Date

Name

Address

City ST Zip

Dear Name:

The intent of this letter isto communicate the coordination of your benefits while you are on leave. We want you to understand the leave process and ensure that you maintain your benefits as they best fit your personal needs.

There are 4 types of leave available based on employee need;

  • Short Term Disability Leave – through The Hartford for up to 13 weeks based on medical need with doctor approval. Provides 67% of pay to a max of $500 a week, after a one week waiting period.Employee pays employee portion of benefits.
  • FMLA Leave – Federal requirement, based on eligibility and FMLA qualifying events. This leave protects your position and benefits for up to 12 weeks during a one year period and overlaps with Short Term Disability Leave. Unpaid leave; personal sick or vacation leave can be used. Employee pays employee portion of benefits.
  • Long Term Disability Leave - through The Hartford after the 13 week short term leave based on medical need with doctor approval. Provides 50% of pay to a max of $3,000 a month. Employee pays employee and employer portion of benefits.
  • Leave of Absence–Unpaid leave up to 6 months. This leave can overlap with the disability leave and will permit you to continue health and dental benefits for six months after the 12 week FMLA leave.Employee pays employee and employer portion of benefits
  • Continuation of Benefits – Available after Leave of Absence. For premium rates call Art Walsh at 913-647-0362.

FMLA - Family Medical Leave

Family Medical Leave (FMLA) begins on the first day of a qualifying event and, when taken for a medical condition, will occur at the same time as yourshort term disability leave. FMLAleave provides employment and benefit protection for qualified individuals for 12-weeks during a one year period. While on FMLA leave, benefits remain in place and the benefit cost continues at the current employee premium rates shown below.

Note:

  • Health and Dental benefits have shared premiums
    60% employer & 40% employee
  • Long Term Disability & Basic Life benefits have shared premiums
    50% employer & 50% employee
  • Vision, Supplemental Life, Humana Accident, Critical Illness & Whole Life benefits have premiums that are 100% employee paid
  • FSA medical & dependent care contributions are 100% employee paid

Your FMLA Leavehas been approved from XX/XX/XX to XX/XX/XX.
The monthlyamount of premiums due for your estimated leave are $XXX
(Customize employee payments with the employee.
-Premiums can be deducted from pay ahead of time or
-Premiums can be deducted from pay during the leave, if part of the leave will be paidor –Premiums can be paid via a check during the leave. – Do not include premiums paid by check as pretax premiums on employee W-2).

The date(s)this employee premium should come out of your paycheck (required for pretax premiums) is XX/XX/XX
OR
The date your check for employee premiums must be received at our office is XX/XX/XX.

Leave of Absence forBenefits

You are also eligible for a Leave of Absence,after 12 weeks of FMLA leave.This leave can overlap with the disability leave and will permit you to continue health and dental benefits for six months after the 12 week FMLA leave. During this leave you are responsible for both the employer & the employee portions of your benefits; 100% of the premium. The Leave of Absencebegins at the time you no longer receive regular pay from your employer.

If you are approved for Long Term Disability you will no longer pay the Long-term Disability premium. You are eligible to continue Basic Life and Accidental Death and Dismemberment coverage for one year following the date of your Short-term Disability effective date. At the one year date of your disability you will have the option of converting your life insurance to a personal policy.

If you make FSA contributions for medical or dependent care please read and complete the included form.

Your Leave of Absence has been approved from XX/XX/XX to XX/XX/XX.
The total cost of your monthly benefits will be $XXXX.
Please make your check payable toXXX and mail it to XXXXeach month by XX/XX/XX.

Continuation of Benefits

Prior to the end of your six month Leave of Absenceyou will be contacted to determine if you are interested in continuingHealth & Dental benefits for an additional 18-month period. The continuation benefit premium costs are greaterthan the premiums on the employee plan. Call the Archdiocese with questions; 913-647-0362.
The monthly premium for the Continuation of Health & Dental benefits is:

Monthly Health Premium $XXXXX
Monthly Dental Premium $XXXXX

Sincerely,

(Name)

(Title)
(Phone number)

Cc: (parish priest, school principal or others if applicable)

FSA Choices when Ending Employment
or for Leave of Absence

2 options to choose from

1. You may stop contributing to your FSA account when you leave employment, submit your medical claims to zero out your FSA account before your last day of work and close the account. (Example: Your last day is August 31st and will have $800 sitting in your FSA account from your paychecks through August. Your FSA contributions will stop at the end of August. You MUSTsubmit $800 of expenses before your last day to zero out your account). YOU MUST SUBMIT ALL EXPENSES TO NUSYNERGY BEFORE YOUR LAST DAY OF EMPLOYMENT.

OR

2. Before your last day, you can fund the remaining months of contributions to your FSA, so all contributions for that year have been made before you leave employment. You then have until March 15th to incur expenses, as you would normally. (Example: You contribute $100 a month and your last day is August31st. Before your last day, you will contribute for 4 additional months, $400, for Sept., Oct., Nov., & Dec. Then you will have until March 15th for additional claims and until March 31st to submit those claims). Talk to your location administrator to decide who should make the final payment to NueSynergy if you chose this option. If the contribution comes out of your paychecks, it is a pretax contribution and lowers your taxable income. If you write a check to NueSynergy, it is not a pretax contribution.

The Archdiocese FSA Company is;

NueSynergy

855-890-7239 Phone 855-890-7238 Fax

11221 Roe Ave., Ste. 200

Leawood KS 66211

I, ______(print your name)

have chosen FSA Option ______and have notified my location administrator.

Signature of Employee

12/2014