2022 Benefits Guide

Accident Insurance

Accident Insurance

Services Benefit Payout
Emergency Room Treatment $50
Ground Ambulance $240
Urgent Care Facility Treatment $50
Outpatient Ambulatory Surgery Benefit $150
Physical Therapy $50/day
X-Ray $50
Fractures Common Fractures: Finger/toe ($160), Hand/wrist/ankle/foot ($1,200), Collarbone ($960)
Dislocations Common Dislocations: Elbow ($750), Shoulder ($1,000)
Other Benefits Over 80 coverages have been increased - please visit the Knowledge Hub for more information

Critical Illness Insurance Benefit

Critical Illness Insurance Benefit

  Initial Benefit Recurrence Benefit
Cancer 100% of initial benefit 50% of initial benefit
Heart Attack 100% of initial benefit 50% of initial benefit
Stroke 100% of initial benefit 50% of initial benefit
Coronary Artery Disease Needing Surgery 100% of initial benefit 50% of initial benefit
Major Organ Transplant* 100% of initial benefit Not applicable
Advanced Dementia, including Alzheimer's Disease 100% of initial benefit Not applicable
Additional Covered Illnesses** 25% of initial benefit Not applicable

*Irreversible failure of heart, lung, pancreas, entire kidney or liver, or any combination thereof.
**Additional covered illnesses include: Addison’s disease (10%); ALS (Lou Gehrig’s disease); benign brain tumor (100%); bone marrow transplant; carcinoma in situ; cerebral palsy (100%); cystic fibrosis (100%); multiple sclerosis (definitive diagnosis); muscular dystrophy; myasthenia gravis; occupational HIV (100%); severe burns (100%); sickle cell anemia (excluding sickle cell trait) (100%); skin cancer (10%); systemic lupus erythematous (SLE); systemic sclerosis (scleroderma) (10%); and Type 1 diabetes (100%). More information on covered illnesses can be found in the Knowledge Hub.

Critical Illness Insurance Rates

Critical Illness Insurance Rates

  INDIVIDUAL INDIVIDUAL +1 FAMILY
Your age **

$10,000

 

$10,000 (individual)

+$5,000 (+1)

$10,000 (individual)

+$5,000 (per dependent)

<25 $1.94 $3.18 $3.28
25 – 29 $2.74 $4.38 $4.88
30 – 34 $4.14 $6.28 $7.28
35 – 39 $6.34 $9.24 $10.98
40 – 44 $8.64 $12.84 $15.88
45 - 49 $12.64 $18.18 $22.58
50 – 54 $17.14 $24.58 $30.88
55 – 59 $20.94 $31.44 $40.78
60 – 64 $26.14 $37.74 $48.18
65 – 69 $26.34 $39.64 $51.78
70+ $35.74 $49.38 $61.88
  INDIVIDUAL INDIVIDUAL +1 FAMILY
Your age **

$20,000

 

$20,000 (individual)

+$10,000 (+1)

$20,000 (individual)

+$10,000 (per dependent)

<25 $3.00 $4.08 $4.28
25 – 29 $4.34 $6.48 $7.48
30 – 34 $7.14 $10.28 $12.28
35 – 39 $11.54 $16.18 $19.68
40 – 44 $16.14 $23.38 $29.48
45 - 49 $24.14 $34.08 $42.88
50 – 54 $33.14 $46.88 $59.48
55 – 59 $40.74 $60.58 $79.28
60 – 64 $51.14 $73.18 $94.08
65 – 69 $51.54 $76.98 $101.28
70+ $70.34 $96.48 $121.48

*$5,000 of individual coverage is included at no cost with HSA Plan enrollment.

** Age of individual Notre Dame faculty/staff member. Initial rate locked upon enrollment on or after January 1, 2020 as long as you maintain the coverage.

Dental Plans

Dental Plans

  DELTA PREMIER DELTA PPO POS
  Participating Dentist Non-Participating Dentist Participating Dentist Non-Participating Dentist
Network Delta Premier Other Dentists Delta PPO POS Delta Premier/Other
Deductible $50 individual/$150 family $50 individual/$150 family
Diagnostic and Preventive 100% 100% of usual and customary 100% 100% of usual and customary
Basic Services 50% (after deductible) 50% of usual and customary (after deductible) 80% (after deductible) 50% of usual and customary (after deducible)
Major Services 50% (after deductible)
Annual Benefit $1,000 per person, per year $1,500 per person, per year
Orthodontic 50% maximum lifetime benefit of $1,500 50% maximum lifetime benefit of $1,500
Periodontics 50% 50% 80% 50%
Endodontic 50% 50% 80% 50%

Vision Plan

Vision Plan

  Member Cost Out-of-Network-Allowance
Exam with Dilation $0 Up to $35
NEW! Retinal Imaging $15 copay Allowance up to $20
Frames

$0 copay, plus

20% off balance over $150

Up to $65
Standard Plastic Lenses
Single $10 copay Up to $25
Bifocal $10 copay Up to $40
Trifocal $10 copay Up to $55
Progressive Lens (Standard) $75 copay Up to $40
Contact Lenses
Fit and Follow-up (Standard) Up to $40 N/A
Fit and Follow-up (Premium) 10% off retail price N/A
Conventional

$0 copay, plus

15% off balance over $130

Up to $104
Disposables $0 copay, plus balance over $130 Up to $104
Frequency
Exams, Frames, Lenses or Contact Lenses Once every calendar year

Note: The vision plan covers either glasses or contacts annually, but not both.

Medical Plan Overview

Medical Plan Overview

    HSA PPO
Preventive Care   100%, no deductible 100%, no deductible
Deductible In-Network

$2,000 individual

$3,750 true family

$500 individual

$1,000 family

Out-of-Network

$4,000 individual

$7,500 true family

$1,000 individual

$2,000 family

Coinsurance (plan pays after deductible is met)

In-Network 85% 85%
Out-of-Network 65% 65%
Out-of-Pocket Maximum In-Network

$3,000 individual

$6,200 family

$3,000 individual

$6,000 family

Out-of-Network

$6,000 individual

$12,400 family

$6,000 individual

$12,000 family

Primary Care In-Network Actual cost of service until deductible met, then plan pays 85% 100% after $30 copy per physician office visit
Out-of-Network Actual cost of service until deductible met, then plan pays 65% of usual and customary Actual cost of service until deductible met, then plan pays 65% of usual and customary
Specialist In-Network Actual cost of service until deductible met, then plan pays 85% 100% after $35 copy per physician office visit
Out-of-Network Actual cost of service until deductible met, then plan pays 65% Actual cost of service until deductible met, then plan pays 65%
Urgent Care In-Network Actual cost of service until deductible met, then plan pays 85%* $50*
Wellness Center Office Visit $30 access fee + actual cost of services (i.e. labs) until deductible met $15
Lifetime Maximum Unlimited Unlimited
Notre Dame Contributions to Funding Account

Health Savings Account

$500 individual

$1,000 +1 or family

N/A
Includes Accident Insurance** Individual coverage only N/A
Includes Critical Illness Insurance*** $5,000 individual coverage N/A

*Immediate and primary care are also available at the Notre Dame Wellness Center, with a $15 copay for PPO medical plan, and $30 for HSA plan.
**For more information on accident insurance, including rates and information on adding additional coverage for yourself or your dependents, see page 5 of the 2022 Benefits Guide.
***For more information on critical illness insurance, including rates and information on adding additional coverage for yourself or your dependents, see page 6 of the 2022 Benefits Guide.

Funding Account Comparison

Funding Account Comparison

  HSA FSA LPFSA
Medical Plan Anthem HSA Anthem PPO Anthem HSA
Who Funds University and you You You
University Contribution

$500 (individual)

$1,000 (+1 or family)

None None
IRS Limits

$3,650 individual

$7,300 family

$2,750* $2,750*
Unused Money Rolls Forward to Next Year Yes No. Unused money only rolls forward to March 31, 2023 No. Unused money only rolls forward to March 31, 2023
What Funds Are Used For Eligible medical expenses + dental and vision expenses Eligible medical expenses + dental and vision expenses Eligible dental and vision expenses
Portable Yes. Unused funds are yours to keep No. Unused money forfeited if you leave Notre Dame No. Unused money forfeited if you leave Notre Dame
Tax Benefit Tax-free dollars, does not count as income Pre-tax contributions, taxes may be reduced Pre-tax contributions, taxes may be reduced
Can Be Invested Yes No No

*2021 limit. The federal limit for 2022 was not released at the time of publication.