Department of Management Services and Human Resources
www.campbellcountyva.gov
OVERVIEW
Benefit Enrollment Period 1
HSA Eligibility past age 65 2
Frequently Asked Questions 2
Qualified Life Events 2
KNOW YOUR BENEFITS
Health Insurance Coverage 3
Dental Insurance 3
Health Savings Account (HSA) 3
Dependent Care Coverage 4
Insurance Premiums 4
Enrollment Guide 5
CHIP Notice 7
Benefit Enrollment Form 9
2021 Health/Dental
Insurance Packet for New Hires
Contents
New
Employee Packet
Campbell County Department of
Management Services and
Human Resources
Darlene Cowart, HR & Benefits Coordinator
PO Box 100 │47 Courthouse Lane; 1st Floor
Rustburg, VA 24588
Ph: (434) 332-9794 │Fax: (434) 332-9666
Welcome home to Campbell County!
In the next few pages, we invite you to learn more about our
Health and Dental Insurance programs, and our Employee
Health Savings Account, which you will have an opportunity to
voluntarily contribute to.
During this timeframe, you may ask questions, make decisions
about you and your family’s healthcare needs and select the
coverage that best suits your individual needs.
As you review the programs, please choose from the following
benefit programs:
Health and Dental Insurance
Voluntary Employee Health Savings Account
(HSA) contributions
Dependent Care Coverage
Please read this packet carefully. All full-time employees will
need to respond by completing the Benefits Enrollment form.
In addition, please remember that this orientation period (within
three days of hire) is the only time to select/adapt your benefit
coverage until our next annual Open Enrollment period
(October), outside of a qualifying event. You will have an op-
portunity during the month of June to make changes to your
Health Savings Account (HSA) election.
The annual Open Enrollment Period is your opportunity to
review your benefits and make any changes for the year
ahead. Outside of Open Enrollment, the only time you can
make a change to your benefits is if there is a qualifying life
event.
Again, for newly hired employees, all benefit enrollment
forms are due within three days of hire. Any forms received
after this timeframe cannot be processed without a qualify-
ing event. Take some time to learn about your options, eval-
uate you and your familys needs, and choose the benefits
that will best serve you (and your eligible family members).
If you experience a qualifying event, please notify the
Department of Management Services/HR within
31 calendar days.
Some examples of such events include:
Marriage;
Birth or adoption of a child;
Divorce and/or Legal separation;
Death or loss of a dependent;
Change in spouse’s employment status causing a
loss and/or a gain of coverage;
Change in your own employment status;
Change in residence;
Eligibility for Medicare.
Changes in health and/or dental coverage due to a
qualifying event are effective the date of the qualifying
event. Additional premium may need to be collected
depending on timing of the event with payroll run dates.
We recognize that you may have questions as you read through the packet. In case you do, please know
we are here for you. Feel free to contact us, should you require assistance in completing your forms.
HSA Eligibility past age 65
Qualified Life Events
Please note: Enrollment in any type of Medicare makes you ineligible to
contribute to an HSA, per IRS regulations.
Employees past age 65 who are actively working and receive
employer HSA contributions and/or elected voluntary HSA
contributions to be deducted from their pay; must notify the
employer seven months prior to the date they expect to apply
for social security benefits so that employer and if applicable,
voluntary employee contributions can be stopped at the
appropriate date. This is because when you apply for Social
Security, Medicare Part A will be retroactive for up to six
months (as long as you were eligible for Medicare during those
six months). If you do not stop contributing six months before
you apply for Social Security, you may have a tax penalty.
If an employee past age 65 continues to defer social security
but applies for Medicare, they should notify the employer the
month before the Medicare effective date.
If you are an active employee turning age 65 in 2021 and/or
become Medicare eligible in 2021,
and are enrolled in Campbell
County’s HDHP with HSA, you
should contact us to discuss the
impact enrolling in Medicare will
have on your HSA.
It is your responsibility to determine
your eligibility for contributions to
an HSA. If the County continues to
fund an HSA on your behalf past
the date you are eligible, you will
be responsible for any IRS penalties
and payment of back taxes.
You may contact Darlene Cowart , HR and Benefits Coordina-
tor, at 434-332-9794 or email to schedule an appointment at
decowart@campbellcountyva.gov.
What is the benefit enrollment deadline for
newly hired employees?
Enrollment forms for all new employees are
due by close of the business day on third
day of hire.
What is a Health Savings Account (HSA)?
An HSA is a tax-favored savings account that may be
used to pay for qualified healthcare expenses for your-
self, your spouse and your IRS tax-qualified dependents.
Am I eligible to participate in the HSA program?
HSA’s are governed by the Internal Revenue Code (IRC),
and you must meet the following eligibility requirements
to qualify for a HSA:
must be enrolled in a high deductible health plan
(HDHP);.
cannot be covered by any other healthcare plan,
flexible spending account (FSA) or enrolled in Medi-
care; and
cannot be claimed as a tax dependent on someone
else’s tax return.
How much may I contribute annually to my HSA?
In 2021, the maximum IRS HSA contributions for Employee
only coverage is $3,600, and for Employee + 1, Family,
and for couples who are both employed by the County is
$7,200. If you are age 55, or older, you may contribute
an additional $1,000 annually.
Please note: You must include the County’s portion in
your maximum annual contribution. For example, if you
select Employee only coverage, this means your contri-
bution could be no greater than $2,599.92 per year
($216.66 monthly), and for the remaining coverage plans
offered, could be no greater than $5,199.96 annually
($433.33 monthly).
2
Frequently Asked Questions
Health Savings Account
(HSA) Contributions
Campbell County will
continue to make employer
contributions into your HSA
for each month you have
the Anthem HDHP and
remain eligible for the
contribution.
If you elect to have
e m p l o y e e v o l u n t a r y
contributions to your HSA,
remember the voluntary
contribution in addition to
the employer contribution
cannot exceed the IRS
maximum limits.
*If you are over age 55, an
additional $1,000 may be
contributed until your
effective Medicare date.
DID YOU KNOW... Blue View Vision benefits are
included in your health insurance coverage?
After a $15 co-pay (In-Network provider), a
routine eye exam is covered once per calen-
dar year. Additional savings can be found by visiting a
participating provider. Enjoy up to 35% off the retail
price of frames, and 15% off the retail price of non-
disposable contacts.
To locate a provider, login to your Anthem account, or
call Member Services at 1-866-723-0515.
3
Health Insurance Coverage
The HDHP Summary of Benefits Coverage (SBC) is available to provide thor-
ough benefit information; however, for specific questions, please feel free to
ask a member of our staff, or call Anthem directly.
Prescription drug costs contribute to the overall annual deductible. Once
you meet your annual deductible, you will be responsible for 20% of the cost
until you meet your out-of-pocket maximum. (Based on using an In-Network
provider)
2021 Monthly Employer HSA
Contribution for Employees
enrolled in Anthem HDHP
Employee Only
$83.34
Employee +1
$166.67
Employee + Family
$166.67
The 2021 IRS Maximum Limits
are as follows:
Employee Only
$3,600
Employee +1
$7,200
Employee +Family
$7,200
Family
(Both spouses Employed)
$7,200
LiveHealth Online
Use LiveHealth Online for a video visit with a doctor from the comfort of
your home.
Using LiveHealth Online, you can have a private and secure video visit with
a board-certified doctor 24/7 on your smartphone, tablet or computer with
a webcam. A doctor can assess your condition, provide a treatment plan
and even send a prescription to your pharmacy, if needed.
To sign up, visit livehealthonline.com or download the free
LiveHealth Online app to your mobile device.
Dental Insurance Coverage
As with most dental plans, our coverage provides two exams/
cleanings per year.
For more detailed information, please review the Dental Insurance
Summary of Benefits Coverage (SBC), or feel free to ask a member of
our staff, or call Anthem directly.
Dependent Care
Campbell County offers de-
pendent care reimbursement
accounts. The dependent
care assistance account
allows you to pay for out-of-
p o c k e t , w o r k - r e l a t e d
dependent day-care costs
with pre-tax dollars.
The annual plan limit which
may be allocated to the
d e p e n d e n t c a r e
reimbursement is $5,000.
Your contributions are subject
to the IRS “use-it-or-lose-it”
rule, meaning that any
unused funds which remain in
your dependent care
account will be forfeited at
the end of the plan year.
If you are interested in
participating, please select
this option on your enclosed
Benefits Enrollment form and
indicate the amount to be
d e d u c t e d f r o m y ou r
paycheck.
For additional information,
please contact Darlene
Cowart at (434)332-9794, or
hr@campbellcountyva.gov.
Insurance Premiums
4
Each year, with the aid of a consultant, Campbell County forecasts the upcoming
year’s total benefit costs. As part of this study, we review our benefit programs and
make revisions and updates to ensure we continue to offer a competitive,
cost-effective, benefit program to you and your family. Below is the premium chart
outlining the monthly premiums for the 2021 pl an year.
(Effective January 1December 31, 2021)
Monthly Anthem HDHP Health Insurance Premium
Employee Only Employee +1 Employee +Family
Premium $620.71 $1,126.40 $1,640.41
County Pays $545.71 $895.40 $993.41
Employee Pays $75.00 $231.00 $647.00
Monthly Anthem Dental Insurance Premium
Employee Only Employee +1 Employee +Family
Premium $28.57 $52.82 $82.32
County Pays $15.82 $15.82 $15.82
Employee Pays $12.75 $37.00 $66.50
Monthly Health Savings Account (HSA) Employer Contribution
Employee Only Employee +1 Employee +Family
Employer Contribution $83.34 $166.67 $166.67
Employee Contribution
You determine the amount appropriate, up to the IRS maximum
Monthly Insurance Premiums for Health & Dental
Both Spouses Employed by Campbell County
Health Dental
Premium $1,640.41 $82.32
County Pays $1,360.41 $29.32
Employee Pays $280.00 $53.00
NOTE:
Those who are Medicare eligible
and have existing KeyCare 500
coverage may continue with this
coverage and pay the same
premium as listed above;
however, they will not receive the
monthly HSA contribution.
Please carefully review each section of the Benefits Enrollment Form.
You must make an election for each benefit section on the form, or
waive cov-erage. If you are unsure what to complete, please use this
quick question and answer guide to help you with your enrollment pref-
erences.
EMPLOYEE INFORMATION SECTION
Please complete the top section of the form with your employee infor-
mation.
SECTION 1: ANTHEM HEALTH INSURANCE HDHP
Choose the box that indicates enrollment or waiver of health insurance
coverage.
SECTION 2: ANTHEM DENTAL INSURANCE
Choose the box that indicates enrollment or waiver of dental insurance coverage.
SECTION 3: AUTHORIZE OR WAIVE PRE-TAX SALARY REDUCTION
This section only needs to be completed if you have or are enrolling in health/dental insurance. In compliance with Section 125 of
the Internal Revenue Code for cafeteria plans, participants are provided an opportunity to receive certain benefits on a pre-tax
basis. Section 4 is where you would indicate your selection of pre-tax or after-tax deductions.
SECTION 4: COVERED INDIVIDUALS
This section only needs to be completed if adding or health and/or dental insurance coverage for you and/or any family member.
SECTION 5: HEALTH SAVINGS ACCOUNT (HSA)
The Health Savings Account contribution section should be completed by any employee enrolling in the County’s High Deductible
Health Plan. Please carefully review the IRS HSA Eligibility Requirements and check the box to acknowledge your understanding
that it is your responsibility to ensure all IRS guidelines and regulations are adhered to as it relates to your HSA account.
If you would like to make a monthly contribution, please indicate the amount in the space provided. If you do not wish to make a
voluntary contribution to your account, please select “decline.”
You will remain eligible to receive the County’s contribution to your account, as long as you meet the eligibility requirements es-
tablished by the IRS.
SECTION 6: DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
Be sure to indicate the dependent care contribution amount you want deducted from your paycheck each month, or decline
dependent care coverage.
If enrolling in the dependent care flex spending account for the first time, additional enrollment information on the program will be
forwarded to you.
SECTION 7: AUTHORIZATION AND SIGNATURE
Please sign and date to authorize deduction of the necessary premiums from your paycheck or to confirm declination of cover-
age.
Enrollment Guide
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Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your
employer, your state may have a premium assistance program that can help pay for coverage, using
funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP,
you won’t be eligible for these premium assistance programs but you may be able to buy individual insur-
ance coverage through the Health Insurance Marketplace. For more information, visit
www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below,
contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or
dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it
has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible
under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t al-
ready enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60
days of being determined eligible for premium assistance. If you have questions about enrolling in your
employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
As a resident of Virginia, you may be eligible for assistance paying your employer health plan premiums.
Please contact the State for more information on Medicaid eligibility at 1-800-432-5924 or CHIP at 1-855-
242-8282. https://www.coverva.org/hipp/
This information is provided as of July 31, 2020. For more information on special enrollment rights,
contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/agencies/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless
such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot
conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number,
and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507.
Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the
collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested
parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including sugges-
tions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention:
PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB
Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 1/31/2023)
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8
BENEFITS ENROLLMENT / CHANGE FORM
New Hire Hire Date:
IRS Qualifying Event* Date of Event:
Type of Event: Marriage/Divorce Birth/Adoption of Child
Loss of Coverage through Employer/Spouse Other:
*If an IRS qualifying event, a Benefits Enrollment / Change Form must be submitted to the Benefits Coordinator within 31-days of the event.
If the form is not submitted within the 31-day time frame, the change cannot be made until the next open enrollment period.
NAME (LAST, FIRST, MI)
M F
SINGLE
MARRIED
DATE OF BIRTH
GENDER:
MARITAL STATUS
STREET ADDRESS
CITY
STATE ZIP CODE
HOME PHONE
EMAIL ADDRESS
You must make an election for each benefit or decline coverage.
CHOOSE 1 OF THE COVERAGE LEVELS:
Selection
Anthem High Deductible Health Plan
Employee
Pays
Employer
Pays
Total
Premium
Employee Only
$75.00
$545.71
$620.71
Employee + 1
$231.00
$895.40
$1,126.40
Employee + Family
$647.00
$993.41
$1,640.41
Employee + Family - Both spouses
employed by CC & eligible for coverage
$280.00
$1,360.41
$1,640.41
DECLINE MEDICAL COVERAGE
CHOOSE 1 OF THE COVERAGE LEVELS:
Selection
Anthem Dental Plan
Employee
Pays
Employer
Pays
Total
Premium
Employee Only
$12.75
$15.82
$28.57
Employee + 1
$37.00
$15.82
$52.82
Employee + Family
$66.50
$15.82
$82.32
Employee + Family - Both spouses
employed by CC & eligible for coverage
$53.00
$29.32
$82.32
DECLINE DENTAL COVERAGE
ENROLLMENT TYPE AND DEADLINES CHECK ONE
EMPLOYEE INFORMATION
SECTION 1: MEDICAL – ANTHEM HDHP (High Deductible Health Plan)
Premiums deducted monthly for 12 months
SECTION 2: ANTHEM DENTAL
Premiums deducted monthly for 12 months
EMPLOYER USE ONLY
BENEFIT SELECTION
DATE ENTERED/APPLICABLE
ANTHEM HEALTH
ANTHEM DENTAL
HSA
DC-FSA
EFFECTIVE DATE
OF COVERAGE
Authorize pre-tax salary reductions I understand my premiums for health and/or dental will be taken from my salary
prior to the calculation of taxes reducing my gross taxable wages.
Waive all pre-tax benefits I understand my pay will have the required insurance premiums with after-tax deductions.
Be sure to check the appropriate boxes for the coverages you elect.
SELECTION
NAME
(LAST, FIRST, MI)
DATE OF
BIRTH
(MM/DD/YY)
SEX
(M/F)
SOCIAL SECURITY
NUMBER
HEALTH
DENTAL
Add
Remove
EMPLOYEE
Add
Remove
SPOUSE
Add
Remove
CHILD
Add
Remove
CHILD
Add
Remove
CHILD
Add
Remove
CHILD
Please answer the questions below if enrolling in health insurance:
1)
Does any covered individual listed above enrolling in the health insurance have other health insurance coverage? No Yes
If you answered yes to the above question, please list the individual(s), the insurance carrier, policy #, and effective date.
NAME
(S) INSURANCE CARRIER POLICY # EFFECTIVE DATE
2)
Does any covered individual(s) listed above enrolling in health insurance have Medicare coverage? No Yes
If you answered yes to the above question, please list the individual(s), the Medicare Number, effective dates for Medicare Part A,
Medicare Part B, and Medicare Part D.
NAME(S) INSURANCE CARRIER Medicare # EFFECTIVE DATE
Review HSA Eligibility Requirements
Federal regulations prohibit you from opening or contributing to an HSA if you do not meet all the following requirements:
Covered under a qualified high deductible health plan on the first day of the month
Not covered by any other health plan, including your spouse’s health insurance, or Medical Flexible Spending Account (FSA)
Not enrolled in any part of Medicare or Tricare
Have not received Veteran’s health benefits in the past 90 days prior to an HSA initial enrollment
Not claimed as a dependent on another person’s tax return
Decline Employee Voluntary HSA Monthly Contribution
Employee Voluntary HSA Monthly Contribution $ per month
Election will be for the calendar year unless a change is made during mid-year HSA open enrollment in June for July processing.
SECTION 3: PRE-TAX AUTHORIZATION
SECTION 4: DEPENDENTS
SECTION 5: HEALTH SAVINGS ACCOUNT
I understand it is my responsibility to ensure all Internal Revenue Service guidelines and applicable regulations
are adhered to as it relates to my HSA account.
HSA CONTRIBUTIONS
(Monthly HSA deposits available on payday)
Monthly Employer HSA Contribution for enrollees in Anthem High Deductible Plan
Employee Only
Employee + 1
Employee + Family
Employer Contribution to HSA
$83.34
$166.67
$166.67
Employee Voluntary Contributions
-you determine the amount appropriate for your needs up to the IRS maximum.
IRS 2021 HSA Contribution Limits (Employer + Employee)
Employee Only
Employee + 1
Family
Family
(Do uble Spo use - Both Emplo yed by
CC & B enefit Eligible)
$3,600
$7,200
$7,200
$7,200
Please note: You must include the County’s HSA portion in your maximum annual contribution. For example, if you select Employee only
coverage, this means your contribution could be no greater than $2,599.92 per year ($216.66 monthly), and for the remaining coverage
plans offered, could be no greater than $5199.96 annually ($433.33 monthly).
Additionally, if you are age 55 or over, you may contribute $1,000 more annually, which equals $3,599.92 per year ($299.99 per
month) for those on the Employee Only plan, and $6199.96 annually ($516.66 per month) for those on the remaining coverage plans.
Covers eligible dependent care expenses for your federal tax dependents. To be eligible, expenses must be necessary
to enable you or your spouse to be gainfully employed or in search of gainful employment or to attend school on a
full-time basis and must be for the care of a child under 13 years of age or a disabled dependent adult.
DECLINE Dependent Care
I elect to enroll for a monthly amount of $ for a total annual amount of $
PLEASE NOTE: The 2021 IRS annual contribution limit is $5,000. For the dependent care assistance benefit, a statement will need to be
provided from the service provider including the amount of the expense, the name of dependent, address, the taxpayer identification number
of the service provider, and the dates of service. Reimbursement will be for amounts up to the balance in my account at the time of the
request. Any amounts not used during a plan year for dependent care will be forfeited and will not be paid to me in cash or used to provide
benefits specifically for me in a later plan year.
I hereby authorize Campbell County to deduct the necessary premiums, if any, from my paycheck. I cannot
change or revoke any of my elections at any time during the plan year unless I have a qualifying life event. Changes
to (employee) HSA contributions are allowed in June (to be effective in July) and November (to be effective
January 1) of each year. Pre-tax benefits are not subject to federal income or FICA taxes which could result in a
reduction in the Social Security benefits I receive at retirement if I earn less than the annual FICA taxable wage
base.
If declining coverage, I certify I have been given the opportunity to apply for coverage for myself and eligible
dependents, if any. I understand I am declining enrollment for myself and, if applicable, my eligible dependents. I
may be able to enroll myself and my eligible dependents in this plan if I have a qualifying event.
Signature of Employee Date
________________________________________________________________________________
Signature of Organizational Representative Date
SECTION 6: DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
Elected amount will be deducted monthly for 12 months
SECTION 7: AUTHORIZATION AND SIGNATURE
PLEASE READ, SIGN, AND DATE