Page 13 - CHI 2022 Benefits Guide
P. 13
2022
Benefits Guide
Cost of Coverage
Medical Rates Per Week
Option 1—PPO Option 2—HDHP
Non-Tobacco Tobacco Non-Tobacco Tobacco
Employee $37.00 $49.00 $24.00 $36.00
Employee and Spouse $118.00 $130.00 $82.00 $94.00
Employee and Child(ren) $77.00 $89.00 $55.00 $67.00
Family $152.00 $164.00 $110.00 $122.00
Tobacco Surcharge
To promote healthy lifestyle choices, C.H.I. requires tobacco users to pay a tobacco surcharge of $12 per
week. If enrolling in medical coverage for the irst time, you must sign a non-tobacco status veriication. If
a non-tobacco status veriication is not received it will be assumed you are a tobacco user and the tobacco
surcharge will apply.
Tobacco users may complete a tobacco cessation program to be exempt from the tobacco surcharge. If you
would like to enroll in the tobacco cessation program, see Human Resources for more information.
It is your responsibility to notify Human Resources if you are no longer a tobacco user during beneits
enrollment or during the plan year.
Dental Rates Per Week Vision Rates Per Week
Employee $2.10 Employee $0.77
Employee and Spouse $4.20 Employee and Spouse $1.45
Employee and Child(ren) $4.20 Employee and Child(ren) $1.53
Family $5.25 Family $2.25
Note: medical, dental, vision, and FSA beneit deductions are taken on a pre-tax basis.
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Benefits Guide
Cost of Coverage
Medical Rates Per Week
Option 1—PPO Option 2—HDHP
Non-Tobacco Tobacco Non-Tobacco Tobacco
Employee $37.00 $49.00 $24.00 $36.00
Employee and Spouse $118.00 $130.00 $82.00 $94.00
Employee and Child(ren) $77.00 $89.00 $55.00 $67.00
Family $152.00 $164.00 $110.00 $122.00
Tobacco Surcharge
To promote healthy lifestyle choices, C.H.I. requires tobacco users to pay a tobacco surcharge of $12 per
week. If enrolling in medical coverage for the irst time, you must sign a non-tobacco status veriication. If
a non-tobacco status veriication is not received it will be assumed you are a tobacco user and the tobacco
surcharge will apply.
Tobacco users may complete a tobacco cessation program to be exempt from the tobacco surcharge. If you
would like to enroll in the tobacco cessation program, see Human Resources for more information.
It is your responsibility to notify Human Resources if you are no longer a tobacco user during beneits
enrollment or during the plan year.
Dental Rates Per Week Vision Rates Per Week
Employee $2.10 Employee $0.77
Employee and Spouse $4.20 Employee and Spouse $1.45
Employee and Child(ren) $4.20 Employee and Child(ren) $1.53
Family $5.25 Family $2.25
Note: medical, dental, vision, and FSA beneit deductions are taken on a pre-tax basis.
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