
• $50,000 minus the highest total amount of outstanding loan balance(s) from the
plan during the 12-month period to the date the loan is made.
• In calculating the maximum loan amount, it is the employee’s responsibility to
consider any outstanding loans they may have from other retirement plans offered
through their employer. The Hartford uses only information available under its
group retirement plan contracts and will not be responsible for any adverse tax
consequences that may result.
Effect of Borrowing on • Proceeds of loan to be taken pro-rata from all available investment options
Account (except SDBA)
• SDBA balance, if applicable, not included in calculation of available loan amount
• Before any terminations or distributions to participant or beneficiary, the account
balance will be reduced by the amount of any outstanding loan balance
Loan Interest Rate / • Loan rate: “Prime + 1”. However, a different rate may be set by the plan sponsor
Calculation • Rate fixed for term of loan
• Daily interest calculation
• All interest repaid to the participant account – allocated to account per
participant’s current investment election
Loan Repayment • Repayment occurs via payroll deduction
• Frequency bi-weekly

• No partial prepayments allowed

• Early repayment (in full) allowed; check remittance generally allowed only for
early payoff of loan
• Repayments are returned to participant account according to their current
investment election
Limit on Number of • One active loan at a time AND only one loan in a 12 month period
Outstanding Loans
Loan Fees • One-time set up fee – $50
• Taken from participant account on a pro-rata basis from all investment
options with a balance (except SDBA fund)
• Setup fee deducted from account in addition to principal amount of loan

Rev. 10/16/07 Page 1

 THE HARTFORD GROUP RETIREMENT PROGRAMS
LOAN PROGRAM FAST FACTS
The following information is intended to serve as a quick reference on the features of The Hartford’s
Government Market loan program available for 457(b), 403(b) and governmental 401(a) plans 1.

FEATURES
Documentation Applicable to • Plan Sponsor’s governing plan document must make provision for loans
Plan Sponsor or Participant • Plan Sponsor’s Administrative Services Agreement with the Hartford (if
applicable to plan) must make provision for loans
• Participant Loan Application & Agreement detailing terms, conditions and
applicable fees
• Participant loan guide (included with terms & conditions)
• Spousal Consent for Loan Security form (if applicable)
Plan Sponsor Reporting: • Plan Summary Statements detail net loan activity and outstanding loan balance
Plan Summary Statements, • Internet details net loan activity and outstanding balance
Internet • Sponsor notification of loan defaults
Participant Reporting: • Loan confirm issued with check to participant
Statements, Confirms, • Loan amortization schedule
Internet and VRU • Outstanding loan(s) and recent payments detailed on statements
• Internet detail includes: loan balance(s), date of loan, amount borrowed, interest
rate, payoff date, last payment date and loan payment amount
• VRU detail includes: loan balance(s), payoff amount and loan modeling
Plan Administrator's Guide • Contains Loan program overview and processing details

Hartford Customer Service 1-800-528-9009

Rev. 10/16/07 Page 2

 Print Clear
Loan Application& Agreement - 457(b)
Mail Address: Overnight Mail Address:
Retirement Plan Service Center Retirement Plan Service Center
Hartford Life Insurance Company Hartford Life Insurance Company
PO Box 1583, Hartford, CT 06144-1583 1 Griffin Road North, Windsor, CT 06095-1512

Group Number: Plan Name: Social Security Number:

150163 Stanislaus County
Employee Name: Last, First, M.I.

Address: City, State, Zip

Home Phone: Work Phone/Ext.:

A. To be completed by the Participant

EMPLOYEE REQUEST FOR LOAN: I hereby request to borrow from my account balance under the Plan: (I understand that I may not
request a loan, or have an outstanding loan, if my benefit is in pay status.)
$______________________ or, if less is available, the Maximum Amount Available ($1,000 minimum).
The Maximum Amount Available ($1,000 minimum). The Maximum Amount Available is determined on the valuation date on which the
loan proceeds are to be issued from the plan. The Maximum Amount Available is the lesser of 50% of the vested account balance or
$50,000 (reduced by the highest outstanding balance during the last twelve months of all loans made from this Plan).

Loan Fees: I understand and agree that the total loan amount due and payable will include a processing fee of $50 to be deducted
from my Participant’s account under the Plan in the same manner as the amount borrowed. Additionally, a maintenance fee of $12.50
will be deducted from my Participant’s account at the end of each calendar quarter.

Source of Loan Funds: I understand that the proceeds of my Loan and any Loan Fee will be withdrawn from my account under the Plan
against all available investment choices (except a Self Directed Brokerage Account) and from each contribution source on a pro-rata basis.

Loan Repayment Terms: I agree to repay this loan to my account through payroll deductions within:
1 Year 2 Years 3 Years 4 Years 5 Years
_______ Years (Greater than 5 Years is permitted for the purchase of principal residence only).

Payroll Deduction Authorization: I understand and authorize loan repayments to be made by payroll deduction for each pay period in
which a payment is due in accordance with the terms of the Promissory Note and Loan Agreement, starting with the first applicable pay-
period following the date this loan is entered into or as soon as administratively practicable and continuing until the loan is repaid in full.
I understand that loan repayments will be invested in the investment choices under the Plan in accordance with my most current
investment election on file with the Plan Administrator (except a Self Directed Brokerage Account).
B. Required to be completed by the Plan Administrator:
Loan Interest Rate: (Interest rate will default to Current Plan Loan Interest Rate currently on file with The Hartford unless otherwise
specified.) _____________%
Payroll Frequency: Weekly X Bi-Weekly Semi-Monthly Monthly
First Loan Repayment Date: _________/_________/____________
C. Signatures
I understand and agree to the terms of the Loan Agreement as stated on page 2 of this application. I understand that I may fully repay
the outstanding amount of this loan without penalty. Partial prepayments are not allowed. Upon my retirement, death or termination of
employment or termination of the Plan prior to the full repayment of the loan, the outstanding principal amount of the loan will be
considered due and payable. My vested account balance will be reduced by the amount of outstanding principal balance of the loan
before any distribution to me or my beneficiary, whichever is applicable. I understand and agree that with the loan proceeds I will receive
a Promissory Note. I understand and agree that none of the terms or provisions of this Promissory Note may be waived, altered, modified
or amended except in writing and duly executed by me and the Plan Trustees. I further understand my endorsement of the check
representing this loan shall constitute my agreement to all terms of the Promissory Note and Loan Agreement. If I return the check to
Hartford Life unsigned, I authorize Hartford Life to deduct a reprocessing fee of $75 from my account under the Plan.

___________________________________________ ___________________________
Employee's Signature Date
Please forward this application to your Plan Administrator for final review and approval.

I approve this loan as shown and certify that the above data in regard to the participant is true and accurate to the best of my knowledge and,
as applicable, that I have considered any other loan made from any other plan of the employer in determining the amount available to the
Participant. I hereby direct Hartford Life to issue the loan proceeds accompanied by a Promissory Note to the Participant based upon the
information indicated above. I understand that the loan request will be processed as of the date it is received in good order at Hartford Life.

Plan Administrator's Signature Please make a copy for your records. Date
Loan 457-2 PYRL Rev. 01.12 Page 1 of 2 loanstan.pdf
Loan Agreement
I agree that the following terms will apply to the Loan issued to me by the Plan.

Terms of the Plan: This Loan Agreement and the Loan being made to me are subject to the terms of the Plan as now in effect or later
amended, including any rules made by the Plan Administrator under the authority of the Plan. The pertinent provisions and defined terms
of the Plan and rules of the Plan Administrator are considered in the terms of this Agreement.

Effect of Borrowing - Limitations: I agree that the amount borrowed will be advanced from my investment accounts maintained under
the Plan on my behalf in accordance with the Plan provisions. I understand that the maximum Loan amount is limited to the lesser of
50% of my vested account balance under the Plan or $50,000 reduced by the highest outstanding balance on any loan(s) made to me
from this Plan (or any other Plan sponsored by the Employer) during the twelve months period ending on the date this Loan is made.

Effect of Repayment: As I repay this Loan, the repayment (both principal and interest) will be credited to my Plan account and invested
in accordance with the terms of the Plan. I will be provided with a complete repayment schedule for this Loan.

Loan Terms: The basic terms of the Loan are specified in the Promissory Note provided with the loan proceeds. I promise to repay this
Loan in the manner and to the extent required by this Agreement and rules of the Plan Administrator.

Repayment of Loan: During any period I am employed by the Employer, I hereby authorize the Plan Administrator to deduct from my
salary, or amounts paid in lieu thereof, the repayment amounts set forth in the Promissory Note. During any period of time when I am
not receiving salary or amounts paid in lieu thereof (such as certain periods of layoff or leaves of absence) or my salary or other
payment is insufficient to make the required repayment or if I should cancel my salary deduction authorization, I agree to make the
scheduled repayment when due (or any deficiency therein) by check to the Plan Administrator

Event of Default: If any of the following events occur before this Loan plus interest is repaid in full, there shall be an event of default:
(1) termination of my employment for any reason (including death); (2) a distribution is required to be made under a qualified domestic
relations order affecting my account and the distribution would exceed my interest in the Plan less the amount of the Loan outstanding
plus accrued but unpaid interest; or (3) my failure to repay the Loan for three consecutive months. Upon the event of default, I
acknowledge that the entire balance of the Loan plus any accrued but unpaid interest shall be considered immediately due and payable.
If I do not repay the Loan within 31 days of an event of default, I authorize the Plan Administrator to foreclose on the outstanding Loan
by deducting the unpaid Loan balance plus accrued but unpaid interest from my account, to the extent permitted by law.

Early and Late Repayment: I have the right to repay at the end of the any month in full (but not in part) the outstanding principal balance
of the Loan plus accrued but unpaid interest to the date of such repayment.

Security Interest: I understand that the Loan shall be secured by a lien on my interest in the Plan equal to the value of the outstanding
principal plus interest. Accordingly, I grant a security interest in, and a general lien upon, the vested balance of my Plan account as
security for the payment when due of the principal and interest on the Loan.

Defined Terms: “Plan” means the Eligible Deferred Compensation Plan funded by a Hartford Life Insurance Company investment
product identified by the Group No. on this document. “Employer” means the Plan’s sponsor. The term “Loan,” “Plan Administrator,” and
“Trustee(s)” have the meaning given such terms under the Plan.

Loan 457-2 PYRL Rev. 01.12 Page 2 of 2 loanstan.pdf

FLEXIBLE SPENDING ACCOUNTS

GENERAL INFORMATION

Flexible spending accounts allows you to use pre-tax dollars to help reduce your taxable
gross and pay for certain out-of-pocket expenses.

To enroll in a Flexible Spending Account, all you have to do is estimate how much money
you spend for out-of-pocket health care and/or dependent care expenses for the plan year
and complete the County Benefit Enrollment Form indicating your annual pledge and semi-
monthly contribution.

Employees can enroll:

♦ When they are hired as a full time employee

♦ Within 30 days of the addition of an eligible dependent
♦ During the County’s annual Open Enrollment – effective January 1st of each year.

Annual pledges must be allocated semi-monthly for 24 continuous pay periods for the plan
year. The only exception to change or stop a semi-monthly deduction would be due to a
qualifying event.

Any money left in an account at the end of the plan year, for which the employee does not
have an eligible claim, will be forfeited pursuant to federal guidelines. Employees have 90
days after the end of the plan year to claim incurred expenses, which were incurred late in
the plan year.

DEPENDENT CARE SPENDING ACCOUNT

MAXIMUM ANNUAL CONTRIBUTION - $5,000.00

($2,500.00 if married filing separate)

Estimating dependent day care expenses is easy. For example if your child spends all but
two weeks a year in day care and you spend $50 per week, your expenses are $2,500 per
year (50 weeks x $50).

You cannot claim Dependent Care Tax Credits on your income tax return if you have a
Dependent Care Spending Account.

To file a claim for expenses you can either mail a claim form with copies of receipts
describing the service and the amount for the service to WageWorks, or the said
information can be faxed. The provider’s tax ID number is required for all dependent day
care claims. You may also use your Take Care Debit Card that is provided by WageWorks.

01/10
FLEXIBLE SPENDING ACCOUNT – (CONTINUED)

HEALTH CARE SPENDING ACCOUNT

MAXIMUM ANNUAL CONTRIBUTION – $2500.00

You should estimate any out of pocket expenses for the coming plan year. Examples of
covered expenses would be; office visit co-pays, medications, orthodontics, and chiropractic
visits. See list of qualifying medical expenses on the WageWorks website.

Eligible expenses would also be covered for a spouse and any person who would qualify as
a dependent, under federal income tax rules (even if not covered by your health insurance
company).

If you should miss a paycheck due to an unpaid absence, you will be responsible for the
FSA admin fee. Failure to pay the admin fee while on unpaid absence will result in an
adjustment to your paycheck when you have returned to paid status. There will also be an
adjustment to your semi-monthly contribution to the FSA account in order to meet the your
Annual Pledge.

For further information on how a Flexible Spending Account works or how to figure your
annual contribution, you can contact Employee Benefits at 525-5717 or WageWorks.

WageWorks
PO Box 14054
Lexington, KY 40512
Phone: (800) 800-950-0105
Fax: (877) 782-8889
http://www.takecarewageworks.com

PERSONNEL/PAYROLL CLERKS:
Employees can obtain forms from the Employee Benefits web site,
@ http://www.stancounty.com/riskmgmt/risk-eb-forms-sub-main.shtm
or from the WageWorks web site.

01/10
EMPLOYEE ASSISTANCE PROGRAM

The County provides an Employee Assistance Program (EAP) for all full time employees
and their dependents. This plan is offered through ReliaStar ING and includes several
EAP options.

OPTIONS

• ComPsych Employee Assistance Program

A comprehensive assistance program with clinicians available by phone 24 hours
a day, seven days a week. Confidential referrals to local counseling services for
employees and dependents with up to five visits at no charge.

• ComPsych Crisis Intervention

Crisis Intervention is designed to help organizations effectively handle a traumatic
incident 24 hours a day. By providing knowledgeable and reliable crisis
intervention and critical incident counseling, ComPsych helps employees and
organizations recover from crises more quickly, reducing business disruption.

Crisis Intervention features:

o Custom plans and preparation for emergencies
Our critical incident response programs are customized to meet the various
types of critical incidents that an employee might experience.
o 24/7 worldwide access to critical incident specialists
Crisis Intervention includes a vast network of providers who meet strict
credentialing requirements and conduct on-site counseling sessions both
for groups and individuals.
o Immediate response
Our counselors can begin crisis intervention and management consultation
in as little as two hours when necessary.
o Post-event reporting and consultation
ComPsych experts provide a management report and give
recommendations, including follow-up services and planning for future
crises.

Department Managers/Supervisors/HR Personnel call ComPsych at 877-533-2363

• Estate Guidance
Estate Guidance from ComPsych offers you the ease of online Will preparation.

• Financial Issues
ComPsych provides consultation with Certified Financial Planners and Certified
Public Accountants if you have a concern about a financial matter.

6/11
 • Legal Services
ComPsych provides immediate, confidential access to staff attorneys who are
dedicated to providing practical and understandable information and assistance
for a broad range of legal issues.

• Travel Assistance
ING Travel assistance provides planning services, emergency services (legal
assistance, translation, medical referrals), and emergency transportation services.

• Funeral Planning and Concierge Service

ING works with Everest Funeral Planning to offer assistance researching,
planning, negotiating and scheduling funeral services.

Procedures to obtain services:

Eligible employees will need to identify themselves as an employee of County of

Stanislaus when calling the below phone numbers.

• For services offered by ComPsych - call 877-533-2363 or visit their website at:
www.guidanceresources.com
Web ID: MY5848i
Company: County of Stanislaus

• ING Travel Assistance- call 800-859-2821 or visit their website at:

www.europassistance-usa.com. User Name: ing Password: assistance

• For Funeral Planning services- call 800-456-5050 or visit their website at:
www.everestfuneral.com/ing.

Fliers with general EAP information follow this page.

For EAP Policy information, please refer to the County’s Personnel Manual on the
Human Resources web page.

6/11
 An Overview of
Your ComPsych®
GuidanceResources®
Program

No matter what’s going on in your life, Online Information, Tools and Services
ComPsych® GuidanceResources® is here to help. GuidanceResources® Online is your one stop for expert
Personal problems, planning for life events or simply information to assist you with the issues that matter
managing daily life can affect your work, health and to you, from personal or family concerns to legal and
family. GuidanceResources is a no-cost, company- financial concerns. Each time you return, you will
sponsored benefit that is available to you and your receive personalized, relevant information based on
dependents to provide confidential support, resources your individual life needs. You can:
and information to get through life’s challenges. This ››Review in-depth HelpSheetsSM on your topics
flyer explains how GuidanceResources can help you. ››Get answers to specific questions
››Search for services and referrals
Confidential Counseling on Personal Issues ››Use helpful planning tools
Your Employee Assistance Program (EAP) is a ››Order pre-screened reference books
confidential counseling service to help address the
personal issues you are facing. This service, staffed by
ComPsych®
experienced clinicians, is available by calling a toll-
free phone line available 24 hours a day, seven days a
GuidanceResources®
Copyright © 2008 ComPsych Corporation. All rights reserved.

week. A Guidance Consultant will refer you to a local

counselor or to resources in your community. Call any
Call: 877.533.2363
time with personal concerns, including: TDD: 800.697.0353
››Relationships › Job pressures
Online: guidanceresources.com
››Problems with your children › Marital conflicts
››Substance abuse › Grief and loss Enter your company Web ID: MY5848i
››Stress, anxiety or depression › Empty-nesting
EB.P.DI.41 152083 v.1008

Access Your ComPsych® GuidanceResources® Program Access Your ComPsych® GuidanceResources® Program

The single source for confidential support, expert information The single source for confidential support, expert information
and valuable resources, when you need it the most. Available 24 Please detach and valuable resources, when you need it the most. Available 24
hours a day, 7 days a week. wallet card along hours a day, 7 days a week.

the dotted lines.

Call: 877.533.2363 Online: guidanceresources.com Call: 877.533.2363 Online: guidanceresources.com
TDD: 800.697.0353 Company ID: MY5848i TDD: 800.697.0353 Company ID: MY5848i

EB.P.DI.41 152083 v.1008 Copyright © 2008 ComPsych Corporation. All rights reserved. EB.P.DI.41 152083 v.1008 Copyright © 2008 ComPsych Corporation. All rights reserved.
 How Your ComPsych®
GuidanceResources®
Program Can Help

EstateGuidance ®

The Importance of Having a Will Logon to EstateGuidance to:

››Complete a customized will for your estate
There are many reasons to have one. ››Utilize an intelligent online questionnaire to guide
A will is one of the most important legal documents
you through the process
for you to have. It ensures that you will control who
››Name a guardian for your children
gets your property, who will be the guardian of your
››Name an executor(s) to settle your estate
children and who will manage your estate when
››Specify funeral and burial wishes
you die.
››Make revisions at no cost for up to 30 days
Now you have the ability to create a
simple will* at no cost. * A simple will does not cover credit shelter trust, printing
EstateGuidance is an employee benefit that offers you or certain other features. These features are available at
an additional cost.
the ease and simplicity of online will preparation–right
on your PC! Just access the site using the directions
provided and supply the information at the prompts. ComPsych®
Your will can be completed online and downloaded GuidanceResources®
to your computer. In addition, you will receive
instructions about how to execute your will and store Your single source for confidential support,
it, as well as access to Web-based support.
expert information and valuable resources.
Available 24 hours a day, 7 days a week.

Instructions to Access EstateGuidance

Visit: www.EstateGuidance.com
Enter your company name and ID: MY5848i

EB.P.DI.22-1 134533 v.1008 Copyright © 2008 ComPsych Corporation. All rights reserved.
 How Your ComPsych®
GuidanceResources®
Program Can Help

Financial
Issues
Even though money doesn’t buy happiness, not Online Information, Tools and Services
having enough of it to pay the bills can cause a lot of Here are a few of the issues our financial experts
unhappiness. Even if you can pay the bills, there still can help you with:
may not be enough money left over to reach long- ››Debt management
term financial objectives like college and retirement. ››Family budgeting
For these reasons, most of us need help with money ››Financing college
management and financial planning from time to time. ››Tax questions
How it works ››Retirement planning
When you call GuidanceResources® with a concern
››Real estate
about a financial matter, a Guidance Consultant will
››Investment options
talk to you about your specific situation and schedule
››Mortgages, loans and refinancing
a phone appointment for you with one of our staffed
financial experts. ComPsych employs an in-house
staff of experts, including Certified Public Accountants ComPsych®
(CPAs), Certified Financial Planners (CFPs) and other GuidanceResources®
professionals exclusively dedicated to providing Your single source for confidential support,
telephonic information. Our experts are not associated
expert information and valuable resources.
with any financial institution and are thereby able to
provide impartial information. Available 24 hours a day, 7 days a week.
You can make an unlimited number of calls to our
financial experts as you work to make your bank
account fiscally fit.

Call: 877.533.2363 Online: guidanceresources.com

TDD: 800.697.0353 Enter your company Web ID: MY5848i

EB.P.DI.20-1 134531 v.1008 Copyright © 2008 ComPsych Corporation. All rights reserved.
 How Your ComPsych®
GuidanceResources®
Program Can Help

Legal
Issues
In the movies we often hear a character say, Here are a few issues our attorneys
“My attorney will contact you,” but the reality is can help you with:
that few of us have our own attorney. Plus, legal ››Divorce and family law › Wills
matters can be complicated and often times ››Landlord-tenant issues › Living wills
intimidating. For these reasons, GuidanceResources® ››Real estate › Living trusts
offers a legal consultation resource available to you ››Credit issues › Name change
and your dependent family members to help if you ››Immigration › Prenuptial agreement
have legal questions or concerns. Best of all, it is ››DUI/DWI
a free and confidential service.
Please note: GuidanceResources cannot help you with
How it works any employment related issues.
When you call GuidanceResources with a concern
about a legal matter, a Guidance Consultant will talk
to you about your specific situation and schedule a ComPsych®
phone appointment for you with one of our staffed GuidanceResources®
attorneys. If you need more immediate help, you can
be put in a queue to talk to an attorney as soon as one
Your single source for confidential support,
becomes available. expert information and valuable resources.
If following your consultation, your legal matter
Available 24 hours a day, 7 days a week.
requires representation, you can receive a referral to
a local attorney in the GuidanceResources network
whose services are available to you at a discount.
How may we help you?

Call: 877.533.2363 Online: guidanceresources.com

TDD: 800.697.0353 Enter your company Web ID: MY5848i

EB.P.DI.21-2 134532 v.1008 Copyright © 2008 ComPsych Corporation. All rights reserved.
 ING Travel Assistance

Security When You Travel

We live in a highly connected world where frequent domestic

and international travel is the norm. ING Travel Assistance offers
you enhanced security for your leisure and business trips. You and
your dependents will have toll-free or collect-call access to the ING
Travel Assistance customer service center or access to the services
provided on the website 24 hours a day, 365 days a year – from
anywhere in the world.

Covered Services Pre-Trip Information Emergency Personal Services

These valuable services help you In the event of an unexpected situation
When traveling more than 100 miles start your trip the right way. ING of a non-medical nature, ING Travel
from home, ING Travel Assistance Travel Assistance can provide you Assistance offers access to several
offers you and your dependents four with important, up-to-date travel valuable services, including:
types of services: Pre-Trip Information, information including: • Urgent message relay
Emergency Personal Services, Medical • Immunization requirements • Interpretation/translation services
Assistance Services, and Emergency • Visa & passport requirements • Emergency travel arrangements
Transportation Services. • Foreign exchange rates • Recovery of lost or stolen luggage
• Embassy/consular referral or personal possessions
• Travel/tourist advisories • Legal assistance and/or bail bond
• Temperature & weather conditions
• Cultural information

IF YOU NEED EMERGENCY OR PRE-TRIP SERVICES… ING TRAVEL ASSISTANCE

…use the contact information on the reverse and identify yourself as an
eligible participant in the ING Travel Assistance program. Contact ING Travel Assistance 24 hours a day,
You will be asked to provide some additional information in order to confirm 365 days a year for Pre-Trip Information,
your eligibility under this program. Once your eligibility has been verified,
ING Travel Assistance will arrange and provide the Emergency Transportation Emergency Personal Services, Medical Assistance
Services previously described. Services, and Emergency Transportation Services
Please note: Covered services are only eligible for payment through ING Travel
Assistance if ING Travel Assistance was contacted at the time of service and
arranged for the service. If costs are incurred for other services, you are In the US, Toll Free: 800.859.2821
responsible for those costs or reimbursement of Worldwide, Collect: 202.296.8355
those costs if initially paid by ING Travel Assistance;
ING Travel Assistance will ask for your credit card Email: [email protected]
and debit your account for the required amount. Web: www.europassistance-usa.com
User ID- ing Password- assistance

ReliaStar Life Insurance Company, a member of ING

ING TRAVEL ASSISTANCE

Medical Assistance Services Include: Exclusions and Limitations ING Travel Assistance also reserves
• Medical referrals for local A. ING Travel Assistance shall not the right to suspend, curtail or limit
physicians and dentists provide services enumerated if the its services in any area in the event
• Medical case monitoring covered service is sought as a result of rebellion, riot, military uprising,
• Prescription assistance and of your or your dependent’s: war, terrorism, labor disturbance,
eyeglass replacement • Involvement in any act of war, strikes, nuclear accidents, acts of
• Arrangement and payment of invasion, acts of foreign enemies, God or refusal of authorities to
emergency medical services (up to hostilities (whether war is declared permit ING Travel Assistance to
$10,000 with a written guarantee or not), civil war, rebellion, fully provide services.
of reimbursement from the eligible revolution, and insurrection, C. If you request a transport related
participant.) military or usurped power; to a condition that has not been
• Travel against the advice of a deemed medically necessary by a
Emergency physician; physician designated by ING Travel
Transportation Services* • Travel for the purpose of obtaining Assistance in consultation with a
Should you need medical care or medical treatment; local attending physician or to any
assistance while traveling, ING Travel • Travel in any country in which the condition excluded hereunder, and
Assistance can help. When deemed U.S. State Department issued the Employer or Plan Sponsor
medically necessary by an ING Travel travel restrictions; agrees to be financially responsible
Assistance designated physician, • Commission of or attempt to for all expenses related to that
evacuation and transportation to the commit an unlawful act; transport, ING Travel Assistance
nearest adequate medical facility that • Being under the influence of drugs will arrange but not pay for such
can properly treat your condition will or intoxicants unless prescribed by transport to a medical facility or to
be arranged and paid for on your a physician; your residence and will make such
behalf. Additional transportation • Pregnancy and childbirth (except arrangements using the same degree
services include: for complications of pregnancy); of care and completeness as if ING
• Visit of family member or friend • Mental or emotional disorders, Travel Assistance was providing
• Return of traveling companion unless hospitalized; service under this agreement. A
• Return of dependent children • Participation as a professional in waiver of liability will be required
• Return of vehicle athletics; prior to arranging these transporta-
• Return of mortal remains • Services provided for which no tion services.
charge is normally made;
How It Works • Travel within 100 miles of your D. ING Travel Assistance shall not be
At any time before or during a trip, you permanent residence, unless in a responsible for any claim, damage,
may contact ING Travel Assistance for foreign country. loss, cost, liability or expense which
assistance services. It is recommended B. The services described above arises in whole or in part as a result
that you keep a copy of this summary currently are available in every of ING Travel Assistance’s inability
with your travel documents. Use the country of the world. Due to to reach the Employer’s or Plan
wallet card to have convenient access political and other situations in Sponsor’s authorized Contact
to the numbers that you need. certain areas of the world, ING person for any reason beyond ING
Travel Assistance may not be able Travel Assistance’s control, or as a
* The services listed above are subject to a maximum
combined single limit of $150,000. to respond in the usual manner. result of the failure and/or refusal
It is your responsibility to inquire of the Employer or Plan Sponsor to
whether a country is “open” for authorize services proposed by ING
assistance prior to your departure Travel Assistance.
and during your stay.

www.ing.com/us www.ingemployeebenefits-us.com
Products that span the financial spectrum. Distribution through customers’ channel of choice. Services to help manage financial, benefits, and retirement programs. The ING family of
companies in the United States provides financial solutions for individuals, organizations and companies. Through a network of wholly owned, indirect subsidiaries, we help people pre-
pare for a financial future. Your goals are our business. Insurance products and services provided by ReliaStar Life Insurance Company. ING Travel Assistance services provided by Europ
Assistance USA, 1825 K Street N.W., Suite 1000, Washington, DC 20006. Products and services may not be available in all states. © 2007 ING North America Insurance Corporation.

PDF.EB.P.MS.33-2 (9/07) Retirement Insurance Investments Your future. Made easier.SM

 Funeral Planning and Concierge Service
Offered through ING Employee Benefits

The death of a family member is one of life’s most stressful times. It requires grieving survivors to
quickly make many decisions about funeral services, something most of us know little about.

Employees and eligible family members have access to Everest Funeral Planning and Concierge
Service to assist with funeral planning and negotiation at time of need as well as pre-planning tools
that can be used to research and document decisions and wishes.

Everest is an independent service that works exclusively on behalf of their clients and is not
associated with any funeral home or service provider.

Services Provided by Everest

Employees eligible for Group Life coverage, their spouse/partner and children under the age of 25
are entitled to the following services at no cost:

• Unlimited use of Everest's secure, online planning tools to include personalized PriceFinder
Reports that compare local funeral home prices nationwide.

• Round-the-clock, toll-free access to Everest Advisors who can answer general funeral planning
questions.

• Concierge services at or near the time of death, to provide personal assistance including
planning a funeral or memorial service and negotiating prices with the funeral home(s)
selected by the family.

Additional Information & Access

To access this benefit go to the Everest Enrollment site to create your personal user ID and profile
which can be used to enter Everest’s Planning Tools Center.

www.everestfuneral.com/ing

If you do not have internet access, or would like further information or assistance, contact an
Everest Service Advisor at 1-877-456-5050.

Insurance products are issued by ReliaStar Life Insurance Company and ReliaStar Life Insurance
Company of New York, members of the ING family of companies. Only ReliaStar Life Insurance
Company of New York is admitted and its products issued, within the state of New York. Products
and services may not be available in all states. Funeral Planning and Concierge Service provided by
Everest Funeral Package, LLC., 1300 Post Oak Blvd., Suite 1210, Houston, TX 77056
MANAGEMENT DISABILITY PLANS

LONG TERM DISABILITY PLAN (LTD)

SHORT TERM DISABILITY GUIDELINES

MANAGEMENT LONG TERM DISABILITY PLAN (LTD)

GENERAL INFORMATION

Stanislaus County offers Management/Department Head employees a Management Long Term

Disability (LTD) plan through ReliaStar Life Insurance Company.

LTD, insurance provides financial protection for eligible employees by paying a portion of their
income while they are disabled. Some disabilities many not be covered or may have limited
coverage. The amount an individual receives is based on the amount of their monthly pre-disability
earnings. In some cases, eligible employees can receive disability payments even if they work while
they are disabled.

BENEFITS AT A GLANCE

Eligible Class(es):

 All Management & Department Head employees who have completed the waiting period and
who are in active employment for a minimum of 25 hours per week in the employ of the
employer (herein referred to as employees within the eligible classes).

 Employees must be citizens or residents of the United States or Canada.

Waiting Period:

 The waiting period is the period of time between the date of the active employment and the first
day of the calendar month coincident with or next following the date of employment.

 Except that, if you are an employee on the date of issue and have previously satisfied the waiting
period, there is no waiting period.

 If your employment ends and you are rehired within one year, your previous work while in an
eligible class will apply towards the waiting period. All other contract provisions apply.

Elimination Period:

 360 days

 Benefits begin the day after the elimination period is completed.

Gross Monthly Benefit:

 60% of monthly pre-disability earnings to a maximum of $6,000 per month.

03/03
 MANAGEMENT SHORT-TERM DISABILITY GUIDELINES

Management employees who are medically unable to work due to illness or injury
(other than job-related illness or injury, which is already covered by Worker's
Compensation,) maybe eligible to receive 50% of their monthly salary. The Short-term
Management Disability Plan (STD) is a self-insured program that provides 11 months
of benefits once the 30 consecutive calendar day waiting period has been satisfied.
Benefits start on the 31st day of the disability and benefits are coordinated with
available accruals for maximum of 11 months per disability. Note: This plan was
designed to provide managers' with short-term coverage while meeting County’s fully
insured Long Term Disability plan’s 360 day elimination period. LTD benefits begin
the day after the elimination period has been completed. (See Management LTD
brochure)

Reminder: Eligible employees should be placed on Family Medical Leave if they

meet eligibility requirements. See FMLA Procedures.

Procedure to Complete Management Disability Claim Statement:

1. The employee or Department Head must complete and sign application. Forms
not fully completed will be returned.
2. The employee or Department Head must attach a completed and signed
Attending Physician’s Statement of Impairment and Function form. This form
will provide medical proof that employee’s illness or injury is disabling to the
point where employee is unable to perform the essential functions of their
position. Also, the Physician’s Statement will include a expected return to work
date.
3. Submit the signed and dated claim form with Attending Physician’s Statement
of Impairment and Function form to the CEO-Risk Management Division.
4. Employee is responsible for submitting a physician note after each physician
visits or no less than quarterly throughout the 12 month short-term disability
plan to CEO-Risk Management Division.
5. Annual sick accruals normally given to employees on January 1st will not be
credited while employee is still out on disability but will be credited per pay
period as appropriate.
6. Each new illness or injury requires employee to meet a 30 consecutive day
waiting period and entitles employee to maximum of 11 months of benefits. If
an employee returns to work for more than 30 days and then goes out again,
they will need to file a new claim form, provide physician note and meet a new
30 consecutive day waiting period. After meeting the new waiting period for
the same illness or injury, Employee will be eligible to use the remainder of
their maximum of 11 months of benefits.
7. During 30 consecutive day waiting period, 100% of employee’s paycheck will
come from employee’s accruals. Beginning on 31st day, reimbursement will be
50% accruals and 50% County disability plan.
K:Benefits/Mgt Short Term Disabiltiy
Rev. 5/20/04
 CHIEF EXECUTIVE OFFICE
Risk Management Division

1010 10TH Street, Suite 5900, Modesto, CA 95354

P.O. Box 1723, Modesto, CA 95353-1723

Phone: 209.525.5710 Fax: 209.525.5779

Management Short Term Disability Claim Statement

One of the management employee benefits is a self-insured limited income protection plan. This plan provides that if you are
temporarily unable to work due to illness or injury (other than job related illness or injury which is already covered by Workers’
Compensation) the county will continue paying 50% of your monthly salary for up to twelve months starting on the 31st day of
disability.

To be eligible for the benefit, an employee must file this form with Risk Mgmt. It must be completed and returned to Risk Mgmt.
within 30 days of the “first day of disability”. A Department Head may file a claim on behalf of an eligible employee.

The employee must attach to this claim form, medical proof that the illness or injury is disabling to the point where the employee
cannot continue on the job. Medical proof in the form of a statement from a physician or psychiatrist is subject to independent
verification by a county paid medical examination.

To be completed by Employee
Full Name of employee (please print) male Date of Birth
female
Occupation

Nature of sickness or injury (if due to accident, explain when, where and how Date of first medical treatment
it happened) for this condition

Date on which you were first unable

to work because of this condition

My 30 day waiting period will be from _____________________________ to ________________________

If you have recovered or returned to work, give date If still totally disabled, when do you expect to return to work?

Names and addresses of physician who have been consulted because of this condition

Name Address

Have you been confined to a hospital for this disability? Yes No If yes, please complete

Name of Hospital Address from through

I hereby authorize any physician, hospital or other institution or person to furnish County of Stanislaus or its authorized representative, any
information which they may request concerning my medical history or any examination, treatment, or prescriptions I may have received. A
photostatic copy of this authorization shall be considered as effective and valid as the original.

Date ___________________ Signature of Employee or / Department Head __________________________________

♦ When you have completed this form, please return to Risk Mgmt. along with Attending Physician’s Statement
 CONTENTS
OUTLINE OF COVERAGE . . . . . . . . . . . . . . . . . . . . . . . . 1

CERTIFICATION PAGE . . . . . . . . . . . . . . . . . . . . . . . . . . 2

SCHEDULE OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . 3

EMPLOYEE'S INSURANCE . . . . . . . . . . . . . . . . . . . . . . . 5

DISABILITY INCOME INSURANCE . . . . . . . . . . . . . . . . . . . 7

CONVERSION RIGHTS . . . . . . . . . . . . . . . . . . . . . . . . . 13

CLAIM PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . . 14

GENERAL PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . 15

DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

B-8313 (8-09 DRAFT)

C00TC

i
 CONTENTS
IF YOU HAVE A QUESTION ABOUT YOUR POLICY, IF YOU NEED
ASSISTANCE WITH A PROBLEM, OR IF YOU HAVE QUESTIONS
ABOUT A CLAIM, YOU MAY WRITE OR CALL US AT:
ReliaStar Life Insurance Company
P.O. Box 20
Minneapolis, Minnesota 55440
Telephone Number: (800) 955-7736
YOU WILL NEED TO PROVIDE YOUR POLICY NUMBER WITH ANY
COMMUNICATION.
IF YOU DO NOT REACH A SATISFACTORY RESOLUTION AFTER
HAVING DISCUSSIONS WITH US, OR OUR AGENT OR REPRESEN-
TATIVE, OR BOTH, YOU MAY CONTACT THE FOLLOWING UNIT
WITHIN THE DEPARTMENT OF INSURANCE THAT DEALS WITH
CONSUMER AFFAIRS:
California Department of Insurance
Consumer Communications Bureau
300 South Spring Street, South Tower
Los Angeles, California 90013
Outside Los Angeles: 1-800-927-HELP (1-800-927-4357)
Los Angeles: (213) 897-8921

ii
 RELIASTAR LIFE INSURANCE COMPANY
OUTLINE OF COVERAGE
This outline is only a summary of certain provisions in your certif-
icate. You must consult the policy and certificate for contract pro-
visions regarding coverage.
Disability Income Protection Coverage
Section(s) of Certificate
BENEFITS ............................................................ Schedule of Benefits
Disability Income Insurance
EXCEPTIONS, REDUCTIONS
AND LIMITATIONS .............................................. Schedule of Benefits
Disability Income Insurance
General Provisions
ELIGIBILITY, TERMINATION
AND CONTINUATION ....................................... Employee's Insurance
PREMIUMS: Information about your premium contribution for cov-
erage may be obtained from the Participating Employer.

1
 RELIASTAR LIFE INSURANCE COMPANY
Minneapolis, Minnesota 55440
ReliaStar Life Insurance Company (ReliaStar Life) certifies that it has
issued the Group Policy listed below to the Policyholder. All benefits are
controlled by the terms and conditions of the Group Policy.
The Group Policy is on file in the Policyholder's office. You may look at
the Group Policy there.
ReliaStar Life also certifies that the person named below is insured
under the Group Policy.

31640-7DISABILITY
CSAC Excess Insurance Authority

*If you are actively at work on the effective date. If you are not, your
insurance is effective on the date you return to active work.
The insurance included in this certificate applies to you only if you have
elected and are insured for it.
The certificate summarizes and explains the parts of the Group Policy
which apply to you. This certificate is not an insurance policy. In any
case of differences or errors, the Group Policy rules.
This certificate replaces any other certificates ReliaStar Life may have
given you under the Group Policy.

Registrar

2
 SCHEDULE OF BENEFITS
Disability Income Insurance – Monthly Income Benefits
The Monthly Income Benefit is calculated as follows:

Total Disability The lesser of 60% of your Basic Monthly

Earnings or $6,000, minus Other Income.

Partial Disability (A divided by B) times C, minus Other

Income.

A = your indexed Basic Monthly Earnings minus your current monthly

earnings.
B = your indexed Basic Monthly Earnings.
C = The benefit you would receive if you were totally disabled (before
Other Income is subtracted).
"Other Income" does not include sick leave benefits provided through
your employer until the gross monthly benefit plus your sick leave bene-
fits exceed 100% of your Basic Monthly Earnings.
Note: During the first 12 months of Monthly Income Benefits, your
Monthly Income Benefit will not be reduced by any current monthly
employment earnings until the gross monthly benefit plus your current
monthly employment earnings exceed 100% of your pre-disability Basic
Monthly Earnings. Your Monthly Income Benefit will then be reduced
by that excess amount.
In no event will your Monthly Income Benefit plus Other Income be
greater than your predisability Basic Monthly Earnings.
Basic Monthly Earnings – your monthly salary or wage on the day
before the date you became disabled. It does not include bonuses,
commissions or overtime pay. For Partial Disability, Basic Monthly
Earnings are indexed. To determine indexed Basic Monthly Earnings,
your predisability Basic Monthly Earnings are increased by 5% on the
one-year anniversary of your first benefit.
Minimum Monthly Income Benefit ....... The greater of $100 or 15% of
the Gross Monthly Income Benefit
Benefit Waiting Period ............................................................ 360 days

3
 SCHEDULE OF BENEFITS
Maximum Benefit Period

Age at disability Maximum benefit period

• Less than age 61 to age 65
• 61 but less than 62 48 months
• 62 but less than 63 42 months
• 63 but less than 64 36 months
• 64 but less than 65 30 months
• 65 but less than 66 24 months
• 66 but less than 67 21 months
• 67 but less than 68 18 months
• 68 but less than 69 15 months
• 69 and over 12 months

Survivor Benefit ............................... 3 times the gross monthly benefit,

subject to any necessary adjustments

4
 EMPLOYEE'S INSURANCE
Eligibility
The employee is eligible on the first day of the month on or after the
date the employee starts continuous service with the Participating
Employer.
The employee must meet the following conditions to become insured –
• Be eligible for the insurance.
• Be actively at work.
• Apply for the insurance, if the employee must pay any part of the
premium.
• Give ReliaStar Life proof of good health, which it approves, if the
employee applies for insurance more than 31 days after becoming eli-
gible.
Effective Date of Employee's Insurance
The employee's insurance starts on the latest of the following dates:
• The date the employee becomes eligible.
• The date the employee returns to active work if the employee is not
actively at work on the date insurance would otherwise start. Excep-
tion: The employee's insurance starts on a nonworking day if the
employee was actively at work on the employee's last scheduled
working day before the nonworking day.
• The date the employee applies for insurance, if the employee must
pay any part of the premium.
• The date ReliaStar Life approves the employee's proof of good health,
if proof is required.
Effective Date of Change in Amount of Insurance
If there is an increase in the amount of your insurance, the increase will
take effect on –
• the effective date of the increase, if you are actively at work on that
date.
• the date you return to active work, if you are not actively at work on
the date your insurance increases.
• the nonworking day on which the increase was effective, if you were
actively at work on your last scheduled working day before the non-
working day.
A decrease in the amount of your insurance will take effect on the date
of the decrease.

5
 EMPLOYEE'S INSURANCE
Termination of Insurance
Your insurance stops on the earliest of the following dates:
• The date you are no longer actively at work for the Participating
Employer.
• The date you are no longer eligible for insurance under the Group
Policy.
• The date the Group Policy stops.
• The date you retire.
• The date the Participating Employer stops subscribing to the agree-
ment establishing the CSAC Excess Insurance Authority.
ReliaStar Life stops providing a specific benefit to you on the date that
benefit is no longer provided under the Group Policy.
Family and Medical Leave Act of 1993
Certain employers are subject to the FMLA. If you have a leave from
active work certified by your employer, then for purposes of eligibility
and termination of coverage you will be considered to be actively at
work. Your coverage will remain in force so long as you continue to
meet the requirements as set forth in the FMLA.
Reinstatement
ReliaStar Life will reinstate your insurance if you stop work and then
return to work within 12 months. You will be eligible for insurance on
the date you return to active work with the Participating Employer.

6
 DISABILITY INCOME INSURANCE
Monthly Income Benefits
Qualifying for Benefits
ReliaStar Life pays benefits if you become disabled and qualify to
receive benefits. The benefit payable is based on the Schedule of Ben-
efits in effect on the date you became disabled.
To qualify for benefits, all of the following conditions must be met:
You must –
• be insured on the date you become disabled and the condition
causing your disability is not excluded from coverage.
• be insured on the date the benefit waiting period begins.
• send written notice of the disability as described in the Claim Proce-
dures Section.
• be receiving regular and appropriate care and treatment.

Benefit Waiting Period

The benefit waiting period is the length of time you must be contin-
uously disabled before you qualify to receive any benefits. Exception:
You may return to work for up to 30 days during the benefit waiting
period without having to begin a new benefit waiting period. The days
you work do not count toward meeting the benefit waiting period. Any
part of a day worked will count as a full day for purposes of this section.
The benefit waiting period begins on the first day you see a doctor and
he or she states in writing that you are disabled because of sickness or
accidental injury.
The benefit waiting period is shown on the Schedule of Benefits.
Benefit Payments
Monthly income benefits are paid at the end of each month for the
period for which you qualified. If you are disabled for part of a month,
the benefit payable is based on 1/30th of your monthly income benefit
for each day you are disabled.
Monthly income benefits are determined as shown on the Schedule of
Benefits. Benefits continue while you are disabled up to the maximum
benefit period shown on the Schedule of Benefits. You must complete
the benefit waiting period before any benefits are payable.

7
 DISABILITY INCOME INSURANCE
Other Income
Other Income is income you and your dependents are eligible to
receive because of one of the following:
• your age.
• the same or related disability for which you are eligible to receive ben-
efits under the Group Policy.
Other Income is subtracted from the benefit you would otherwise
receive, as shown on the Schedule of Benefits. ReliaStar Life con-
siders you to be eligible to receive Other Income benefits whether or
not you apply for them, until you send ReliaStar Life written proof that
the benefits were denied or contested. When ReliaStar Life receives
written proof that Other Income benefits were denied or contested,
ReliaStar Life will pay benefits you are qualified to receive. However, if
the denial of Other Income benefits is not final, you must pursue the
Other Income Benefits to the fullest extent possible.
Other Income includes, but is not limited to, the following:
• Federal Social Security benefits.
• State Disability benefits.
• Railroad Retirement Act benefits.
• Other government disability or retirement income.
• Worker's Compensation benefits.
• No fault accident wage replacement plan benefits.
• Sponsored short term or long term disability income or retirement plan
benefits. Sponsored means that your past or present employer admin-
istered, paid part of the cost of, or made a payroll deduction for the
plan.
Other Income also includes the following:
• Salary continuance benefits provided through your employer.
• Salary, commission, bonus or any other income you earn from any
work while receiving benefits, except as explained for Partial Disability
or the Rehabilitative Work Benefit.
Other income includes only the following retirement benefits:
• Early retirement benefits you are receiving that are voluntarily
selected.
• Retirement benefits that are unreduced by age for which you are eli-
gible on the later of the following:
– the date you reach age 62.
– normal retirement age.
ReliaStar Life considers retirement benefits received before age 62, or if
later, before normal retirement age, to be voluntarily elected until you
provide written proof satisfactory to ReliaStar Life that you did not elect
to receive benefits voluntarily.

8
 DISABILITY INCOME INSURANCE
Exceptions: Benefits will not be reduced by –
• retirement benefits attributable to employee contributions.
• retirement or disability benefits you receive from a past employer, if
these benefits have been paid continuously to you for more than 2
years before you become eligible to receive benefits under the Group
Policy.
• benefits paid by a group or franchise creditor disability plan.
• income received from a profit sharing plan, thrift plan, individual retire-
ment account, tax sheltered annuity, stock ownership plan, or a non-
qualified plan of deferred compensation.
• disability or retirement benefits which are received under an employ-
er's retirement plan but are rolled over or transferred to any eligible
retirement plan as defined by the Internal Revenue Code.
• Federal Social Security benefits if your disability begins after age 70
and you were receiving Social Security benefits while continuing to
work.
• a cost of living increase to any other income benefit after the initial
other income benefit becomes payable.
Minimum Monthly Income Benefit
If you receive Other Income, it will be subtracted from the benefit you
would otherwise receive. However, after you qualify for monthly income
benefits, ReliaStar Life will pay you at least the minimum monthly
income benefit shown on the Schedule of Benefits.
Lump Sum Payments
Other Income you receive as a lump sum will be prorated into monthly
amounts. The prorated amount will be subtracted from the benefit you
would otherwise receive, until the total amount subtracted equals the
lump sum payment. ReliaStar Life will determine the prorated amount
using the first of the following methods that applies:
• Divide the Other Income lump sum into monthly amounts based on
the amount of Other Income you were receiving from the same source
prior to receiving the lump sum payment.
• Divide the Other Income lump sum into monthly amounts based on
the monthly amount you could have received in lieu of the lump sum
payment.
• Divide the Other Income lump sum into monthly amounts over the
remaining maximum benefit period.

9
 DISABILITY INCOME INSURANCE
Overpayment
If ReliaStar Life pays you a larger benefit than you should have
received, ReliaStar Life may recover any overpayments it made.
ReliaStar Life will recover from you the full amount of the overpayment
through one or more of the following means:
• Require you to return the overpayment in one lump sum.
• Stop payment of benefits until the full overpayment is repaid.
• Require you to assign any Other Income to ReliaStar Life.

Any minimum monthly income benefit otherwise payable will not be paid
until the overpayment is recovered.
Waiver of Premium
ReliaStar Life waives your premium during any period for which monthly
income benefits are payable. If ReliaStar Life waives your premium it is
the Policyholder's responsibility to refund to you any contribution you
may make after qualifying for benefits.
Termination of Benefits
ReliaStar Life stops paying benefits on the earliest of the following:
• The date you are no longer disabled.
• The end of the maximum benefit period for any one period of disa-
bility. The maximum benefit period is shown on the Schedule of Ben-
efits.
• The date you no longer qualify for benefits under all the conditions
listed.
• The date of your death.
• The date you fail to provide written proof of disability.
• The date you cease to be under regular and appropriate care of a
doctor, or unreasonably refuse to undergo an examination by a doctor
of ReliaStar Life's choosing.
• The date you unreasonably refuse to receive medical treatment that is
generally acknowledged by doctors to cure or improve your condition
so as to reduce its disabling effect.
• The date you unreasonably refuse to work with the assistance of mod-
ifications made to your work environment, functional job elements or
work schedule, or adaptive equipment or devices, that a qualified
doctor has indicated will accommodate the limiting factors of your
medical condition.
If the Group Policy or the Disability Income Insurance part of the Group
Policy terminates after you qualify to receive benefits, ReliaStar Life
continues your benefit payments. Benefits are paid as long as you con-
tinue to qualify according to the terms of the Group Policy in effect on
the date you qualified.

10
 DISABILITY INCOME INSURANCE
Recurrent Disability
If you are receiving monthly income benefits, a recurrent disability is a
disability due to the same cause which occurs after you have returned
to full-time work for less than 6 months.
ReliaStar Life pays benefits for a recurrent disability which is a contin-
uation of a previous disability.
A recurrent disability has –
• no additional benefit waiting period.
• the same maximum benefit period as the previous disability.

Benefits payable under this recurrent disability provision will stop if ben-
efits are payable to you under any other group disability policy.
Exclusions
ReliaStar Life will not pay benefits if your disability results from any of
the following:
• Sickness or injury which occurs in any armed conflict, whether
declared as war or not, involving any country or government.
• Sickness or injury which occurs while you are on military service for
any country or government.
• Intentionally self-inflicted injury, whether you are sane or insane.
• Injury which occurs when you commit or attempt to commit a felony.
• Injury suffered in a fight in which you are the aggressor.
• Sickness or injury which is the result of a pre-existing condition, if you
become disabled during the first 12 months your insurance is in effect.
A pre-existing condition is a sickness or accidental injury for which,
during the 3 months immediately before the date your insurance
started, you did one or more of these:
– Saw a doctor for treatment.
– Received medical services or advice.
– Took prescribed drugs.
ReliaStar Life will not pay benefits for the portion of any period of disa-
bility that you are confined in a penal or correctional institution as a
result of conviction for a criminal or other public offense.
ReliaStar Life will not pay an additional benefit for disability caused by
both sickness and accidental injury or by more than one sickness or
accidental injury.
Rehabilitative Work Benefit
You may receive adjusted benefits if you qualify and engage in
rehabilitative work. To qualify for adjusted benefits you must provide
ReliaStar Life with proof of your earnings upon request and you must
be working –
• for pay or profit, and
• under an approved rehabilitation program.

11
 DISABILITY INCOME INSURANCE
The amount of your adjusted benefit will be your monthly income
benefit minus 50% of the income you receive from rehabilitative work.
If you are receiving monthly income benefits, your adjusted benefit will
not be less than the minimum monthly income benefit shown on the
Schedule of Benefits.
If the conditions listed above are met, the Rehabilitative Work Benefit
will apply on the later of the following dates:
• Twelve months following the date monthly income benefits become
payable.
• The date monthly income benefits for partial disability stop.

Limitation for Mental Disorder, Alcoholism or Chemical

Dependency
When disability is due in whole or in part to mental disorder, alcoholism,
or chemical dependency, ReliaStar Life limits monthly income benefits
to a maximum of 24 months while you are not hospital confined.
This maximum applies to any and all such periods of disability during
your lifetime.
If at anytime during the 24 month period, you are hospital confined for
the same disability, ReliaStar Life pays benefits for as long as you
remain hospital confined, up to the maximum benefit period. After your
release from the hospital, ReliaStar Life continues payment of benefits
for any remaining portion of the 24 months for which you are qualified
to receive non-hospitalized benefits.
Survivor Benefit
ReliaStar Life pays the Survivor Benefit shown on the Schedule of Ben-
efits if you die –
• while receiving monthly income benefits, and
• before the end of the maximum benefit period.

ReliaStar Life pays the Survivor Benefit to your lawful spouse. If you do
not have a spouse, ReliaStar Life will pay the benefit in equal shares to
your eligible children, if any. If you do not have a spouse or eligible
children at the time of death, ReliaStar Life will not pay a Survivor
Benefit.
An eligible child is your child under age 19 or student dependent age
19 but less than 23. Child includes your –
• natural or adopted child, who is dependent on you for support and
maintenance.
• child who is placed in your home for purposes of adoption.
• child who is primarily dependent on you for support and lives with you
in a permanent parent-child relationship and who is your stepchild,
foster child, or a child for whom you are legal guardian.

12
 CONVERSION RIGHTS
Disability Income Insurance (Not available to residents
of FL, IN, LA, MI, NY, OR, SD or WV)
If your long term disability insurance stops under the Group Policy, you
may have a Conversion Right. The Conversion Right allows you to
obtain long term disability income insurance without proof of good
health.
Conditions for Conversion
You may convert your long term disability insurance if coverage under
the Group Policy terminates for any of the following reasons:
• You resign.
• You are terminated for cause.
• You are laid-off.
• You go on a leave of absence.

You do not have to supply medical evidence of your insurability to

convert your insurance. You must have been insured for at least 12
consecutive months prior to your insurance terminating under the Group
Policy. The 12 months can be a combination of insurance under the
Group Policy and a prior plan of group long term disability insurance,
whether insured or self-funded, sponsored by the Policyholder.
You must apply for conversion of your insurance and pay the first
premium within 31 days after termination of coverage under the Group
Policy. If approved, your long term disability conversion insurance cov-
erage will become effective on the day after your long term disability
insurance ends under the Group Policy. The benefits and amounts of
insurance under the conversion coverage may differ from those under
the Group Policy. ReliaStar Life reserves the right to have your conver-
sion coverage issued by another insurance company.
You may not convert your insurance under the Group Policy if your
insurance terminates for any of the following reasons:
• Termination of the Group Policy.
• The Group Policy is amended to exclude from coverage the class of
employees to which you belong.
• You no longer belong to a class eligible for coverage under the Group
Policy.
• You retire.
• You fail to pay any contributions required for your insurance.
• You are disabled under the terms of the Group Policy.

If you become covered for long term disability benefits under another
group plan within 31 days after termination of your insurance under the
Group Policy, you may not convert your insurance under the Group
Policy.

13
 CLAIM PROCEDURES
Submitting a Claim
You or someone on your behalf must send ReliaStar Life written notice
of the loss on which your claim will be based. The notice must –
• include information to identify you like your name, address and Group
Policy number.
• be sent to ReliaStar Life or one of its licensed agents authorized to
accept claims.
• be sent within 20 days after the loss for which claim is based has
occurred or as soon as reasonably possible.
Claim Forms
ReliaStar Life or its authorized agent will send proof of loss claim forms
to you or to the Policyholder to give to you. ReliaStar Life will send the
forms within 15 days after ReliaStar Life receives your notice of claim.
You or someone on your behalf must return the completed proof of loss
claim forms to ReliaStar Life within 90 days of the loss. Even if you do
not receive the forms, written proof of loss must be sent to ReliaStar
Life within 90 days after the loss or as soon as reasonably possible.
Written proof of loss includes details of how the loss occurred. It also
includes copies of itemized doctor, hospital and prescription drug bills or
receipts.
Benefit Payments
Benefits under the Group Policy are paid when proof of loss is
received.
Benefits are paid to you. Any monthly income benefit remaining unpaid
at the time of your death will be paid to your survivors or your estate in
the following order:
1. Your spouse.
2. Your children.
3. Your estate.
Time Payment of Claims
Subject to due proof of loss, all accrued benefits payable under the
Group Policy will be paid at the end of each month during the period for
which ReliaStar Life is liable. Any balance remaining unpaid at the end
of such period will be paid as soon as possible after receipt of written
proof of loss.

14
 GENERAL PROVISIONS
Free Choice of Doctor
You have the right to choose any doctor.
Health Insurance Assignment
You may not transfer to anyone else –
• ownership of any certificate issued under the Group Policy.
• Disability Income Insurance under the Group Policy.

Legal Action
Legal action may not be taken to receive benefits until 60 days after the
date proof of loss is submitted according to the requirements of the
Group Policy. Legal action must be taken within 3 years after the date
proof of loss must be submitted.
If the Policyholder's state requires longer time limits, ReliaStar Life will
comply with the state's time limits.
Exam
When reasonably necessary, ReliaStar Life may have you examined
while you are claiming benefits. The exam will be conducted by one or
more doctors of ReliaStar Life's choice. ReliaStar Life has the right to
defer or suspend payment of benefits if you fail to attend an exam or
fail to cooperate with the doctor. Benefits may be resumed, provided
that the required exam occurs within a reasonable time and benefits are
otherwise payable.
Incontestability
Your insurance has a contestable period starting with the effective date
of your insurance and continuing for 2 years while you are living.
During that 2 years, ReliaStar Life can contest the validity of your insur-
ance because of inaccurate or false information received relating to
your insurability. Only statements that are in writing and signed by you
can be used to contest the insurance.

15
 GENERAL PROVISIONS
Reimbursement
If ReliaStar Life pays disability income benefits for sickness or acci-
dental injury caused in whole or part by the act or omission of another,
you must –
• reimburse ReliaStar Life for the benefits paid if you recover damages
for lost income by settlement, court order, judgement or otherwise.
• provide ReliaStar Life with a lien and order directing reimbursement
for benefits. The lien and order may be filed with –
– the person whose act caused the sickness or accidental injury,
– their agent,
– the court, or
– your attorney.
• cooperate with ReliaStar Life, including execution, completion, and
filing of any document deemed by ReliaStar Life necessary to protect
its reimbursement rights.
ReliaStar Life has a first priority claim against –
• amounts which are or may be subject to reimbursement.
• any person who is or may be obligated to pay damages for lost
income. This includes any insurer of you.
ReliaStar Life will be reimbursed first before other claims against
amounts recovered or recoverable from persons who are or may be
obligated to pay damages for lost income, even if the amounts are not
enough to reimburse ReliaStar Life in full or compensate you in full for
damages sustained.
ReliaStar Life has no obligation to pay attorney's fees or other legal
fees to your attorney for recovery of amounts subject to reimbursement.
ReliaStar Life will have the right to intervene in any suit or other pro-
ceedings to protect its reimbursement rights. Any settlement proceeds
received by you or your attorney will be held in trust for ReliaStar Life's
benefit. ReliaStar Life's rights herein are binding upon and enforceable
against your legal representatives, heirs, next of kin, and successors in
interest.

16
 DEFINITIONS
Accidental Injury – bodily injury resulting from a sudden, violent, unex-
pected and external event. ReliaStar Life considers all injuries received
in one accident as one accidental injury. Infection resulting from a cut
or wound caused by an accident is also an accidental injury.
Accidental injury does not include poisoning, disease or any other type
of infection, except as stated above.
Active Work, Actively at Work – the employee is physically present
at his or her customary place of employment with the intent and ability
of working the scheduled hours and doing the normal duties of his or
her job on that day.
Alcoholism – a disorder of psychological and/or physiological depend-
ence or addiction to alcohol which results in functional (physical, cogni-
tive, mental, affective, social or behavioral) impairment.
Approved Rehabilitation Program – a process of receiving medical,
psychological or vocational services intended to restore you to a condi-
tion that allows you to perform your own occupation or any occupation
which you are or could reasonably become qualified to do by education,
training or experience. The program must have ReliaStar Life and
doctor approval for your return to work.
Chemical Dependency – a disorder of psychological and/or physiolog-
ical dependence or addiction to psychoactive drugs or medications
which results in functional (physical, cognitive, mental, affective, social
or behavioral) impairment.
Complication of Pregnancy – a condition that requires hospital con-
finement and that is distinct from pregnancy, but is adversely affected
or caused by pregnancy. Examples are: acute inflammation or disease
of the kidney or bladder, cardiac decompensation, missed abortion, an
ectopic pregnancy, nonelective caesarean section, and eclampsia.
Complication of pregnancy does not include: normal delivery, elective
caesarean section, miscarriage, elective abortion, false labor, occa-
sional spotting, morning sickness, excessive vomiting, preeclampsia
and other conditions associated with a difficult pregnancy.
Damages for Lost Income – any payments which in whole or part can
reasonably be considered compensatory for lost income, regardless of
designation.

17
 DEFINITIONS
Disability, Disabled – Partial or Total Disability as defined below.
Partial Disability, Partially Disabled – sickness or accidental injury
which has caused the following:
• During the benefit waiting period and the first 24 months of disability
benefits, you are able to perform at least one of the essential duties of
your regular occupation on a full-time or part-time basis but you are
unable to perform all of the essential duties of your regular occupation
on a full-time basis and as a result you are unable to earn more than
80% of your basic monthly earnings.
Economic factors such as, but not limited to, recession, job obsoles-
cence, paycuts, and job sharing will not be considered in determining
whether you meet the requirements stated above.
Total Disability, Totally Disabled – sickness or accidental injury which
has caused the following:
• During the benefit waiting period and the first 24 months of disability
benefits, the inability to perform with reasonable continuity all of the
essential duties of your regular occupation and as a result you are not
working at all.
• After you have qualified for monthly income benefits for 24 months,
the inability to perform with reasonable continuity all of the essential
duties of any gainful occupation and as a result you are not working at
all.
Economic factors such as, but not limited to, recession, job obsoles-
cence, paycuts, and job sharing will not be considered in determining
whether you meet the requirements stated above.
Doctor – a person who is licensed to practice medicine in the state in
which treatment is received and is providing treatment or advice in
accordance with the license. He or she must possess the necessary
training and qualifications, according to generally accepted medical
standards, to evaluate and treat your condition.
A doctor is a person other than:
• you.
• anyone related to you by blood or marriage.
• an employee of the employer.
• anyone living with you.

18
 DEFINITIONS
Employee – an active Management Employee residing in the United
States who is employed by the County of Stanislaus (a Participating
Employer) and is regularly scheduled to work on at least a
25-hour-per-week basis.
Such employees of the following companies and affiliates controlled by
the Participating Employer are included: Stanislaus Council of Govern-
ments.
Temporary and seasonal employees are excluded.
Essential Duties – substantial and material acts necessary to pursue
an occupation in the usual and customary way. If you were normally
required to perform essential duties in excess of 40 hours per week or
8 hours per day prior to becoming disabled, ReliaStar Life will consider
you still able to perform the essential duties if you are working or have
the capacity to perform such duties at least 40 hours weekly or 8 hours
daily.
Gainful Occupation – any occupation that you could reasonably be
expected to perform satisfactory in light of your age, education, training,
experience, station in life, and physical and mental capacity.
Gross Monthly Benefit – your monthly income benefit before other
income is subtracted.
Group Policy – the written group insurance contract between ReliaStar
Life and the Policyholder.
Hospital – an institution licensed as a hospital in the state in which it is
located, which meets the following conditions:
• Provides, for a fee from its patients, diagnostic, medical, surgical, psy-
chiatric or rehabilitative services for the care and treatment of people
who are injured or sick.
• Has a staff of one or more doctors available at all times.
• Has 24-hour-a-day services of R.N.'s or other nursing services
reporting to the doctor in charge.
• Has inpatient facilities.
• Is accredited by one of the following:
– The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO).
– American Osteopathic Hospital Association (AOHA).
– American Osteopathic Association (AOA).
– Commission on Accreditation of Rehabilitation Facilities (CARF).
Hospital is not an institution that is mainly a rest home, extended care
facility or home for the aged.

19
 DEFINITIONS
Mental Disorder – a clinically significant behavioral or psychological
syndrome or pattern that occurs in a person and is associated with
present distress (a painful symptom) or disability (impairment in one or
more important areas of functioning) or with significantly increased risk
of suffering death, pain, disability, or an important loss of freedom.
ReliaStar Life uses standard classification manuals such as the Diag-
nostic and Statistical Manual of Mental Disorders and International
Classification of Diseases to determine whether a condition should be
considered a mental disorder.
Determination of a mental disorder is made regardless of its original
cause.
Nonworking Day – a day on which the employee is not regularly
scheduled to work, including time off for the following:
• Vacations.
• Personal holidays.
• Weekends and holidays.
• Approved nonmedical leave of absence.

Nonworking day does not include time off for any of the following:
• Medical leave of absence.
• Temporary layoff.
• The Participating Employer suspending its operations, in part or total.
• Strike.

Period of Disability – all periods of disability which have the same

cause are considered one period of disability. A new period of disability
begins when any of the following happen:
• You become disabled due to the same cause after you have been
actively at work on a full-time basis with the Participating Employer
continuously for at least 6 months.
• The new disability results from a cause or causes unrelated to that of
any previous disability, separated by active work with the Participating
Employer.
Policyholder – CSAC Excess Insurance Authority. A Participating
Employer is defined as a unit of government who has subscribed to the
agreement establishing the CSAC Excess Insurance Authority.

20
 DEFINITIONS
Regular and Appropriate Care – means:
• You personally visit a doctor or licensed practitioner supervised by a
doctor as often as is medically required, according to generally
accepted medical standards and consistent with the stated severity of
your medical condition, to effectively manage and treat your sickness
or injury.
• You are receiving care which conforms with generally accepted
medical standards for treating your sickness or injury and is consistent
with the stated severity of your medical condition.
• Care is rendered by a doctor whose specialty or experience is appro-
priate for your disability according to generally accepted medical
standards.
Regular Occupation – the activity which, immediately prior to disa-
bility, you were regularly performing and which was your source of
income from the Participating Employer.
Your regular occupation is not limited to the specific position that you
held with the Participating Employer.
ReliaStar Life – ReliaStar Life Insurance Company, at its Home Office
in Minneapolis, Minnesota.
Sickness – any physical illness, mental disorder, normal pregnancy or
complication of pregnancy.
Written, In Writing – signed, dated and received at ReliaStar Life's
Home Office in a form ReliaStar Life accepts.
You, Your – an employee insured for Employee's Insurance under the
Group Policy.

21
 RELIASTAR LIFE INSURANCE COMPANY
CERTIFICATE BOOKLET RIDER
CSAC Excess Insurance Authority
31640-7DISABILITY
County of Stanislaus
Your certificate has been changed as follows. Please insert this rider in
your certificate. This rider is subject to all of the terms of the Group
Policy.
I. DISABILITY INCOME INSURANCE
The "Survivor Benefit" provision is changed to read as follows:
Survivor Benefit
ReliaStar Life pays the Survivor Benefit shown on the Schedule of Ben-
efits if you die –
• while receiving monthly income benefits, and
• before the end of the maximum benefit period.

ReliaStar Life pays the Survivor Benefit to your spouse or domestic

partner. If you do not have a spouse or domestic partner, ReliaStar
Life will pay the benefit in equal shares to your eligible children, if any.
If you do not have a spouse or domestic partner or eligible children at
the time of death, ReliaStar Life will not pay a Survivor Benefit.
An eligible child is your child under age 19 or student dependent age
19 but less than 23. Child includes your –
• natural or adopted child, who is dependent on you for support and
maintenance.
• child who is placed in your home for purposes of adoption.
• child who is primarily dependent on you for support and lives with you
in a permanent parent-child relationship and who is your stepchild,
domestic partner's child, foster child, or a child for whom you are legal
guardian.

RB-8313-1
II. CLAIM PROCEDURES
The "Benefit Payments" provision is changed to read as follows:
Benefit Payments
Benefits under the Group Policy are paid when proof of loss is
received.
For Disability Income Insurance, benefits are paid to you. Any monthly
income benefit remaining unpaid at the time of your death will be paid
to your survivors or your estate in the following order:
1. Your spouse or domestic partner.
2. Your natural and adopted children.
3. Your estate.
III. DEFINITIONS
The following definition is added:
Domestic Partner – another adult with whom you have registered
your domestic partnership with the California Secretary of State. A
copy of the certified registration form may be required as proof.
IV. EFFECTIVE DATE
This Certificate Booklet Rider is effective on the later of the following
dates:
• January 1, 2005.
• The effective date of your insurance.

Registrar

RB-8313-2
 IN CASE OF THE DEATH OF A COUNTY EMPLOYEE/RETIREE

If an employee dies while at work report the death to the Chief Executive Office and the CEO-RMD as
soon as practicable. This may require a mandatory report to OSHA (within 8 hours of our knowledge -
see OSHA Reporting Requirements on page 2 of this document). If the employee dies during non-work
hours please report the death to CEO-RMD the next business day. The following is a list of resources
that may be of use to a deceased employee’s family:

Employee Assistance Program

Employees and their immediate family members also have access to CompPsych available 24
hours a day, seven days a week at 877-533-2363 or on line at https://guidanceresources.com. The
County’s company Web ID is MY5848i.

Funeral Planning and Concierge Service

Employees with County life insurance and their e ligible family members have access to Everest
Funeral Planning and Concierge Servi ce (1-877-456-5050) to assist with fu neral planning and
negotiation at tim e of need as well as pre-pl anning tools that can be us ed to res earch and
document decisions and wishes. Additional information can be found at:
http://www.stancounty.com/riskmgmt/common/docs/eb-forms/eap-funeral.pdf

Retirement Benefits
Contact StanCERA at 209-525-6393. Cash-out of retirement benefits and
or death benefit for the Retiree are administered by StanCERA. A copy of the death certificate is
required. A copy of the marriage license may also be required. The family should call ahead to
determine what documentation will be required.

Health Department
820 Scenic Drive, Modesto, (phone (209) 558-8070) Death certificates, are provided by the
Health Department at a current fee of $10.00 per copy. Families will need death certificates for
many purposes related to benefits and insurance. Note: For confirmation of copy fee, please call
the above number as prices are subject to change.

Sheriff’s Office-Coroner’s Division

939 Oakdale Road, Modesto, (phone (209) 525-4630). If the death is under investigation,
survivors may need the assistance of this office in many matters involving the death certificate,
funeral arrangements, etc.

Veterans Burial Benefits

121 Downey Ave Ste 102, Modesto, (phone (209) 558-7380) This office can assist with
information regarding Veteran’s burial benefits, life insurance or other relevant benefits if the
employee/retiree was a veteran of the armed forces.

Social Security Administration

1521 N Carpenter Rd Ste E-1, Modesto,
(phone (209) 523-2670) Survivors should contact the Social Security Office nearest to their home
to determine what Social Security benefits might be available to the employee/retiree’s survivors.

ValleyFirst Credit Union

1419 J Street, Modesto, (phone (209) 549-8500). If the employee/retiree was a credit union
member, information on loan payment insurance and shares is obtainable here.

06/11
PARS

Eligibility

PARS is a benefit that Stanislaus County provides to all eligible Part Time/Extra Help,
Temporary or Seasonal Employees in lieu of Social Security. In general, all employees must be
covered by Social Security or a qualifying alternative plan (e.g., PARS). There are special rules
for Part Time/Extra Help, Temporary or Seasonal Employees. There are also some employees
who are exempt from coverage.

The following categories of employees are excluded and not eligible for alternative plan
coverage (PARS):

♦ An employee who is a member of a retirement system within the same state or political
subdivision if working for the same employer.

♦ A full time employee that is a member of a retirement system.

♦ Rehired retirees who return to work for the same or another employer in a position covered
by the same retirement system they retired under.

♦ Part time employees that are hired on or after the age of 59 ½.

♦ Elected officials earning less that $1000 annually.

♦ Any employee serving on a temporary basis in case of fire, storm, earthquake, flood, or
other similar emergency or an independent contractor.

♦ Employees not currently accruing a retirement benefit, but who, as a former participant,
previously accrued sufficient deferred benefits to meet the new law’s requirements.

Forms

If an employee is hired into a Part Time/Extra Help, Temporary or Seasonal Position, they must
be given the following forms and information:

♦ Designation of Beneficiary- This form must be completed by the employee. The form is
sent to CEO-Personnel and kept in their file.

♦ SSA-1945 Notification Cover Letter- This letter must accompany the SSA-1945 Notice.

♦ SSA-1945 Notice- This form must be signed by the employee. The form is sent to CEO-
Personnel which will then be forwarded to PARS.

♦ General Information Sheet

♦ Plan Summary

03/07
Distribution Process

Stanislaus County notifies Phase II Systems, the PARS Trust Administrator, of the occurrence
of the events mentioned below:

♦ Separation or Termination- 60 day waiting period for distribution.

♦ Retirement- 60 day waiting period or no waiting period if over 59 ½.

♦ Permanent and Total Disability- No waiting period.

♦ Changed employment status to a position covered by another retirement system (e.g., Part
Time to Full Time)- 24 month waiting period.

♦ Death- No waiting period.

The Request for Distribution is processed by PARS, and a PARS-ARS Distribution Package is
mailed to the Participant (process may take 3-4 weeks depending on the last day of service).
Upon receipt of all correctly completed forms, the PARS Trustee will then process a
distribution of the Participant’s account (process may take up to 90 days).

03/07
 Designation of Beneficiary Form
Public Agency Retirement Services (PARS)
Instructions:
1. Read carefully the rules for designating a beneficiary below, and sign in the spaces provided.
2. Complete the appropriate sections (Section 1 must be completed, see rules below regarding section 2) of this form and return
it to:
County of Stanislaus
Personnel Department
P.O. Box 3404
Modesto, CA 95353-3404
Rules for Designation of Beneficiary:
1. It is your responsibility to keep your Designation of Beneficiary current.
2. You reserve the right to revoke or change your Designation of Beneficiary, subject to the other provisions of
these Rules.
3. If, upon your death, there is no valid Designation of Beneficiary on file with the Trust Administrator, any death benefits which
become due will be paid in accordance with the Plan Document.
4. The plan requires that if you are married, your surviving spouse/registered domestic partner will be your sole primary
beneficiary, unless your spouse/registered domestic partner waives this right.
5. If you wish to designate a person or persons other than your spouse/registered domestic partner or in addition to your
spouse/registered domestic partner, you must obtain the notarized consent of your spouse/registered domestic partner in
writing on this form by completing Section 2. Failure to obtain your spouse/registered domestic partner’s consent in these
instances will render the designation invalid. Any consent by a spouse/registered domestic partner applies only to that
spouse/registered domestic partner and not any future spouse/registered domestic partner. Therefore, if a new marriage
occurs, a new Designation of Beneficiary form should be completed and the new spouse/registered domestic partner’s consent
must be obtained. If you are unmarried complete Section 1 only.
6. If the location of your spouse/registered domestic partner is unknown, you must attach to this form a notarized statement
stating that your spouse/registered domestic partner cannot be located.
7. You are considered married if you are under decree of separate maintenance or decree of legal separation.
8. If you wish to have your PARS account distributed under the terms of a Living Trust, your PARS account must be mentioned
by name in the Trust Document. If your current Living Trust does not contain specific reference to your PARS account, you
may designate the Living Trust as a beneficiary using this form. All rules pertaining to the designation of a beneficiary apply to
the designation of a Living Trust.
I have read and understand these rules.

Participant’s Signature Date

Section 1: Designating a Beneficiary

Participant Name: Social Security # - -
Participant Address:
City : State: Zip: Phone #:
Name of Beneficiary: Relationship:
Beneficiary Address:
City: State: Zip: Phone:

Participant’s Signature Date

Section 2: Spousal /Registered Domestic Partner Consent (Do not complete this section if you are unmarried)
I hereby consent to the above beneficiary designation of my spouse/registered domestic partner, a participant in this
plan. I understand that in consenting to the designation of anyone except myself, I am waiving rights to a survivor
benefit that I would be legally entitled to at a later date.

Spouse/Registered Domestic Partner Signature Date

Signature of Notary Date

Revised March, 2005

PARS SSA-1945 NOTIFICATION COVER LETTER

Stanislaus County is required to provide you this notice, Form SSA-1945, to read and sign at the
beginning of your employment with our organization. We are required to do so under federal law,
Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004.

This notice must be provided to you because you are serving in a position, in which you as employee and
Stanislaus County as employer will not be contributing to Social Security on your behalf.

You must do the following:

• Read the notice

• Sign the notice
• Return the notice to Department Payroll/Personnel Clerk

What is the purpose of the notice?

The purpose of the notice is to inform you about how Social Security law may impact public employees
who work in positions not covered by Social Security. This can be a complicated is sue, so we encourage
you to seek out add itional information to determine whether the laws m entioned in the notice pertain to
you by doing the following:

• Check the Social Security website at www.socialsecurity.gov

• Employees in a PARS, FICA Alternative Pl an can contact (800) 540-6369 for further
information.
• Neither PARS nor Stanislaus County provides tax, accounting, or legal advice. You should see
your tax consultant, accountant or attorney for advice.

Why will I not be in Social Security?

Not all em ployees working in governm ent positions are required to be in Social S ecurity. Instead of
being in Social Security, Stanislaus County has part-time, seasonal, and tem porary employees such as
yourself in the PARS Plan. This p lan offers you gr eater flexibility, po rtability, and potentially higher
benefits. For more information on this plan, please see http://www.stancounty.com/riskmgmt/ and click
on the Employee Benefits section or contact PARS at www.parsinfo.org and (800) 540-6369.
 County of Stanislaus
STATEMENT CONCERNING YOUR EMPLOYMENT IN A
JOB NOT COVERED BY SOCIAL SECURITY

Employee Name:______________________________ Employee ID:____________

Your earnings from this job are not covered under Social Security. When you retire, or if you
become disabled, you may receive a pension based on earnings from this job. If you do, and you
are also entitled to a benefit from Social Security based on either your own work or the work of
your husband or wife, or former husband or wife, your pension may affect the amount of Social
Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the
Social Security law, there are two ways your Social Security benefit amount may be affected.

Windfall Elimination Provision

Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is
figured using a modified formula when you are also entitled to a pension from a job where you did
not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you
were not entitled to a pension from this job. For example, if you are age 62 in 2005, the maximum
monthly reduction in your Social Security benefit as a result of this provision is $313.50. This
amount is updated annually. This provision reduces, but does not totally eliminate, your Social
Security benefit. For additional information, please refer to the Social Security publication,
“Windfall Elimination Provision.”

Government Pension Offset Provision

Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit
to which you become entitled will be offset if you also receive a Federal, State or local government
pension based on work where you did not pay Social Security tax. The offset reduces the amount of
your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under
Social Security, two thirds of that amount, $400, is used to offset your Social Security spouse or
widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per
month from Social Security, $500 - $400 = $100. Even if your pension is high enough to totally
offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age
65. For additional information, please refer to the Social Security publication, “Government
Pension Offset”.

For More Information

Social Security publications and additional information, including information about exceptions to
each provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-
1213, or, for the deaf or hard of hearing, call the TTY number 1-800-325-0778, or contact your
local Social Security office.

I certify that I have received Form SSA-1945 that contains information about the possible
effects of the Windfall Elimination Provision and the Government Pension Offset Provision
on my potential Social Security benefits.

________________________________________ _________________________
Signature of Employee Date

Form SSA-1945
County of Stanislaus
Alternate Retirement System Plan
Plan Information Sheet
for Part-Time, Seasonal, and Temporary Employees
Introduction 3) If you are unmarried at the time of your death, your
account balance will be paid to your estate unless
A federal law, the Omnibus Budget Reconciliation Act of
you have designated another beneficiary.
1990 (OBRA 90), requires that governmental employees
who are not members of their employer’s existing
4) You may obtain a Designation of Beneficiary Form
retirement system be covered by Social Security or an
from your employer or from PARS.
alternate plan.
Becoming Eligible for a Benefit
You are enrolled in an alternate plan called the Public
Agency Retirement Services Alternate Retirement System
1) You (or your beneficiary in the event of your death) will
Plan (PARS ARS). PARS ARS satisfies federal
be eligible to receive your PARS ARS account balance
requirements and provides cost savings to you and your
when one of the following events occurs:
employer when compared to Social Security. The PARS
ARS plan only requires a minimum contribution of 7.5%
a. Termination of Employment
to your retirement account.
b. Retirement
c. Permanent and Total Disability
This information is a general description of what you can
d. Death
expect as a participant in PARS ARS. The Plan Document
e. Changed employment status to a position
provides a detailed description and contains all of the
covered by another retirement system*
specific legal requirements of the plan. A copy of the
plan document is available for review with your employer.
*If there have been no contributions into your PARS ARS
account for two (2) years, you may be eligible for a
Enrollment in the PARS ARS Plan is automatic for
distribution of your account.
eligible employees.
Receiving Your Account Balance
Effective July 5, 1995 and thereafter:
1. Each pay period, 5.50% of your wages will be 1) The County will notify PARS of your termination after a
deducted from your pay and deposited into your period of 250 consecutive calendar days. Upon
PARS ARS account. Your contributions are made notification from the County, appropriate forms will be
on a pre-tax basis. sent to you by mail. Within 90 days of PARS’ receipt of
all correctly completed forms, the account will be
2. Each pay period, your employer will also distributed.
contribute the equivalent of 2.0% of your wages
to your PARS ARS account. Employer 2) Your distribution options are:
contributions are also made on a pre-tax basis.
a. You may elect to receive a one-time lump-
3. Investment activity will be credited to your PARS sum cash payment. If your account balance
ARS account based on your monthly account is greater than $200, your distribution may be
activity and will accumulate tax-free until your subject to federal and/or state income tax
termination form the plan and the distribution of withholding. If you are under age 59½, your
your account balance. distribution may also be subject to an excise tax
withholding.
Designating a Beneficiary
b. If your account balance is greater than $200,
1) In the event that you pass away while contributing to you can defer tax withholding from your
the PARS ARS Plan, your account balance will be distribution by electing a direct rollover to a
distributed to your beneficiary. traditional IRA or to an eligible employer plan
that accepts rollovers (e.g. 403(b), 457(b),
2) If you are married at the time of your death, your 401(k), etc.).
spouse/registered domestic partner is automatically
your beneficiary. If you wish to designate someone For further information or for questions about your
other than your spouse/registered domestic partner, account, please contact PARS.
you may do so by submitting a Designation of
Beneficiary Form. (800) 540-6369
Monday – Friday
9:00AM – 5:00PM Pacific Time

PARS P.O. Box 12919, Newport Beach, CA 92658 Rev. 2/07

 •
•
•
•
•
•

County of Stanislaus

PARS
Alternate Retirement System

• • • • • • • • • • • • • •

Plan Summary

For Part-Time, Seasonal and Temporary Employees

Revised Sept, 2004

 TABLE OF CONTENTS

INTRODUCTION ............................................................... 2

PARTICIPATION............................................................... 3

YOUR PARS-ARS ACCOUNT.......................................... 4

VESTING........................................................................... 4

DISTRIBUTION OF BENEFITS ........................................ 5

DESIGNATING A BENEFICIARY..................................... 6

FOR ADDITIONAL INFORMATION.................................. 6

Page 1
 INTRODUCTION

Background
A federal law, the Omnibus Budget Reconciliation Act of 1990 (OBRA 90),
mandates that employees of public a gencies who are not members of the
employer’s existing retirement system as of January 1, 1992 be covered under
Social Security or an alternate plan.

The PARS Alternate Retirement Syst em (PARS-ARS) satisfies federal

requirements and provides substantial cost savings compared to Social Security.
Social Security requires that the equ ivalent of 12.4% of your salary be
contributed each month; however, PARS-ARS requires only a 7.5% contribution
to your retirement account.

The information in this packet is designed to provide a general description of

what you can expec t as a par ticipant in PARS-ARS. The Plan Docum ent
contains a more detailed descript ion and your employer has a copy whic h you
may read. The Plan Document shall gover n if this description st ates something
different.

Plan Sponsor
PARS-ARS has been established by your employer, the County of Stanislaus
(the “County”).

Plan Administrator
The County appointed Plan Administrator is responsible for determining the
provisions of the Plan, dire cting distributions, and estab lishing investment policy.
The current Plan Administrator is Mr. David Dolenar, Deputy Executiv e Officer
CEO-Risk Management Division. For info rmation and questions, please contact
the Employee Benefits Unit at (209)525-5717.

Page 2
Public Agency Retirement System (PARS)
PARS is a 401(a) tax-qualified multiple employer trust. PARS is made up of
California governmental agenc ies such as school districts, community colleges,
cities, counties, and other special distri cts. The County has implemented the
Alternate Retirement System through PARS.

PARS Trustee
The Union Bank of California is the Trustee for PARS. The duties of the Trustee
include receiving and investing Plan contributions, safeguarding Plan assets, and
distributing benefits to eligible Plan participants or beneficiaries at the direction of
the Plan Administrator.

PARS Trust Administrator

Phase II Systems is the Trust Administrator for PARS. The PARS Trust
Administrator’s functions inc lude record keepi ng of individual account balanc es,
Plan accounting, coordination of benefit distributions, and communication of Plan
provisions.

If you have any questions regarding this Plan, please call the PARS Trust
Administrator at (800) 540-6369.

PARTICIPATION
You are eligible to participate in PARS -ARS if you meet one of the eligibility
requirements listed below.

Eligible Employees are:

• Part-time (less than 20 hours per week)

• Seasonal (five months or less per year)
• Temporary (contract of two years or less in duration)
• Not covered by another Retirement System

Page 3
 YOUR PARS-ARS ACCOUNT
(Effective July 5, 1995)

Employee Contribution
Each pay period, 5.5% of your salary will be deducted from your wages and
deposited into your PARS-ARS account. Y our contributions are made on a “pre-
tax” basis.

Employer Contribution
Each pay period, your employ er will al so contribute the equiv alent of 2. 0% of
your salary to your PARS-ARS account. Employer contributions are also made
on a “pre-tax” basis.

Investment Earnings and Administrative Expenses

Investment earnings minus plan administrat ive expenses will be credited to your
PARS-ARS account based on your monthly account activity and will accumulate
tax-free until termination from the plan and the distribution of your funds.

SPECIAL NOTE

A PARS-ARS account balance statement is available any time upon request from
the PARS Trust Administrator (Phase II Systems) by calling
(800) 540-6369.

VESTING
Vesting refers to your right to or your ownership of y our account. With PARS-
ARS, you are immediately 100% vested in your account.

Page 4
 DISTRIBUTION OF BENEFITS

Eligibility for Distribution

You or your beneficiary will receive your PARS-ARS account balance after your
employment ends for any of the following reasons:

• Termination of employment
• Retirement
• Permanent and Total Disability
• Death
• Changed employment status to a position covered by another
Retirement System*

*If you become eligible for another retirement plan, your account balance must remain
in PARS-ARS for twenty-four (24) months as mandated by federal law, after which you
will be able to request distribution of your funds.

Receiving Your PARS-ARS Account Balance

When PARS is notified by y our employer that your employment has ended and
you are eligible for distribution, appropriate distribution forms will be s ent to you.
It is your responsibility to complete these forms and return them to the PARS
office. Within 90 days of PARS’ receipt of all correctly completed forms yo u will
receive your account balance in a lump-sum distribution.

You do not pay income taxes on your PAR S-ARS Account as it accumulates.
When you begin to receive benefits, the f unds received become t axable income.
If you choose to receive benefits before age 59½, those funds may be subj ect to
additional federal and state excise taxes. If your a ccount balance exceeds $200,
you may avoid excise taxes by directing PARS to transfer the balance of y our
PARS-ARS account to:

• an IRA
• another retirement plan that accepts rollovers
• your County 457 Deferred Compensation account

Page 5
 DESIGNATING A BENEFICIARY

If you die while em ployed, your account balance will be dis tributed to your
beneficiary. If you are married at the ti me of your death, your spous e is
automatically your beneficiary. If you wish to designate someone other than your
spouse as your beneficiary, you must do so in writing and your spouse must sign
a spousal consent.

To designate a beneficia ry, please contact the PARS Plan Administrator, CEO-
Risk Management Division Employee Benefits Unit at (209)525-5717, for a
Designation of Beneficiary For m. You may also download this form from the
Employee Benefits Website http://www.stancounty.com/riskmgmt/.

If you are unmarried at the time of your death, your account balance will be paid
to your estate unless you have designated another beneficiary.

FOR ADDITIONAL INFORMATION

Additional questions about the Plan should be direc ted to the PARS Trust
Administrator, Phase II Systems. Written requests should be mailed to:

PARS
P.O. Box 10009
Costa Mesa, CA 92627

Participants are encouraged to call th e toll-free number on week days from 9:00
a.m. to 5:00 p.m. to speak to a client services specialist:

(800) 540-6369

PARS is not licensed to provide and does not offer tax, accounting or legal advice. You
are urged to consult with appropriate professionals regarding the tax, accounting and
legal implications of participating in PARS-ARS.

Page 6
ORACLE PEOPLESOFT SELF SERVICE

Oracle PeopleSoft Self Service gives you direct access to your own Benefits, Payroll
and Training information online.

 Under Self Service Benefits Information you have the ability to view your
benefits summary and change your Deferred Compensation voluntary
contributions and Life Insurance Beneficiaries.

 Under Self Service Benefits Life Events you have the ability to make your own
life event changes if you get married, divorced, or have a baby. Once you enter
the information online, you only need to send us the proof. No more filling out
forms!

 Under Self Service Payroll you have the ability to view your Paycheck
information online and also print your own Paycheck Advice Notice. You also
may have the ability to enter your own Time Card information online if your
department is participating. This is located under Time Reporting.

 Under Self Service Learning and Development you have the ability to view
your training history online. You also have access to view the list of available
County training classes and after obtaining approval from your supervisor, enroll
yourself with just a click of a button!

To learn how to login and use the Self Service features, go to the County’s Intranet site
at: http://intranet/ to access the Self Service Tutorials, which are located under the drop
down menu Resources> Self-Service Tutorials.

The Intranet is also where you access the Oracle PeopleSoft application. It is located
under the drop down menu Applications> PeopleSoft.

Your PeopleSoft User ID is usually your email address user name. For example:

E-mail address is: [email protected]

PeopleSoft UserID is: TESTERJ (UPPERCASE)

If you have never logged in to Oracle PeopleSoft before, contact your Department’s
HR/Payroll Clerk to receive a temporary password. You will be required to reset your
password as soon as you log in. Please follow the instructions to change your password
to a combination of letters, numbers and a special character.

If you have any issues logging in to PeopleSoft, just call 525-HELP.

Now you are ready to use Self Service!