Dependent Eligibility Requirement Plan Coverage Documentation Requirement
Spouse

Husband or wife of a covered employee

  • Medical
  • Dental
  • Vision
  • Supplemental Spouse Life Insurance
  • A copy of your marriage certificate

AND One of the following:

  • A copy of the most recent Federal tax return confirming this dependent is your spouse.
  • A document dated within the last 60 days showing current relationship status such as a recurring monthly household bill or statement of account.
  • Signed and notarized affidavit declaring you are married.
  • The document must list your spouse's name, the date, and your mailing address.
  • Acceptable documents include a utility bill, bank account statement, or credit card statement.
  • Unacceptable documents include checks/deposit slips, coupon books, advertisements or solicitations, envelopes with a postmark date, or any type of insurance cards or health insurance documents.
Same-Sex Domestic Partner

A person of the same gender who meets the following criteria:

  • Shares a residence with an eligible employee for at least 6 months.
  • At least 18 years of age.
  • Is not related to the employee by blood to a degree of closeness that would prohibit legal marriage.
  • Listed as Domestic Partner on the most recent notarized CSU Affidavit of Domestic Partnership.
  • Is not in relationship solely for the purpose of obtaining benefit coverage.
  • Is not married or separated from any other person.
  • Medical
  • Dental
  • Vision
  • Dependent Life
  • Supplemental Same-Sex Domestic Partner Life Insurance
  • Notarized Affidavit of Domestic Partnership
  • Two proofs of joint ownership or joint residency issued within last 6 months
Dependent Child

Child related to a covered employee up to age 26 including:

  • Biological child
  • Adopted child
  • Step child
  • Legal Ward
  • Child which employee or spouse of employee is legal guardian
  • Child(ren) may be married, do not have to reside with parents, or be financially dependent upon them, and may be eligible to enroll in their employer's plan
  • Medical
  • Dental
  • Vision
  • Dependent Life
  • A copy of the child's birth certificate/hospital birth record or adoption certificate naming you or your spouse as the child's parent. The document must list the first and last names of the child and parent(s) OR a copy of the court order naming you or your spouse as the child's legal guardian or custodian.

Please Note: If you are covering a stepchild you must also provide documentation of your current relationship to your spouse as requested.

Dependent Child
(Same-Sex Domestic Partner)

Domestic Partner Child up to age 26 with relationship to a covered employee:

  • The child of the employee's covered Same-Sex Domestic Partner:
    • Biological, adopted or legal ward
  • Medical
  • Dental
  • Vision
  • Dependent Life
  • Required documentation for Same-Sex Domestic Partnership
  • State issued birth certificate
  • Adoption certificate
  • Court ordered document of legal custody
Disabled Dependent

Child related to covered employee including:

  • Biological child
  • Adopted child
  • Step child
  • Legal Ward
  • Child which employee or spouse of employee is legal guardian.
  • Child(ren) may be married, do not have to reside with parents, or be financially dependent upon them, and may be eligible to enroll in their employer's plan.

Coverage may be extended to a child of any age who is incapable of self-support due to a mental or physical disability.

  • Medical
  • Dental
  • Vision
  • Dependent Life
  • A copy of the child's birth certificate/hospital birth record or adoption certificate naming you or your spouse as the child's parent. The document must list the first and last names of the child and parent(s) OR a copy of the court order naming you or your spouse as the child's legal guardian or custodian.

AND

  • A copy of the physician's documentation declaring the child disabled.

Please Note: If you are covering a stepchild you must also provide documentation of your current relationship to your spouse as requested.

Plan Name MetroHealth Select EPO Plan Medical Mutual Value PPO Plan Medical Mutual Traditional PPO Plan CSU Health & Wellness Services
(Faculty and Staff Only)
Full-Time Faculty/Staff
Employee Only $44.70 $97.02 $142.74 N/A
Family $116.84 $253.14 $372.22
Part-Time Staff (30–39 hours)
Employee Only $106.20 $151.70 $170.18 If you are enrolled in MetroHealth or Medical Mutual plans, you can receive certain health services at no cost at CSU Health & Wellness Services.
Family $365.36 $395.84 $443.82
NOTE: IRS rules require that the payroll premium for same-sex domestic partner's coverage is contributed by employee after-tax and that the value of any benefits provided to a same-sex domestic partner is taxable to the employee.
* The benefit period is based on a calendar year and it is the period of time during which covered services are rendered and benefit maximums, deductibles, and out-of-pocket maximums are accumulated.
MetroHealth Select Medical Mutual Value Plan Medical Mutual Traditional Plan
  • CSU Health and Wellness Services are provided at no cost to Faculty and Staff
  • Covers 100% of preventive care services provided in-network (according to age and gender)
  • Primarily utilizes MetroHealth Select Healthcare Professionals
  • Requires you to Pay 100% for most Non-Network services
  • Option to participate in Health Care Flexible Spending Account
  • CSU Health and Wellness Services are provided at no cost to Faculty and Staff
  • Covers 100% of preventive care services provided in-network (according to age and gender)
  • In-Network coverage through Medical Mutual SuperMed Network
  • Option to participate in Health Care Flexible Spending Account
  • CSU Health and Wellness Services are provided at no cost to Faculty and Staff
  • Covers 100% of preventive care services provided in-network (according to age and gender)
  • In-Network coverage through Medical Mutual SuperMed Network
  • Option to participate in Health Care Flexible Spending Account
In-Network Non-Network In-Network Non-Network In-Network Non-Network
Deductible
Individual $350 Not covered $1,100 $2,200 $600 $1,200
Family $700 Not covered $2,200 $4,400 $1,200 $2,400
Coinsurance After Deductible 10%, after ded. Not covered 20% after ded. 40% after ded. 10% after ded. 30% after ded.
Coinsurance Limit—Medical Only—Excludes Deductibles and Copayments
Individual $1,000 N/A $3,250 $6,500 $1,750 $3,500
Family $2,000 N/A $6,500 $13,000 $3,500 $7,000
Inpatient Facility Services 10%, after ded. Not covered 20% after ded. 40% after ded. 10% after ded. 30% after ded.
Outpatient Facility & X-Ray/ Lab Services 10%, after ded. Not covered 20% after ded. Not covered 10% after ded. 30% after ded.
Preventive Care Office Visit $0 copay, no ded. Not covered $0 copay, no ded. 40% after ded. $0 copay, no ded. 30% after ded.
Office Visit—Primary Care Physician $20 copay Not covered $35 copay 40% after ded. $25 copay 30% after ded.
Office Visit—Specialist $30 copay Not covered $45 copay 40% after ded. $35 copay 30% after ded.
Urgent Care Visit $40 copay Not covered $65 copay 40% after ded. $50 copay 30% after ded.
Emergency Room Visit (copay waived if admitted) 100% after $250 copay 100% after $250 copay $350 copay +20% after ded. $350 copay +20% after ded. $300 copay +10% after ded. $300 copay +10% after ded.
Emergency Room Visit—Non- Emergency $250 copay + 10% after ded. Not covered $350 copay +20% after ded. $350 copay +40% after ded. $300 copay +30% after ded. $300 copay +30% after ded.
MetroHealth Select Medical Mutual Value Plan Medical Mutual Traditional Plan
Prescription Drug Benefits MetroHealth Pharmacy Medical Mutual Express Scripts Medical Mutual Express Scripts Non-Network Medical Mutual Express Scripts Non-Network
Retail Drug (30 day supply) Mandatory Generic Non-Maintenance, Non-Specialty Drugs
Retail Generic (30 day supply) $0 copay $10 copay $15 copay Not covered $10 copay Not covered
Retail Preferred Brand Name (30 day supply) $30 copay $45 copay $50 copay Not covered $40 copay Not covered
Retail Non-Preferred Brand (30 day supply) $60 copay $90 copay $95 copay Not covered $75 copay Not covered
Mail Order Non-Specialty (90 Day Supply) Mandatory Generic Maintenance Drugs
Mail Generic $10 copay $20 copay $30 copay Not covered $20 copay Not covered
Mail Preferred Brand $60 copay $90 copay $100 copay Not covered $80 copay Not covered
Mail Non-Preferred Brand $120 copay $180 copay $190 copay Not covered $150 copay Not covered
Specialty Drugs (Accredo Specialty Pharmacy only)
30 Day Supply Not covered Retail copays apply 10% up to $200 max per prescription Not covered 10% up to $175 max per prescription Not covered
Out-of-Pocket Maximum: Includes Deductible, Copay, and Coinsurance for Medical and Prescription Drugs
Individual $8,150 Unlimited $8,150 Unlimited $8,150 Unlimited
Family $16,300 $16,300 $16,300
Full-Time Faculty and Staff Part-Time Admin Faculty and Staff (30–39 Hours)
Employee Only $3.06 $7.64
Employee + 1 $5.96 $14.90
Family $10.32 $25.80

1 "In-Network Benefits" refers to benefits provided under this plan for covered dental services that are provided by a participating dentist. "Out-of-Network Benefits" refers to benefits provided under this plan for covered dental services that are not provided by a participating dentist.

2 Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

3 R&C fee refers to the Reasonable and Customary charge, which is based on the lowest of (1) the dentist's actual charge, (2) the dentist's usual charge for the same or similar services, or (3) the charge of most dentists in the same geographic area for the same or similar services as determined by MetLife.

4 We will never pay more than the greater of the In-Network Maximum Benefit Amount or the Out-of-Network Maximum Benefit Amount. For example, if a Covered Service is received Out-of- Network and We pay $300 in benefits for such service, $300 will be applied toward both the In-Network and the Out-of-Network Maximum Benefit Amounts applicable to such service.

5 Applies only to Type B, C, & TMJ Services. Deductible will only need to be satisfied one time for in and out of network.

6 Services listed are examples. Please see Certificate of Coverage for a list of all the covered services.

In-Network Provider1
% of Negotiated Fee2
Non-Network Provider1
% of R&C Fee3
Coverage Type

Type A: Preventive6

(exams, cleanings, topical fluoride applications, x-rays, space maintainers, sealants)

100% 100%

Type B: Basic Restorative6

(fillings, simple extractions, crown, denture, and bridge repair, endodontics, oral surgery, periodontics)

80% 80%

Type C: Major Restorative6

(crown, denture, and bridge recementations, implants, bridges, dentures, crowns/inlays/ onlays, general anesthesia, TMJ)

60% 60%

Type D: Orthodontia

60% 60%
Deductible5
Individual $50 $50
Family $150 $150
Annual Maximum Benefit4
Per Person $1,500 $1,200
Orthodontia Lifetime Maximum
Per Person $1,200 $1,200
Basic Vision Plan Opt-Up Vision Plan
Full-Time Faculty and Staff No premium contributions

Employee Only: $5.98

Family: $17.06

Part-Time Admin Faculty and Staff (30–39 Hours)

Employee Only: $.94

Family: $2.70

Employee Only: $6.92

Family: $19.76

Frequency of Coverage 24 months from date of last service 12 months from date of last service

* The Opt-Up also includes enhanced coverage for lenses for eyeglasses, including coverage for tints and photochromic or "transition" lenses.

** See VSP Vision Benefit Summary for coverage specifics and limitations.

In-Network Open Access (Non-Network) Reimbursement Level
Vision Exam 100% after $15 Copay Up to $45
Prescription Glasses $25 copay N/A
Lenses**

100%

Single vision, lined bifocal and lined trifocal lenses

Polycarbonate lenses for dependent children.

Single vision up to $30

Lined bifocal up to $50

Trifocal up to $65

Lens Options** Progressive: covered in full Progressive: Up to $50
Frames

Covered up to plan allowance of $150

$80 Costco allowance

Up to $70
Contact Lenses
(instead of glasses)

$150 allowance for contacts and exam, if elective;

100% covered if visually necessary

VSP requires proof of visual necessity.

If elective, up to $105;

If visually necessary, up to $210

VSP requires proof of visual necessity.

Claims No claim form required Must file claim for reimbursement within 6 months from date of service.
Details of the Health Care FSA are available here and the Dependent Care FSA here. Contact Surency at 866.818.8805 for additional information.
2022–23 FSA Plan Year Deadlines
Payroll Contributions FSA elections made during the annual Open Enrollment period will be deducted on a pretax basis according to your pay periods during July 1, 2022–June 30, 2023, or through May 15 for faculty paid over nine months.
Plan Year Period To Incur Eligible Expenses Participants enrolling for the 2022–23 plan year must incur expenses from July 1, 2022 through September 15, 2023 (which includes a 2½-month grace period).
Claim Filing Deadline

All eligible claims incurred during the plan year period must be received by Surency (not postmarked) no later than November 30, 2022.

If you separate/retire from the University, you have 60 calendar days from your separation date for Surency Flexible Spending Accounts to receive claims which were incurred prior to your last day of employment. Refer to claim filing instructions located on the Health Care and Dependent Care Flexible Spending Account pages on the myCSU Human Resources Benefits website.

• Cost of coverage increases in the month in which your age reaches a new age-band.

• A reduction in employee Supplemental Life coverage may result in a reduction to spouse/same-sex domestic partner coverage if level does not fall within plan rules.

Age Non-Tobacco User Tobacco User
< 25 $0.031 $0.064
25–29 $0.031 $0.064
30–34 $0.037 $0.080
35–39 $0.048 $0.095
40–44 $0.069 $0.138
45–49 $0.113 $0.227
50–54 $0.174 $0.348
55–59 $0.323 $0.646
60–64 $0.392 $0.784
65–69 $0.683 $1.366
70–74 $1.107 $2.214
75 and older $1.558 $3.117
Dependent Life Insurance: $.50 per month for all covered dependents.
Note: Rates are based on tobacco user status. Monthly premium amount is divided between the first two paychecks of each month.

1 Employee and employer contributions and mitigating rates are legislated and are subject to change.

2 Under the State of Ohio Law, a portion of the University's contribution (mitigating rate) is remitted to the State Retirement Systems. The mitigating rate helps to ensure that the funding status of the traditional pension plans is not adversely affected by alternative retirement plans. The mitigating rates are periodically under review and are subject to change.

3 ARP mitigating rates effective July 1, 2017.

Associated Retirement System Employee1 CSU1 Mitigating Rate2
Ohio Public Employees Retirement System (OPERS) 10.00% 14.00% Note: OPERS DC plan has a mitigating rate to the employer contribution that is applied. Contact OPERS for details.
OPERS-LE (Law Enforcement) 13.00% 18.10%
State Teachers Retirement System (STRS) 14.00% 14.00% Note: STRS DC plan has a mitigating rate to the employer contribution that is applied. Contact STRS for details.
Alternative Retirement Plan (ARP) for staff Positions (Contribute at OPERS Rates) 10.00% 11.56%3 2.44%3
Alternative Retirement Plan (ARP) for Faculty Positions (Contribute at STRS Rates) 14.00% 9.53%3 4.47%3
Full Years of Service Vacation Leave
Accrual Per 80 hours active pay status
1–7 3.1 Hours
8–14 4.6 Hours
15–24 6.2 Hours
25 or more 7.7 Hours
Employee Type Number of Hours
Faculty and Salaried Professional Staff 10 hours per month*
Hourly Classified and Professional Staff 4.6 hours per 80 hours worked*
* Pro-rated for Academic Year and Part-Time appointments. Sick pay hours may be used for the employee or immediate family member's illness and/or injury.