Diocese of Columbus
Full Time
Employee Benefits
Enrollment Information
ENROLLMENT / ELIGIBILITY INFORMATION
The Diocese of Columbus offers a comprehensive employee benefits program for you and your family.
You will be enrolled in the following benefits, at no cost to you, provided you meet the current
eligibility requirements:
 Life Insurance - $50,000 coverage
 Short Term Disability Insurance
 Long Term Disability Insurance – Base Plan #1
 Long Term Care Insurance – Base Plan #1
You can also choose to enroll in the following benefits, paid by you through payroll deductions, and
provided you meet the current eligibility requirements:
 Health Insurance – (Cost shared with your employer)
 Dental Insurance – (Cost shared with your employer)
 EyeMed Vision Insurance – (Employee paid)
 Additional Life Insurance – (Employee paid)
 Dependent Life Insurance – (Employee paid)
 Long Term Disability – Buy-Up Plan #2 (Employee paid)
 Long Term Care Insurance – Buy-Up Plan 2, 3, or 4 (Employee paid)
 Long Term Care Insurance – for your spouse and/or other eligible family members
(employee/family member paid)
 Flexible Spending Account (FSA) - up to $2,500 annually can be deducted on a prebasis to use for out-of-pocket expenses related to medical, dental & vision services.
 Dependent Care Account (DCA) - up to $5,000 annually can be deducted on a prebasis for out-of-pocket expenses related to care for your dependent children or parent.
taxed
tax
Additionally, the Diocese offers you a retirement plan, provided you meet the current eligibility
requirements, that is comprised of both employer and employee contributions. After completion of
one (1) year of service, the location of your employment will contribute to a retirement account and at
the same time, will automatically begin your employee contributions as well.
IMPORTANT REMINDERS:
 Unless you have a qualified change in family status, you may add or change coverage
in the benefit plans only during the annual Open Enrollment period.
 You must enroll an eligible dependent within 31 days of a qualifying event by completing
the required form(s) and submitting to the financial individual at your location for
processing. For example, a newborn child must be enrolled within 31 days of birth in
order
for that child to be a covered dependent. Calling the Diocesan Claims
Administrator is not
considered “enrollment” in the plans.
Attached are summaries of benefits for the current calendar year. If you have questions regarding
coverage, please contact the Diocesan Insurance Office at 1-614-224-1221, (option 1).
Eligibility Requirements
All newly hired lay employees and lay teachers scheduled to work 30 hours or more per week for at
least 10 consecutive months a year and receiving a W-2 form, are eligible for employee benefits.
EFFECTIVE DATE: Coverage for new hires will be the first day of the month following the first
working day.
DELAYED EFFECTIVE DATE: Coverage will be delayed if you are not in active employment
because of an injury, sickness, leave of absence, or temporary layoff on the date that the insurance
coverage would otherwise have been effective.
MEDICAL PLAN BENEFIT SUMMARY
PLAN PROVISIONS
NETWORK BENEFITS
Deductible
Out-of-Pocket Maximum
Lifetime Maximum Policy
Benefit
Physician Office Services
Specialist Physician Office
Services
Well Baby/Child Care
Comprehensive Physical
Exams, Routine
Eye Exams
None
$1,000 / $2,000
NONE
NON-NETWORK
BENEFITS *
$250 / $500
$1,200 / $2,400
NONE
$10 Co-Pay
$30 Co-Pay
80% of Eligible Expenses
80% of Eligible Expenses
$10 Co-Pay
$10 Co-Pay
80% of Eligible Expenses
80% of Eligible Expenses
$30 Co-Pay; Eye refraction
limited to every calendar year
Obstetrical Office Visits (Pre & No Co-Pay after initial visit
Post Natal)
Allergy Services – Testing,
80%
Serum, Injections
Professional Fees for
No Co-Pay after initial visit
Surgical/Medical Services
Inpatient Hospital Services
100% of Eligible Services
Emergency Care
$75 Co-Pay
Waived if Admitted **
Emergency Ambulance
100% of Eligible Expenses
Services
Urgent Care Services
$35 Co-Pay
Outpatient Hosp & alternate
No Co-Pay
Facility Services
Outpatient Mental Health &
$10 Co-Pay per Group Visit or
Substance Abuse Services (30
$30 Co-Pay per Individual
Visits per Calendar Year)
Visit
Inpatient Mental Health &
100% Network and NonSubstance Abuse
Network combined 30 Days per
Calendar Year Maximum
Prosthetic Devices & Durable
Medical Equipment
80% of Eligible Expenses
Maximum $2,500 (except
diabetic DME items)
Outpatient Rehabilitation
Services
(Limitations Apply)
Prescription Benefit – Retail
Pharmacy
Prescription Benefit – Mail
Order 90-Day Supply
$30 Co-pay in a Physician’s
Office
No Co-Pay in alternate facility
$10 Tier I / $45 Tier II /
$75 Tier III
$30 Tier I / $60 Tier II /
$90 Tier III
80% of Eligible Expenses;
Eye refraction not covered
80% of Eligible Expenses
80% of Eligible Expenses
80% of Eligible Expenses
80% With Prior Notification
Covered as Network Benefit
Covered as Network Benefit
80% of Eligible Expenses
80% of Eligible Expenses
80% of Eligible Expenses
80% of Eligible Expenses,
Network and Non-Network
combined 30 Days per
Calendar Year Maximum
80% of Eligible Expenses; over
$1,000 requires prior approval
Maximum $2,500 (except
diabetic DME items)
80% of Eligible Expenses
Subject to Coinsurance
Not Covered
*Subject to UCR and balance billing
CATHOLIC DIOCESE OF COLUMBUS
SPOUSAL EMPLOYMENT STATEMENT
This is to verify that my spouse is not eligible for or enrolled in any group health coverage due to one
of the following reasons (please check one):

Group health coverage is not offered to my spouse (must provide verification letter from
spouse’s employer)
 Spouse is self-employed (Must provide some type of verification of self-employment,
i.e.,
letterhead, invoice, etc.)
 Spouse is not employed
 Spouse is also employed by the Diocese
 Spouse is retired
 Spouse is enrolled at his/her place of employment as primary (a copy of the spouse’s
group
health insurance card must be attached to this form and returned to the Insurance
Office at the
address below to be added as secondary coverage)
Name of Spouse’s Employer:
Address:
Phone:
NOTE:
The employee is responsible for notifying the appropriate individual of the Diocese for any changes
that occur during the year in regards to his/her spouse’s employment or benefit status before any
changes will be made to this Program. If providing verification from the spouse’s employer, selfemployment or a spouse’s health card, the Notary witness is not required.
I certify and confirm that this is a true statement by my signature below.
Employee Signature
Date
Witness by Notary,
STATE OF
COUNTY OF
BEFORE ME, the undersigned, a Notary Public, personally appeared
who executed the above Spousal
Employment Statement as a free and voluntary act.
IN WITNESS WHEREOF, I have signed my name and affixed my official notarial seal this
day of
, 20_______.
(SEAL)
Notary Public
My Commission Expires:
PLEASE SEND COMPLETED FORM
Catholic Diocese of Columbus
198 East Broad Street
Columbus, OH 43215-3766
ATTN: Insurance Office
DENTAL PLANS: ADMINISTERED BY UNITED HEALTHCARE OF OHIO
The Base Plan reimburses non-network claims based on a Maximum Allowable Charge fee schedule (MAC),
meaning UHC will not reimburse any amount charged over this set fee schedule. Any amount charged by a
provider over this fee schedule will be the responsibility of the member—this is referred to as balance billing.
The Enhanced (Buy-Up) Plan reimburses non-network claims based on Usual, Customary, and Reasonable
amounts (UCR), reimbursing claims up to 90% UCR. This often results in a higher non-network reimbursement
and less out-of-pocket cost for the member if they choose to go out of network.
Neither plan balance bills a member if services are received at a network provider. Also, neither plan requires a
deductible for any services received. Premium rate information will be available on the online Paycor system
when completing your 2012 benefit elections.
ENHANCED PLAN
BASE PLAN
Plan Pays
Plan Pays
Non-Network Benefits –
Benefits are based on 90th
Benefits are based on Network
percentile of UCR (usual,
allowable
Dentist can balance bill
customary & reasonable)
Dental Benefits
Plan Pays
Plan Pays
Annual Deductible
No Deductible
No Deductible
Calendar Year Maximum
$1,500 per person
$1,000 per person
Lifetime Ortho Maximum
$1,500 per person
$1,000 per person
Preventative Services
In Network Out of Network
Network Allowable
Oral Examination (2x per Year)
100%
90%
100%
Dental Prophylaxis (2x per Year)
100%
90%
100%
Bitewing X-rays (2x per Year)
100%
90%
100%
Full Mouth X-rays (1x per 3 years)
100%
90%
100%
Fluoride Treatments (2x per Year)
100%
90%
100%
Sealants (1x per 3 years – under
80%
70%
50%
16)
Basic Services
Amalgam Restorations (Fillings)
80%
70%
50%
Composite Resin Restorations
80%
70%
50%
(Fillings) – Anterior Teeth
Space Maintainers
80%
70%
50%
Root Canal Treatment
80%
70%
50%
Periodontal Surgery
80%
70%
50%
Simple Extractions
80%
70%
50%
Surgical Extractions – Impacted
80%
70%
50%
Wisdom Teeth
Necessary General Anesthesia
80%
70%
50%
Palliative Treatment (Relief of
80%
70%
50%
Pain)
Major Services
Root Planing
50%
50%
50%
Crowns, Inlays, Onlays
50%
50%
50%
Fixed Bridges
50%
50%
50%
Partial Dentures
50%
50%
50%
Full Dentures
50%
50%
50%
60%
50%
50%
Orthodontic Services (up to 19)
VISION PLAN: ADMINISTERED BY EYEMED
Eye care is a critical component of health benefits which is why the Diocese offers a Vision plan in order to
provide you affordable access. You and your family are offered vision coverage through EyeMed Vision Care.
To find an in-network EyeMed provider visit www.eyemedvisioncare.com or call 1-866-800-5457. It is
important that you select the Insight Network when searching for a provider, as this is your coverage network.
The Insight Network includes LensCrafters, Pearl Vision, Target Optical, Sears Optical, as well as private
practice vision providers.
Vision Benefits
Vision Exam
Vision Exam Frequency
Materials
Materials Frequency:
Lenses/Frames
Lenses
Single Vision
Lined Bifocal
Lined Trifocal
Lenticular
Scratch Resistant Coating
Progressive Lenses
Polycarbonate Lenses
UV Protection
Anti-Reflective Coating
Lens Tinting
Frames
Frame Allowance
Contacts
Elective Contact Lenses ( in lieu of
glasses)
Medically Necessary Contact
Lenses
Other Services
Lasik Surgery
Network (Member Cost)
$15 Co-Pay
Exam: 12 Months
$30 Co-Pay
Lenses: 12 months
Frames: 24 months
Non-Network (Plan Reimburses)
Up to $40
Exam: 12 Months
See cost breakdown below
Lenses: 12 months
Frames: 24 months
Covered in Full
Covered in Full
Covered in Full
N/A
Covered in Full
$95 Standard
$121 - $133 Premium
Up to $40
Up to $60
Up to $80
N/A
$5
Up to $60
$40 (Dependents under 19)
$15
$45
$15
Not covered
Not covered
Not covered
Not covered
$130 allowance, 20% off balance
over $130
Up to $45
Conventional: $105 allowance, 15%
off balance over $105
Disposable: $105 allowance, 15%
balance over $105
Covered in Full
Up to $105
15% off retail or 5% off
promotional price
Not covered
Up to $210
Additional Glasses/Contacts - Network: 40% discount off complete pair eyeglass purchase and a 15%
discount off conventional contact lenses once the funded benefit has been used. Not covered under NonNetwork.
EyeMed Vision Plan – Optional Benefit
Single
Single + One
Family
Monthly Premium
$ 4.50
$ 8.00
$12.00
Employee Share
$ 4.50
$ 8.00
$12.00
Employer Share
None
None
None
LONG TERM CARE (LTC) PLAN: Administered by UNUM
Why Long Term Care?
Long Term Care Insurance
Long term care costs can quickly deplete financial resources. While Long Term Disability is designed to protect
income, Long Term Care policies are asset protection. Your location provides you with a base plan and allows
you to purchase additional coverage at a reduced group rate. You can purchase a LTC policy on yourself, your
spouse, your parents, your in-laws and other extended family members. With Unum’s LTC plan, you select a
monthly benefit amount and benefit duration. When you qualify for the benefit, you receive a monthly check for
the benefit amount you selected. Unlike other traditional LTC plans, Unum does not require the submission of
receipts for reimbursement. Unum offers a total home care benefit, which means family members can provide
care for you at home and you receive the monthly benefit (even if no actual out-of-pocket costs were incurred).
LTC coverage is portable meaning you can take it with you (at the same rate) when you leave employment.
With Unum’s LTC policy, you lock in at the age at which you purchase it (if you buy it at age 40, you
will always pay the 40 year old rate). Rates are age-banded. The plan choices for Diocesan employees and
family members are listed in the table below. You can combine any of the duration and benefit levels (i.e. you
can buy 6 year duration with a $4,000 monthly benefit & inflation protection). If you are interested in
purchasing a LTC policy or looking at the age-banded rates, you may view options and rate information on the
Insurance office website at: http://www.colsdioc.org/Offices/InsuranceOffice/InsuranceEnrollment.aspx
Ohio Average Type of Long Term Care Service:
$165 per day - Semi-private nursing home room
$184 per day - Private room in a nursing home
$2,478 per month Care in an Assisted Living Facility (1 bedroom unit)
$19 per hour - Home Health Aid
$17 per hour - Homemaker Services
Source: http://www.longtermcare.gov/LTC/Main_Site/Paying_LTC/Costs_Of_Care/Costs_Of_Care.aspx
(January 2008)
Do You Have Enough Saved to Pay for Long Term Care Services?
“We suspect that many people are confusing long-term care insurance with other types of coverage, for example
disability insurance provided by employers or Medicare. If this is the case, some Americans may think they have
long term care insurance when they do not.”
Source: The Costs of Long-Term Care: Public Perceptions Versus Reality in 2006; page 8; AARP, 601 E Street
NW, Washington, DC 20049 www.aarp.org © AARP, Dec. 2006
Without accounting for inevitable inflation, the following LTC services will cost you…
• 18 Months in an Assisted Living Facility: $44,604
• 36 Months in an Assisted Living Facility: $89,208
• 12 Months in a Private Nursing Home: $68,448
• 24 Months in a Private Nursing Home: $136,896
• 14 hrs per week for Home Health Aid (1 Year): $13,832
Diocese LTC
Plan Options
Benefit Amount
Benefit Duration
Level of Care
Enhanced Features
Base Plan LTC
$2,000 monthly benefit
Maximum 3 years
Covers LTC facility care
and 50% of Professional
Home Care
N/A
LTC Buy-Up
Up to $4,000 monthly benefit
Up to maximum of 6 years
Option to add 100% of home care
and/or total home care
Option to add a compound inflation rider
PLEASE NOTE THAT THE LTC FORM ON THE FOLLOWING PAGE MUST BE COMPLETED
FOR ANY NEW ENROLLMENT OR CHANGE TO A CURRENT POLICY. THE FORM MAY ALSO
BE OBTAINED FROM THE DIOCESAN WEBSITE (WWW.COLSDIOC.ORG), THE INSURANCE
OFFICE OR FROM THE PAYCOR WEBSITE (WWW.PAYCOR.COM).
GROUP and VOLUNTARY LIFE: ADMINISTEREED BY LINCOLN
FINANCIAL GROUP
Basic Life Insurance (Employer Paid): Life Insurance is one of the key elements of your family’s income
protection planning. Once eligible for this benefit, you will have coverage for $50,000 of Group Life
Insurance. This benefit is offered through Lincoln Financial Group (LFG) at no cost to you.
Voluntary Life and Accidental Death and Dismemberment (AD&D) (Employee Paid)
Along with the Basic Life Insurance the diocese provides, you can also supplement your Life Insurance with
Voluntary Life Insurance and AD&D. This benefit allows you to purchase additional insurance for your
spouse and/or dependent children. AD&D is a provision that gives additional coverage for accidental death
and dismemberments. Should an enrolled person die in a covered accident, the beneficiary would
automatically receive double the Life benefit. Regarding dismemberment, different types of dismemberments
pay different benefits ranging from one half of the benefit to double the benefit. The cost of the AD&D
provision is included in the Life/AD&D rates. Each eligible employee has a good foundation of coverage
with the $50,000 of Life Insurance provided by the Diocese, but many employees will have needs beyond the
employer paid coverage.
The program offers excellent rates that also include the AD&D provision. Employees who elect Voluntary
Life coverage during the new hire process will have an annual option to increase their coverage by one times
their salary during future enrollment periods (not to exceed the Guarantee Issue).
Those employees that do not elect Voluntary Life coverage during the new hire process will only be able to
come onto the plan with the requirement to complete an Evidence of Insurability form. The spouse’s
coverage cannot be more than ½ of the employee’s coverage amount. The Evidence of Insurability form
can be found and downloaded on the Insurance Office website at
http://www.colsdioc.org/Offices/InsuranceOffice/InsuranceEnrollment.aspx
A Spouse and/or Children in a Period of Limited Activity are not eligible for Voluntary Spouse or
Voluntary Child life insurance. A Period of Limited Activity is when a spouse or a dependent is
confined in a health care facility; or, whether confined or not, is unable to perform the regular and
usual activities of a healthy person of the same age and gender.
Employee and Spouse premiums are calculated separately. Spouse premiums will be calculated based on the
following Employee’s age bands:
Age-Bands Monthly Rate per $1,000
< 30
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 99
$ 0.065
$ 0.075
$ 0.095
$ 0.155
$ 0.205
$ 0.395
$ 0.595
$ 0.615
$ 1.075
$ 2.815
$11.365
How many $1,000 increments would you like to purchase?
$
X
(your age band rate) =
monthly cost
Example: Employee age 40 wants to purchase $80,000 of coverage. 80 times the rate (.155) = $12.40 per
month. The maximum of spouse coverage is $40,000. 40 times the rate (.155) = $6.20 per month.
Dependent Children (up to age 24) Rate = $5.00 Monthly. Premium covers all dependent children regardless
of the number of children. Each eligible child will have $25,000 of coverage; a maximum of a $1,000 policy
is available for children whose age is one day to six months.
SHORT-TERM (STD) & LONG-TERM DISABILITY (LTD) PLANS:
ADMINISTERED BY LINCOLN FINANCIAL GROUP
Short Term Disability (STD) - Employer Paid - This coverage is provided at no cost to you
Short-term disability provides employees with a form of income replacement. Workers’ compensation and
health insurance are fine for on-the-job injuries and paying medical bills. However, these plans do not replace
income when a worker is disabled by a non-work related illness or injury. STD insurance provides income
protection to help with your financial obligations during such illnesses or injuries. If you become unable to
work, you will have a seven (7) day elimination period before the short-term disability benefit is payable. The
benefit percentage is 65% up to a maximum weekly benefit of $2,000. The maximum number of weeks that are
payable, including the one-week elimination period, shall not exceed 13 weeks.
Long Term Disability (LTD) - Base Plan - Employer Paid - Provided at no cost to you
Long Term Disability has also been referred to as “paycheck protection.” Nearly everyone protects their car,
home and health with insurance, but many leave their most valuable asset – their income – unprotected. LTD
insurance helps employees maintain their lifestyle and it also gives employees the necessary funds to pay
important bills while disabled due to a non-work related illness or injury. LTD coverage is designed to help
provide you with a level of financial security if you are disabled and unable to work for a long period of time.
The Diocese understands the need for this important long term income protection, and that is why a Base LTD
Plan is included in your benefit package. If you are disabled for more than 90 consecutive days, then the
Diocesan paid Base Plan will pay 40% of your pre-disability earnings up to a $2,500 monthly maximum. This
benefit is payable to a maximum of age 65 or your Social Security Normal Retirement Age (SSNRA). The
benefit would be paid for 12 months if a claim is made after you reach your SSNRA.
Long Term Disability (Buy-up Plan - Employee Paid)
While the 40% Base Plan is a great foundation for your long-term “paycheck protection,” the question is – Can
you live off of 40% of your earnings after taxes until age 65 or your SSNRA? Most people would agree that a
40% taxable benefit would leave them short of the necessary funds to maintain their lifestyle and meet their
future financial goals. This is exactly why your location offers a Buy-Up Plan option. By purchasing the buy-up
option, you will enhance your “paycheck Insurance” and your coverage will be increased to a 65% benefit
rather than the 40% benefit. Not only will the benefit percentage be increased by electing the Buy-Up option,
but your maximum benefit will also be increased from a $2,500 monthly maximum to a $7,500 monthly
maximum. Should you purchase the buy-up plan, the benefit would be 82% tax-free.
By choosing to elect the Buy-Up option you will maximize your “paycheck insurance,” and you will be
protecting your most valuable asset – your paycheck. The Buy-Up Plan has a maximum duration that can go to
age 65 or your Social Security Normal Retirement Age. The cost to enhance your “paycheck insurance” with the
Buy-up option is a very reasonable $14.00 per month. Additionally, the benefits you would receive would be
82% tax-free, thus a larger net income. This benefit is payable to a maximum of age 65 or your Social
Security Normal Retirement Age (SSNRA). The benefit would be paid for 12 months if a claim is made after
you reach your SSNRA.
Why do you need the Buy-Up option rather than just the Base Plan?
1. The 65% buy-up benefit is much closer to your normal take home pay.
2. Your maximum monthly benefit increases to $7,500 rather than $2,500.
3. Should you purchase the buy-up option, the benefit would be 82% tax-free. If you do not purchase the buyup option, the benefit is 100% taxable.
Two-thirds of American families live from paycheck to paycheck. (Source: Parade Magazine, 2006); the
average Long-Term Disability absence lasts two and a half years. (Source: Commissioners Individual Disability
Table A); at the age of 35, an employee has a 50-50 chance of becoming disabled for more than three months.
(Source: Society of Actuaries, April 2000); during the course of your career, you are three and a half times more
likely to be injured and need Disability coverage than you are to die and need Life insurance. (Source: Health
Industry Association of America, 2000).
FLEXIBLE SPENDING ACCOUNT (FSA)
& DEPENDENT CARE ACCOUNTS (DCA)
With a little planning, you can save money on things you normally buy during the year. Take a few moments to
learn about a smart, simple way to prepare for expenses you will have in the upcoming year while saving
approximately 25% on every dollar you spend. By taking advantage of your Flexible Spending Account (FSA)
plan, you get to hold on to more of your paycheck in a special, easy-to-use account. The items listed below are
some of the qualified expenses. A worksheet is available on the Insurance Office website
(http://www.colsdioc.org/Offices/InsuranceOffice/InsuranceEnrollment.aspx) to help you figure out what to
put into your account and what you will save. Then complete your election during Open Enrollment on Paycor
and a portion of the money will be deducted automatically from your paycheck before taxes.
USE PRE-TAX MONEY TO SAVE UP TO 25% ON QUALIFIED EXPENSES:
Typically Healthcare FSA expenses are automatically approved and, in most cases, you do not need to submit
claims or documentation for FSA Card use. However, always keep your receipts. Although it is a Debit Card, it
is treated as a credit card if asked by any cashier when using your FSA Card.
INSTRUCTIONS FOR FSA DEBIT CARD DOCUMENTATION & FILING A CLAIM ONLINE:
Login to the Custom Design Benefits FSA portal at https://www.myflexonline.com/Login/Welcome.aspx; select
the Request Payment button at the top of the screen and follow prompts to complete your claim form
electronically. Then email, fax or mail your receipts to Custom Design Benefits. Retain a copy of the receipts
for your records.
EMAIL: Complete your FSA Claim Form and attach scanned receipts to your email to Custom Design
Benefits. All other questions and forms should be emailed to the Flex email address below.
FAX: Complete your FSA Claim Form and fax with receipts to 513-598-2901.
MAIL: Complete your FSA Claim Form and mail with your receipts. (Please retain a copy of your receipts for
your records.)
FOR QUESTIONS, PLEASE CALL: 800.598.2929 Toll-Free 866.598.2939 Toll-Free 24-Hour Balance
Inquiry www.CustomDesignBenefits.com/MyFlexLogin
[email protected]
[email protected]
513.598.2901
3737 West Fork Road
Cincinnati, OH 45247
QUALIFIED HEALTHCARE ACCOUNT EXPENSES
Acupuncture
Alcoholism treatment
Artificial limbs/teeth
Braces
Chiropractors
Contact lenses & solutions
Costs for physical or mental illness
Crutches
Dental services
Dentures
Diabetic test strips
Dietary supplements prescribed by
a doctor
Drug & Medical supplies (syringes,
needles, etc.)
Eyeglasses*
Eye examinations
Eye surgery (cataracts, LASIK,
etc.)
Hearing devices & batteries
Healthplan expenses
Insulin
Laser eye surgery
Medical supplies
Obstetrical expenses
Orthodontia (braces)
Orthopedic devices
Over-the-counter drugs (with
prescription)
Oxygen
Psychiatric care
Psychological services & care
Rental of Medical Equipment
Smoking cessation drugs*
Smoking cessation programs
Sunglasses*
Weight loss programs or OTC
drugs
(if associated with a specific disease)*
Wheelchair
Vitamins*
Only healthcare expenses not reimbursed
by insurance can be claimed.
*if prescribed by a doctor or may require a
doctor’s letter
of medical necessity.
INELIGIBLE EXPENSES
UNDER THE
HEALTHCARE ACCOUNT
Cosmetic surgery & procedures
Dental bleaching
Marriage or family counseling
Premiums you or your spouse pays
for
insurance
Weight loss for general health or
appearance
14
CATHOLIC DIOCESE OF COLUMBUS
FULL TIME NEW HIRE ENROLLMENT FORM
Name: __________________________________ Location: ____________________________________
(Last Name, First Name, Middle Initial
Home Address, City & Zip: ______________________________________________________________
SS#: _______________ Birth Date: __________ Marital Status: ____ Home Phone #: (___)___________
Job Title: __________________________________________ First Working Day: ________________
Effective Date: ________________ Salary: _______________________________________________
Scheduled Hours Per Week: __________ Pay Frequency: _______________
Status: Full-Time
E-Mail Address: _______________________________________________________________________
Please indicate below the insurance coverage you wish to select:
Medical Benefits:
Dental Benefits (Base):
Dental Benefits (Enhanced):
Vision Benefits:
Employee
Employee
Employee
Employee
Emp. + 1
Emp. + 1
Emp. + 1
Emp. + 1
Family
Family
Family
Family
I decline
I decline
I decline
I decline
If electing Family coverage for Health, Dental or Vision, please list your dependents below and include verifying
documentation (recent tax return – black-out confidential information, birth certificate for children, marriage
certificate for recent marriages, etc.). Please note that dependents will not be covered without their social
security number.
Name
Social Security #
Gender
Date of Birth
__________________
__________________
__________________
__________________
__________________
__________________
_______________
_______________
_______________
_______________
_______________
_______________
______
______
______
______
______
______
___________
___________
___________
___________
___________
___________
Life Insurance: $50,000 _____
Employer Paid
List Beneficiaries:
Name
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
Access to
Other Medical
Yes__ No__
Yes__ No__
Yes__ No__
Yes__ No__
Yes__ No__
Yes__ No__
Full Time
Student
Yes__No__
Yes__No__
Yes__No__
Yes__No__
Yes__No__
Yes__No__
Term Life & AD&D Buy-Up ______________________
(Up to 7 x Salary or $250,000,
(Amount)
(whichever is less) without evidence
of insurability - Employee Paid-Rate Based on Age
Relationship
SSN
DOB
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
Benefit %
___________ Primary
___________ Primary
___________ Primary
___________ Primary
___________ Primary
___________ Contingent
___________ Contingent
___________ Contingent
___________ Contingent
___________ Contingent
Spouse Life Insurance: Spouse Life & AD&D Buy-Up: ___________________
($5,000 up to $100,000 without
(Amount)
evidence of insurability)
Limit 50% of employee election - Employee Paid–Rate Based on Age
Dependent Child Life: Dependent Life & AD&D Buy-up _________________
($25,000 - age over 6 months
(Amount)
$1,000 – age under 6 months) - Employee Paid ($5.00)
Short Term Disability: Plan pays 65% of income after 7 consecutive days of disability.
Employer Paid
Long Term Disability:
Base Plan
Base Plan pays 40% of
Income after 90 days
Employer Paid
_____________ Buy-Up Plan
Buy-Up pays 65% of
Income after 90 days
(Cost to you = $14.00/month)
*Long Term Care: (Complete “Employee Benefit Election Form” below)
______ Base Plan
_____________ Buy-Up Plan
Employer Paid
Employee Paid-Rate Based on Age
Flexible Spending Account (FSA):
Annual Amount
Maximum annual amount is $2,000 (payroll deduction is
required over 24 pays) - $120 annual minimum
Dependent Care Account (DCA):
Annual Amount
Maximum annual amount is $5,000 (payroll deduction is
required over 24 pays) - $120 annual minimum
By my signature below, I hereby authorize the Diocese of Columbus to deduct from my pay the
established employee premium for the benefits I selected above.
I understand these rates will remain in effect throughout the calendar year unless I experience a lifechanging event or my employment is terminated with the Diocese of Columbus.
Employee Signature
Date
* Note: Family Members can also enroll for Long Term Care Programs. The Long Term Care Forms
and rates for family members can be obtained from our website at www.colsdioc.org. Click on Offices
under menu, Insurance Office, Insurance Enrollment, Long Term Care – Family.
Diocese of Columbus
CELL PHONE POLICY
Accident statistics show that the use of cell phones while driving distracts a driver’s attention from
traffic conditions. To promote driver safety and to help reduce the possibility of vehicle accidents in
connection with cell phone use, the Catholic Diocese of Columbus has adopted the following CELL
PHONE POLICY applicable to all employees and volunteers:

Cellular phone calls, both incoming and outgoing, are not permitted at any time while driving a
vehicle for diocesan business.

Diocesan business includes travel between the employee’s work site and external meeting
locations, and between external meeting locations and the employee’s work site.

Accidents occurring while a driver is using a cellular phone may be considered preventable, and
subject to disciplinary action.

A cellular phone’s voicemail feature should be activated to store incoming calls while driving.

This policy applies to both hand-held and hands-free cell phones.

All non-emergency calls should be made once the vehicle is safely parked.
I have read and understand the CELL PHONE POLICY of the Catholic Diocese of Columbus, as
outlined above. After signing and dating this document, return to the bookkeeper at your location
where this will be placed in your employee file.
Employee/Volunteer Signature
Employer:
Revised June 2008
Date