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21)11 Other Northern CA Rates Benefit & Level City E mulovee Benefit & City Employee Level 131m: Shield 1 5545.57 5140.10 I'ERSselect 1 5434.78 545.12 131ue Shield 2 .51.091.15 5280.19 I'ERSselect 2 $869.57 S90.23 Blue Shield 3+ 51.390,49 S392.25 PEKSsekct 3+ 51102.43 5145.31_ PERSchoicc I $469 67 S79.11 PERScarc I $526.67 5344.09 PEKSchoicc 2 $939.35 5158.21 PERScarc 2 . 1.053.35 5688.17_ PEILSchoicc 3+ $1.193.16 5233.67 PERScarc 3 51.341.35 5922.63 Kaiser 1 5526.43 547.89 l'ORAC 1 $441,09 Kaiscr2 $1,052.87 595.77 P(RAC 2 MIL 580.50_ Kaiser 3+ SI.340.73 5152.50 I'OIRAC 3 $L152.02 5131.50 2011 Out -of -State Rates _ Benefit & Level City Employee I Benefit & Level City Employee Kaiser 1 527.82 5257.46 PEltSehoice I 5553.47 583,50 Kaiser 2 1055.65 5514.91 PEItSehoice 2 51,106.95 $166.99 Kaiser 3+ 1344.35 $697.38 PEKSehoicc 3+ 51.439.03 .217.09 In 2011 -2012, the 2010-201 1 medical and dental rates listed above will be further adjusted by 50% of the change, respectively, between the 20- 1.0/ -1-1- 2011/12 dental rates and the CaIPERS 2010/112011/12 Bay Area rates in each individual plan. Employees who wish to waive enrollment in the medical and dental plans and who demonstrate to the satisfaction of the City their enrollment in another medical and dental plan shall receive two - hundred dollars ($200.00) per month for their non - election of medical and dental benefits. In the event both spouses are employed by the City and eligible to enroll in the City's flex benefits plan, one employee may elect not to enroll in the medical and dental plans and will receive the two - hundred dollars ($200.00) per month payment, if enrolled under spouse's coverage. An employee may elect non - enrollment in the medical plan and enrollment in the dental plan and receive one hundred and fifty ($150.00) dollars per month for their non- election. An employee may elect to waive the dental plan only and enroll only in the medical plan and receive fifty dollars ($50.00) per month for their non - election. Re- enrollment in the medical and /or dental plan shall be allowed only based upon a qualifying event as defined by the IRS codes or during an open enrollment period. In 2011, the above opt -out premiums will be increased as follows, based on the employee's status and eligibility during the 2011 benefit year, in accordance with Internal Revenue code (IRC) timelines and qualifying events: Employee rate: Medical $200 + /or dental $50 = $250 /month maximum Two -party rate: Medical $350 + /or dental $50 = $400 /month maximum Family rate: Medical $500 + /or dental $50 = $550 /month maximum No change in dental plan carrier or level of benefits, shall be made unless agreed to by the Management Organization. 3 SL610 final 2010