Benefits Cost Worksheet

For Plan Year 2006-2007

This is NOT an enrollment form. This worksheet is intended to assist you in estimating your out-of-pocket cost for benefits. It is valid for active employees and retired employees only, and does not include supplemental premium sharing offered by individual U. T. institutions.

Download a printable version of the Cost Worksheet.

Please remember this form only provides you (the subscriber) with an estimate of your total out-of-pocket cost per month based on state-appropriated funds and contracted premium rates. Be sure to review available benefits information and provider directories for more information on the plans listed.

Evidence of Insurability may be required to enroll in some of these coverages. For details, see your U.T. Group Benefits Handbook or contact your Campus Benefit Office.

Check here if you are a PART-TIME employee.

Medical out-of-pocket cost PER MONTH:

Decline medical coverage

Plan	Subscriber Only	Subscriber & Spouse	Subscriber & Child(ren)	Subscriber & Family
U T SELECT - All Areas	$0.00	$149.87	$156.75	$295.15
HMO Blue - San Antonio	$26.87	$198.59	$200.71	$360.44
HMO Blue - Houston	$40.99	$249.25	$250.04	$444.14
HMO Blue - El Paso	$0.00	$152.01	$158.99	$299.38
HMO Blue - Dallas / Fort Worth	$12.15	$192.97	$198.66	$366.15
HMO Blue - Corpus Christi	$0.00	$163.38	$170.88	$321.75
HMO Blue - Austin	$25.45	$222.33	$225.92	$408.84
*Why is the Health / Medical Insurance deduction on my pay stub different than the out-of-pocket cost listed on this worksheet?* Health Basic Coverage is inclusive of Subscriber Only Medical coverage plus $3,000 Basic Life coverage for retired employees or $10,000 Basic Life coverage and $10,000 Basic Accidental Death and Dismemberment (AD&D) coverage for active employees. Premium Sharing pays for your Basic Life and Basic AD&D coverage along with the Subscriber's Medical coverage and a portion of your Dependent Medical coverage. Premium Sharing is the portion of your benefits that the University pays for and is listed in a separate category. Premium Sharing shows up as an addition to your gross pay. The total cost of your coverages show up as deductions. The total cost of your coverages minus Premium Sharing should equal the total at the bottom of this worksheet.

Dental out-of-pocket cost PER MONTH:

Decline dental coverage

Plan	Subscriber Only	Subscriber & Spouse	Subscriber & Child(ren)	Subscriber & Family
U T SELECT DENTAL - All Areas	$26.41	$50.14	$55.27	$78.59
Assurant DMO	$10.05	$19.10	$21.11	$30.15

Vision out-of-pocket cost PER MONTH:

Decline vision coverage

Plan	Subscriber Only	Subscriber & Spouse	Subscriber & Child(ren)	Subscriber & Family
Superior Vision Plan	$7.22	$11.20	$11.46	$18.48

U T FLEX monthly salary deductions (Employees Only):

PayFlex Savings Calculator

Medical Expense Account
Decline U T FLEX Medical Expense Account

Minimum Maximum Enter desired monthly deduction in dollars

$15.00
$416 for employees with a 12-month contract

$555 for employees with a 9-month contract
$

Accept FLEX Medical
The U.T. FLEX Card is available to use as a "debit card".

If you would like this card be sure to select it when electing your coverages on UTTOUCH.

Note: There is a one time annual fee of $9.00 that will be accessed from your first monthly FLEX deduction for this card. You may request additional cards free of charge by calling the U.T. FLEX plan administrator. Your annual reimbursement will be your actual election minus the $9.00 fee.

Dependent Day Care Expense Account
Decline U T FLEX Dependent Day Care Expense Account

Minimum Maximum Enter desired monthly deduction in dollars

$15.00 $416 if single or married filing jointly for employees with a 12-month contract

$555 if single or married filing jointly for employees with a 9-month contract

$208 if married and filing separately for employees with a 12-month contract

$277 if married and filing separately for employees with a 9-month contract
Enter desired monthly deduction
$

Accept FLEX Daycare

Voluntary Accidental Death and Dismemberment Insurance out-of-pocket cost PER MONTH (Employees Only)

Employee coverage amount :

Enter your basic annual earnings or contract salary : $

Coverage is available up to 10 times your basic annual earnings or contract salary.

Basic annual earnings and contract salary are rounded up to the next $1,000 increment (e.g. $21,323 would be rounded to $22,000, maximum coverage amount of $220,000).

Total employee coverage cannot exceed $1,000,000.

Spouse coverage amount :

The maximum spouse coverage is 50% of the employee's coverage amount (rounded down to nearest $10,000).

Dependent child(ren) coverage

$10,000 per child for one monthly premium. Employee must have at least $20,000 in voluntary AD&D coverage to elect dependent voluntary AD&D coverage.

Voluntary Group Term Life out-of-pocket cost PER MONTH

Select your coverage amount: Select your age as of September 1, 2006: Enter your basic annual earnings or contract salary: $
Employees may select Spouse coverage amount: Select Spouse's age as of September 1, 2006:
Check for Family Coverage (Employees Only)
Employee voluntary term life coverage is selected in one to six times earnings/salary increments of $1,000. Retiree voluntary term life coverage may be selected in the following amounts: $7,000; $10,000; $25,000; $50,000 Only out-of-pocket cost for Life coverage up to $50,000 is redirected from your check before taxes. Any cost for Life coverage beyond $50,000 is deducted from your pay after taxes. Your pay stub may have an area entitled Premium Redirect which includes all out-of-pocket cost redirected before taxes. All out-of-pocket cost for spouse and family life coverage is deducted after taxes.

Long Term Disability out-of-pocket cost PER MONTH (Employees Only)

Decline LTD coverage

Accept LTD coverage

Enter your basic annual earnings or contract salary: $

Your monthly salary: $

Check this box if you are on a 9-month contract.

Your out-of-pocket cost for LTD is not redirected from your check before taxes. The cost is deducted from your pay after taxes unless otherwise elected. Maximum benefit based on maximum monthly salary of $20,042.

Short Term Disability out-of-pocket cost PER MONTH (Employees Only)

Decline STD coverage

Accept STD coverage

Enter your basic annual earnings or contract salary: $

Your monthly salary: $

Check this box if you are on a 9-month contract.

Your out-of-pocket cost for STD is not redirected from your check before taxes. The cost is deducted from your pay after taxes. Maximum benefit based on maximum monthly salary of $5,000.

Long Term Care out-of-pocket cost PER MONTH

Subscriber coverage:

Subscriber age:

Spouse coverage:

Spouse age:

PLAN A is the Basic Benefit with Guaranteed Benefit Increase Option

PLAN B is the Basic Benefit with Lifetime Automatic Benefit Increase Option
(Inflation Protection)

Although other dependents are eligible for Long Term Care coverage, only the subscriber and spouse coverage is deducted from your check after taxes.