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					                   CHICAGO PUBLIC SCHOOLS
        Department of Human Resources    Benefits Employee Services Team   320 North Elizabeth Street, 1st Fl Chicago, Illinois 60607
                        Telephone 773/553-2820     EmployeeServices@cps.k12.il.us  www.cps-humanresources.org

Ascencion V. Juarez                                                                                 Dale Moyer
Chief Human Resources Officer                                                                       Compensation and Benefits Officer

Veenu Verma                                                                                         Tiffany Taylor
Employee Services Officer                                                                           Benefits Employee Services Team Manager




  Dear Prospective Employee,

  Congratulations on your recent offer of employment with Chicago Public Schools! If you are eligible for
  benefits, you will be able to elect coverage for yourself, your spouse/dependents or same sex domestic partner
  upon completion of staffing. To complete the enrollment process, you will need to provide any required
  documentation (if applicable) within 31 days following your date of hire. Coverage goes into effect the first
  day of the month following the date of hire.

  You must complete your enrollment via the CPS@Work website accessible at the human resources website
  listed above in order to obtain coverage.

  If you do not enroll for coverage within 31 days after your hire date, you will not be able to enroll until the next
  open enrollment period. That means your coverage would not take effect until January 1st of the following
  calendar year.

  If you have any questions, please call our Benefits Employee Services Team at 773-553-2820. One of our
  representatives will be happy to assist you.

  Please read this Benefits Overview to understand the benefits that are available to you and for instructions on
  how to complete the enrollment process.


  Sincerely,

  Tiffany Taylor
  Tiffany Taylor
  Benefits Employee Services Team Manager
                   TO MAKE ENROLLMENT EASY,                      FOLLOW THESE        THREE      STEPS:


S T E P O N E - P R E P AR E                                         S T E P T W O - V I E W T U T O R I AL
Know your username and password. Your username and                   View the Enrollment Training Tutorial:
password for benefits enrollment are the same as your CPS                     Visit http://www.cps-humanresources.org, click “New
email username and password. To access your username                          Hires”, click “Benefits” then click “Benefits
and/or password, please visit the CPS password management                     Enrollment Training Tutorial” to familiarize yourself
website at https://password.cps.k12.il.us or call 3-EXCL                      with the online enrollment process.
(773-553-3925) for help.
                                                                              The training tutorial will guide you through the process
Understand your benefits. Read the information in this                        of making your benefits elections for each type of
Benefits Overview.    Helpful Hint: To prepare for online                     benefit (medical, dental, life, etc.) and how to submit
enrollment you may wish to make notes and have them handy                     your finalized benefits enrollment.
when you are ready to enroll.

Select your choices. You may choose from five Medical                STEP THREE- ENROLL
Plans, two Dental Plans, an Enhanced Vision Plan, Life
Insurance, Personal Accident, Long-term Disability, Group
Legal, Group Financial, and two Flexible Spending Accounts.          You are ready to enroll.       If you are taking advantage of
                                                                     benefits enrollment:
Select your Primary Care Physician.                                           a ) To make your benefit elections, first go to
                                                                                  http://www.cps-humanresources.org.
If you are enrolling in Blue Cross HMO IL:
                                                                              b)   Click “New Hires” near the top of the screen,
         You must obtain the three-digit site code that                            click “Benefits” then click on “click here to enroll
         corresponds with your primary care physician by                           in benefits”.
         visiting http://www.bcbsil.com/providers/index.htm.
                                                                              c)   Log in using your username and password.
         You can select a separate site code for each of your
         eligible dependents.                                                 d ) Click on “Sign In”.
         Your primary care physician and your women’s                         e ) Click “My Personal Information”.
         principal health care provider (OB/GYN) must be in                   f)   Click “My Benefits”.
         the same site.                                                       g ) Click “Benefits Enrollment” in the bottom right
If you are enrolling in Unitedhealthcare HMO:                                     hand corner.
        You must obtain the primary care physician code by                    h ) Make your elections.
        visiting                                                              i)   After you have made your elections, to finalize
        https://www.geoaccess.com/uhc/po/Default.asp.                              your enrollment, click “Submit”.
        You can select a separate site code for each of your
        eligible dependents.
                                                                     S TEP FOUR – AFTER YOU ENROLL
        Your primary care physician and your women’s
        principal health care provider (OB/GYN) can be in
        separate sites as long as both physicians are within         Document Submission. To complete the enrollment, you may
        the participating network.                                   need to submit additional documentation. A summary of
                                                                     required documentation begins on page 12 of this Benefits
If you are enrolling in Compbenefits Dental HMO:                     Overview.
        You must obtain the facility number that corresponds
        with     your   provider      name     by     visiting       Please Note The 31 Day Deadline. Required documentation
        http://www.compbenefits.com/Providers/dentalprovide          must be submitted within 31 days of your date of hire in order
        r_search.html.                                               to complete processing.

PPO members do not need to pre-select a primary care
physician.
MEDICAL CHOICES:                                                     DENTAL CHOICES:
HMO Options: CPS offers two Health Maintenance                       Chicago Public Schools offers two (2) dental options for you
Organization (“HMO”) options. HMOs require that you receive          and your eligible family members.
your medical services only through their network providers,
except in emergencies. CPS offers the following:                     Delta Dental of Illinois. Under this PPO dental option, you
                                                                     can use either an in-network or an out-of-network provider.
     ● BlueCross BlueShield HMO IL                                   The plan will pay a certain percentage of the PPO rate whether
     ● Unitedhealthcare HMO
                                                                     or not you use a network provider. CPS pays the premium for
                                                                     single coverage. However, if you enroll dependents, you must
PPO Options: CPS offers three Preferred Provider                     pay the incremental difference in premiums for those
Organizations (“PPOs”). PPOs do not require that you select a        dependents.
primary care physician. CPS offers the following:
                                                                     CompBenefits Dental HMO. Under this option you may select
    ● BlueCross BlueShield PPO
                                                                     a dentist, using a site code from the provider network
    ● Unitedhealthcare PPO                                           sponsored by CompBenefits. CPS pays the premium for single
    ● Unitedhealthcare PPO w/Health Reimbursement                    or family coverage.
      Account
                                                                                S UMM ARY O F D ENTAL B ENEFITS AND P REMIUMS
The BlueCross BlueShield of Illinois PPO is similar to the                                                     Delt a Dental PPO
Unitedhealthcare PPOs with respect to the benefits that are
                                                                                        CompBenefits        In-          Out-o f-
covered. However, the BlueCross BlueShield deductibles apply
                                                                     Services              DHMO           Net work       Network
to both in-network services as well as out-of-network services.
The Unitedhealthcare PPOs have no deductible when in-
network providers are used.                                                                                   100%      80% of PPO
                                                                     Preventive               100%
                                                                                                                           Rate
Unitedhealthcare PPO with a health reimbursement account             Basic                 8 5-75%            100%      80% of PPO
(“HRA”) is a medical option which provides you with a health                                                               Rate
reimbursement account. Under this option, CPS will contribute
either (i) $500 to the HRA if you enroll only yourself or            Major                 70-65%             100%      50% of PPO
(ii) $1,000 if you enroll yourself and at least one other                                                                  Rate
dependent. Those benefits that would otherwise be covered            Individual Maximums:
by the PPO will be paid first out of the HRA. After the HRA is       Deductible               None          None        $100 ann ually
exhausted, then you must satisfy your deductible.
                                                                     Benefit Limit            None              $1,500 annually
After the deductible has been met, CPS will pay 80% in
network and 50% out of network, of eligible expenses. If you         Employee Contribut ions:
do not exhaust your HRA, the unused amount will be rolled            Employee Only            None                   None
over for your use in the next calendar year.
                                                                     Employee + 1             None            $9.25 per pay period
                                                                     Family                   None           $19.58 per pay period
  Example: You enroll yourself and one dependent in this
  option. CPS contributes $1,000 to your HRA. You and your
  dependent incur $450 in eligible medical expenses during the
  2007 calendar year. The $450 is paid out of the HRA, leaving       O THER H EALTH B ENEFITS :
  $550 in your HRA. There is no out-of-pocket expense for you
  in 2007. In 2008 your HRA will have a beginning balance of         Mental Health and Substance Abuse. If you are enrolled in
  $1,550 for you to use in 2008.                                     any HMO or PPO, Chicago Public Schools offers help for
                                                                     mental health or substance abuse problems. If you are in the
  Example: You enroll yourself and one dependent in this             United Healthcare HMO or any PPO, the plan is administered
  option. CPS contributes $1,000 to your HRA. You and your
                                                                     by United Behavioral Health (UBH) please contact 1-800-711-
  dependent incur $2,000 in eligible medical expenses during the
  year. The first $1,000 of those eligible medical expenses is       6087. If you are in Blue Cross Blue Shield HMO Illinois, please
  paid by the HRA. You pay the remainder. In 2008, your HRA          contact 1-800-242-8244.
  will have a beginning balance of $1,000 if you and your
  dependent continue in this option (i.e. will be replenished with
                                                                     This benefit includes counseling and substance abuse
  $1000 each year).                                                  recovery services that can help you effectively deal with
                                                                     stressful and challenging situations. You may call for such
  Example: You enroll yourself and one dependent in this             personal issues as:
  option. CPS contributes $1,000 to your HRA. You and your
  dependent incur $16,000 in-network eligible medical expenses.                 -Depression                -Anxiety and stress
  The first $1,000 of those medical expenses will be paid by the
                                                                                -Alcohol abuse             -Anger Management
  HRA. The second $2,000 will be paid by you in order to meet
  the deductible. You will then pay 20% of the remainder until                  -Drug Abuse                -Martial problems
  you pay an additional $2,500, to reach your family annual out-
  of-pocket maximum. The remainder will then be paid by the                     -Coping with grief         -Domestic Violence
  Plan at 100%.                                                                 -Eating Disorders          -Medication Management
                                                                                -Compulsive spending or gambling
Vision Benefits. If you are enrolled in one of Chicago Public                    Pharmacy Program. The pharmacy program, administered by
Schools medical options, CPS provides you and your eligible                      Caremark, applies to all medical options. The pharmacy
family members with the Basic Vision Plan administered by                        network includes Walgreens, Dominick’s Osco, CVS, Wal-
Vision Service Plan (VSP). You do not pay a premium for this                     Mart, and others. Please refer to the comparative chart for
coverage. When you use VSP network providers you receive                         applicable co-pays. If Caremark lists your medication as a
an annual eye exam covered in full with a $15.00 co-pay. In                      “maintenance drug”, you have the opportunity to enjoy
addition to eye exams, you will get discounts on eyewear and                     significant cost savings if you use the Caremark mail-
supplies.                                                                        order feature. However, beginning with your sixth refill, failure
                                                                                 to use the mail-order feature will increase your co-pays. See
              Chicago Public Schools Vision Plans                                comparison chart on the next page.
If you are enrolled in one of Chicago Public Schools medical options,
Chicago Public Schools provides you with the Basic Vision Plan with no
monthly premium deduction from your paycheck. For an additional
premium, you may choose the Enhanced Vision Plan. For plan details,              F LEXIBLE S PENDING A CCOUNTS :
see your Benefits Overview.
                              Basic Vision Plan
                                                                                 This benefit will allow you to use or set aside “pre-tax” dollars
In 2008, the Basic Vision Plan provides you one eye exam per year for            to pay for certain medical and dental expenses as well as
$15 co-pay. In addition, you will receive discounts on eyewear.                  dependent care expenses. These flexible spending accounts
                           Enhanced Vision Plan                                  are funded with your voluntary payroll contributions.
You can upgrade your Basic Vision Plan for a monthly premium and
receive coverage for glasses and contacts and discounts on laser vision          Flexible Spending-Health. You may pay for medical
correction. See details below.                                                   expenses not covered by the medical and dental plans, such
                                                                                 as co-pays, deductibles, co-insurance amounts and even over-
                                                                                 the-counter drugs and supplies (See http://www.cps-
                     Basic & Enhanced Vision Plan
                                                                                 humanresources,org for more details.) The maximum amount
Exam covered in full w/ $15.00 co-pay…………………..every 12 months                    you can contribute is $3,000 per year.

                           Enhanced Vision Plan
                                                                                 Flexible Spending-Dependent. You may pay for dependent
                                                                                 care expenses for your dependent children, as well as
                                                                                 dependent parents. The maximum amount you can contribute
Lenses covered in full………………………………………every 12 months
                                                                                 is $5,000 per year.
• Single vision, lined bifocal and lined trifocal lenses.                        Before enrolling in these programs, we recommend that you
• Polycarbonate lenses for dependent children
                                                                                 estimate your expenses for medical and dental benefits as well
Frame…………………………………………………………..every 24 months                                     as dependent care. Any unused amounts in these accounts
• Frame of your choice covered up to $130.                                       cannot be rolled over to the next calendar year and will be
• Plus 20% off any out-pocket costs.                                             forfeited in accordance with IRS regulations.
                                     ~OR~
Contact Lenses…………………………………………. …..every 12 months
When you choose contacts instead of glasses, your $130 allowance applies           Example: You have $4,500 in planned medical expenses
to the cost of your contacts and the contact lens exam (fitting and                for the remainder of 2008. You elect to contribute the
evaluation). This exam is in addition to your vision exam to ensure proper fit     annual maximum amount of $3,000 for Flexible Spending-
of contacts.                                                                       Health. You will not be taxed on that $3,000. (In other
In addition, VSP has negotiated a benefit for wearers of certain types of          words, you fund your FSA on a pre-tax basis.) When you
contacts. If you qualify, the program includes a contact lens evaluation and       need to pay your co-pay use your debit card. For other
initial supply of replacement lenses. Learn more from your doctor or               eligible medical expenses submit a paper reimbursement
VSP.com                                                                            form. If you are in the 20% tax bracket, by using the tax-
                                                                                   preferred nature of this program, you will save approximately
                                Your Co-pays
                                                                                   $600. Services totaling $3000 must be rendered by
Exam……………………………………………………………………...$15.00                                            December 31 in order to be reimbursed. In other words,
Prescription Glasses…………………………………… …………….$25.00                                    rollovers to the next year are not allowed.
Contacts…………………………………………………… No co-pay applies

                      Extra Discounts and Savings
Glasses and Sunglasses                                                           LIFE AND PERSONAL ACCIDENT INSURANCE
• Average 30% savings on additional lens options such as scratch
  resistant and anti-reflective coatings and progressives                        CPS provides basic life insurance coverage of $25,000 per
• 20% off additional prescription glasses and sunglasses, including lens         eligible employee. This benefit is provided to you at no cost.
  options                                                                        You may elect to purchase:
Contacts                                                                                  ● Additional Optional Term Life insurance in amounts
• 15% off cost of contact lens exam (fitting and evaluation)                               equal to one to four times your annual salary, up to
• Available from any VSP doctor within 12 months of your last eye exam                     $750,000.

Laser Vision                                                                              ● Dependent Term Life coverage for your spouse and
You receive discounts for PRK, LASIK and Custom LASIK using wave front                      eligible dependents.
technology. Discounts vary by location, but average 15-20% off the
contracted laser center’s usual and customary price. Additionally, if the                 ● Personal Accident Insurance that matches your
laser center is offering an even lower temporary promotional price, you’ll                  Optional and Spouse/Dependent Life coverage.
receive 5% off the promotional price.

                          Your Monthly Premium

Employee only ………………………………………………………….. $7.40
Employee + One Dependent………………………………………….. $10.81
Employee + Family……………………………………………………… $19.39
To enroll your dependents in dependent life or to enroll in PAI,     These tax deferred compensation programs offer different
you must first elect optional term life coverage. The amount         investment styles so participants can create a well-diversified
available for spousal coverage is $50,000.                           investment strategy. Participants can choose from a menu of
                                                                     multiple investment styles, each of which are diversified and
You must elect coverage for Optional Life equal to or more           have materially different expected risk and return
than $25,000 before electing spouse coverage.                        characteristics. The program provides participants the ability
However if you elect to increase your insurance by more than         to diversify their individual accounts based on their own
one times your annual salary in a year, you will need to provide     investments objectives.
evidence of insurability. New hires can select up to the             Investments:
lesser of three times their covered annual earnings or
$500,000 without providing evidence of insurability                         Money Market Funds
satisfactory to the Prudential Insurance Company of America.                Bond Funds
Additionally, if you are adding your spouse for the first time and          Balanced Funds
you are not a new hire or in a new marriage, evidence of                    U.S. Equity Funds
insurability is required. If you elect to increase your                     Aggressive Equity
insurance by only one times your base salary in a given year
during open enrollment, evidence of insurability will not be                International Equity Funds
required.      This program is insured through Prudential            Your contributions are invested in the investment options you
Insurance Company.                                                   choose. The following companies are authorized to provide
                                                                     services under the CPS TDC program:
LONG-TERM DISABILITY INSURANCE
You have an opportunity to purchase long-term disability (LTD)       Fixed and Variable Annuities:
insurance with two options a 90-day waiting period or a 180-
                                                                              The Hartford Life (serviced by Retirement Plan
day waiting period. Your monthly LTD benefit would be 60% of
                                                                              (Advisors) (312) 701-1100
your monthly earnings, reduced by other income. Evidence of
Insurability is required to increase your coverage from the                   Horace Mann Life Insurance Company (serviced by
180-day to 90-day option or to enroll for the first time. The                 PEB Financial Group) (800) 333-3696
program is insured through Prudential Insurance Company.
                                                                              ING Life Insurance          and     Annuity   Company
GROUP LEGAL SERVICES                                                          (800) 873-9150
The ARAG Group offers a voluntary group legal insurance
                                                                              Variable   Annuity   Life         Insurance   Company
plan that provides you with certain paid–in-full legal benefits
                                                                              (800) 892-5558 EXT. 88815
when a network attorney is used. For more information please
call 1-800-247-4184. The premium is $7.22 per pay period.            Mutual Funds:
                                                                              CitiStreet (800) 835-6685
GROUP FINANCIAL SERVICES
PricewaterhouseCoopers (PwC) offers a voluntary                               MetLife Insurance Company (800) 887-7167
financial planning service that provides you with a
                                                                     You may start your account with as little as $10 per pay period.
comprehensive financial planning program. For more                   The contribution limits for 403(b) and 457 retirement plans are
information please call 1-888-402-4462. The premium is $6.00         $15,500 for 2008 if you are underage 50. If you are 50 or
per pay period.                                                      above, you are entitled to an “age 50 catch-up” contribution of
                                                                     $5,000 for a total contribution of $20,500.
BRIGHT START COLLEGE SAVINGS
Oppenheimer Funds offers parents an easy and convenient              The contribution amount and the “age 50 catch-up” contribution
way to invest in their childrens’ college funds through payroll      amount are separately adjusted for inflation in $500 increments
deductions. For more information and enrollment instructions         after 2009. If you have at least 15 years of service with CPS,
call 1-800-655-4853 or visit www.brightstartsavings.com              you may be eligible to contribute up to an additional $3,000 of
                                                                     pensionable earnings into the 403(b) each year under a special
TAX DEFERRED COMPENSATION                                            “catch-up” provision. Please check with your service provider
Tax Deferred Compensation programs are established under             to determine eligibility.
Section 403(b) and 457 of the Internal Revenue Code and are
available to employees of tax-exempt organizations, such as
public schools. This is one of the best ways to save money for
your retirement years and one of the few methods available
today to defer current income taxes. You decide what
percentage of your gross annual earnings you wish to
contribute for your retirement needs.
Your contributions are deducted from your payroll before
federal income taxes are withheld.
                                                                     HE ALTH M AI NTEN ANCE ORG ANIZATION                                                  P r e f e r r e d P r o vi d e r
                                                               BLUE CROSS HMO ILLINOIS      UNITED HE ALTHC ARE                                             WITH HE ALTH REIM
    BENEFITS    HIGHLIGHTS COVERING
                                                                                                                                                               UNITED HE AL TH
          ONLY ELIGIBLE EXPENSES

                                                                                                                                                                 IN-NETWORK

Health Reimbursement Account (employer paid)                   N/A                                         N/A                                         $ 500 employee only
(Not applied towards deductible nor out-of-pocket                                                                                                      $1,000 employee plus one and
maximum)                                                                                                                                               employee plus family
Annual Deductible (not applicable to services with co-         None                                        None                                        $1,000 per person after HRA is
pay)                                                                                                                                                   exhausted
                                                                                                                                                       $2,000 per family after HRA is
                                                                                                                                                       exhausted
Out-of-Pocket Maximum (including deductible)                   N/A                                         N/A                                         $2,250 per person
                                                                                                                                                       $4,500 per family

Lifetime Maximum Coverage                                      Unlimited                                   Unlimited


Care in Physician’s Office: General doctor office visits       100% after $20 co-pay per visit             100% after $20 co-pay per visit             80% after deductible
such as X-rays, Allergy shots, and Chemo-therapy

Wellness (Preventive Screening): Routine physical check-       $20 co-pay                                  $20 co-pay                                  100%, no co-pay, no deductible
ups for adults and children, mammograms, PSA, pap
smears, physicals, immunizations.

Pre-Certification through ENCOMPASS (PPOs only)                       HMO participants do not require pre-certification through ENCOMPASS
                                                                           referrals are handled through your primary care physician

In Patient Hospital Services
• Hospital (semi-private) room & board                         100% after $125 co-pay per admission        100% after $125 co-pay per admission        80% after deductible


• Doctor’s visits, including specialists, X-ray, lab, drugs,
    surgeon’s fees, and anesthesiologists.                     Covered in full                             Covered in full                             80% after deductible


Out-Patient Hospital Care (including surgery)                  Covered in full after $75 co-pay /visit     Covered in full after $75 co-pay /visit     80% after deductible
Maternity
•    Prenatal/postnatal                                        100% after $20 co-pay                       100% after $20 co-pay                       80% after deductible
•    Hospital coverage (mother and newborn)                    100% after $125 co-pay per admission        100% after $125 co-pay per admission        80% after deductible


Covered Emergency Care
• Emergency care (if emergency)                                100% after $100 co-pay/visit                100% after $100 co-pay/visit                100% after $100 co-pay/ visit


● Ambulance                                                    100%                                        100%                                        100% after deductible


Mental Health and Substance Abuse
•    Inpatient                                                 100% after $125 co-pay/admission, up to     100% after $150 co-pay/admission, up to     80% after deductible
                                                               30 inpatient days per year                  30 inpatient days per year

                                                                                                           100% after $20 co-pay/visit, up to 20       80% after deductible
•      Outpatient                                              100% after $20 co-pay/visit, up to 20
                                                               visits per calendar year                    visits per calendar year

Therapy Physical, occupational and speech therapy              100% for the number of visits which, in     100% for the number of visits which, in     80% after deductible
for restoration of function (Limited to 60 visits per          the judgment of the attending or            the judgment of the attending or
calendar year per therapy)                                     consulting physicians, are sufficient for   consulting physicians, are sufficient for
                                                               significant improvement                     significant improvement
Chiropractic care (Unlimited visits if medically
                                                               100% after $20 Co-pay                       100% after $20 Co-pay
necessary)                                                                                                                                             80% after deductible

Care in skilled nursing facility (up to 120                    100%                                        100%                                        80% after deductible
days/year if medically necessary)


Prosthetic devices and medical equipment                       100%                                        100%                                        80% after deductible


Prescription Drugs (subject to preferred drug list)            Retail (co-pay per prescription)            Retail (co-pay per prescription)            Retail (co-pay per prescription)
•     Retail is for up to 30-day supply                        •      Generic                $10           •      Generic                $10           •      Generic                $10
•      Mail is for up to 90-day supply                         •      Preferred Brand       $25            •      Preferred Brand         $25          •       Preferred Brand      $25
•  Maintenance drugs: five max at retail, then must use        •     Brand                  $40            •     Brand                  $40            •     Brand                  $40
   mail to avoid 40% penalty                                   Mail (co-pay per prescription)              Mail (co-pay per prescription)              Mail (co-pay per prescription)
NOTE: Your costs will be the co-payment or the cost of         •      Generic               $15            •      Generic                 $15          •       Generic              $15
       the prescription, whichever is less. Also, Drug
                                                               •      Preferred Brand       $40            •      Preferred Brand         $40          •       Preferred Brand      $40
       Prescriptions filled without presenting card will
       result in a 40% penalty.                                •      Brand                 $60            •      Brand                   $60          •       Brand                $60
RG ANIZATION                                    PREFERRED PROVIDER ORG ANIZATION
                                                                                                                                 PREFERRED PROVIDER ORG ANIZATION
BURSEMENT                                             UNITED HE AL THCARE
                                                                                                                                     BLUE CROSS BLUE SHIELD
ACCOUNT
CARE
  OUT-OF-NETWORK                                IN-NETWORK                          OUT-OF-NETWORK                                IN-NETWORK                          OUT-OF-NETWORK

  $ 500 employee only                   N/A                                      N/A                                       N/A                                    N/A
  $1,000 employee plus one and
  employee plus family
  $2,000 per person after HRA is        None                                     $600 per person                           $400 per person                        $800 per person
  exhausted                                                                      $1,200 per family                         $1,200 per family                      $2,400 per family
  $4,000 per family after HRA is
  exhausted
  $11,500 per person                    $2,000 per person                        None                                      $2,400 per person                      None
  $34,000 per family                    $4,000 per family                                                                  $4,800 per family
                                                       $2,000,000 inclusive of all covered medical, mental health, and substance abuse benefits
                                                                (Routine and Diagnostic Mammograms are not subject to deductible)

  50% after deductible                  100% after $15 co-pay/visit              50% after deductible                      100% after $25 co-pay/visit            50% after deductible


50% after deductible                    100%, no co-pay, no deductible           50% after deductible                      100%, no co-pay, no deductible         50% after deductible



PPO Participants, you or your physician must call ENCOMPASS Health Management Systems at 1-888-781-9458 for review and pre-certification of certain services and procedures such as
hospitalizations and for non-custodial care in a skilled nursing facility at least one day before an elective admission. For in-patient mental health or substance abuse admission, and to receive in-
network mental health coverage, call United Behavioral Health at 1-800-711-6087. Penalty for failure to pre-certify: 50% capped at $1000 per individual/per event/per confinement.



  50% after deductible                    80% after co-pay                       50% after deductible                      80% after deductible                   50% after deductible



  50% after deductible                    80 after co-pay                        50% after deductible                      80% after deductible                   50% after deductible


  50% after deductible                    80% after co-pay                       50% after deductible                      80% after deductible                   50% after deductible


  50% after deductible                    100% after $15 co-pay/visit            50% after deductible                      100% after $25 co-pay/visit            50% after deductible
  50% after deductible                    80% after co-pay                       50% after deductible                      80% after deductible                   50% after deductible



  50% after $100 co-pay/visit             100% after $100 co-pay/visit           50% after $100 co-pay/visit               100% after $100 co-pay/visit           50% after $100 co-pay/visit


  100% after deductible                   100%                                   100% after deductible                     100% after deductible                  100% after deductible



  50% after deductible                    80%                                    50% after deductible                      80% after deductible                   50% after deductible


  50% after deductible                    80%                                    50% after deductible                      80% after deductible                   50% after deductible

  50% after deductible                    100% after $15 co-pay/visit            50% after deductible                      100% after $25 co-pay/visit            50% after deductible




 50% after deductible                     80%                                    50% after deductible                      80% after deductible                   50% after deductible



  50% after deductible                    80%                                    50% after deductible                      80% after deductible                   50% after deductible




  50% after deductible                    80%                                    50% after deductible                      80% after deductible                   50% after deductible


   ● 60% of the cost of a covered         Retail (co-pay per prescription)       ● 60% of the cost of a covered            Retail (co-pay per prescription)       ●     60% of the cost of a covered
      prescription for generic            •    Generic                 $10          prescription for generic               •     Generic                  $10            prescription for generic
   • 60% of the cost of a covered         •    Preferred Brand         $25       ● 60% of the cost of a covered            •     Preferred Brand          $25     ●     60% of the cost of a covered
      prescription for brand drugs,                                                prescription for brand drugs, up                                                      prescription for brand drugs,
                                          •  Brand                   $40                                                   •     Brand                  $40
      up to 60% of the cost of an                                                  to 60% of the cost of an                                                              up to 60% of the cost of an
      equivalent generic drug if an       Mail (co-pay per prescription)                                                   Mail (co-pay per prescription)
                                                                                   equivalent generic drug if an                                                        equivalent generic drug if an
      equivalent generic is               •    Generic                 $15         equivalent generic is available         •     Generic                  $15           equivalent generic is available
      available                           •    Preferred Brand         $40                                                 •     Preferred Brand          $40
                                          •    Brand                   $60                                                 •     Brand                    $60
   ENCOMPASS:
   ENCOMPASS manages the Pre-certification process for CPS                                       When to call: If you are in a PPO, in order to receive your
   employees/dependents enrolled in the PPO health plans.                                        maximum level of benefits you must get advance approval
   Pre-certification is designed to help ensure that you receive                                 from ENCOMPASS. The services or procedures that require
   quality medical care while discouraging unnecessary                                           approval are listed above. You must call at least 7 days in
   treatment. To ensure that certain treatments and hospital                                     advance for most services requiring pre-certification. You must
   stays are appropriate, you must obtain advance approval                                       call within two (2) business days after emergency treatment or
   from the medical professionals at ENCOMPASS. You may                                          inpatient admissions. All pregnancies must be pre-certified
   call 24 hours a day, seven days a week at 1-888-781-9458.                                     twice, during the first three (3) months or when the pregnancy
                                                                                                 is confirmed (if later) and again within (two) 2 business days
                                                                                                 after admission for delivery.
   ENCOMPASS pre-certification                       is   required       for     the
   following benefits:                                                                           Here are three examples of when to call Encompass:

               •     Inpatient    hospital   care,   including                 acute             Example 1
                     rehabilitation confinements and surgeries
               •     Inpatient skilled nursing facility                                          Physical Therapy (outpatient treatment center and home):
                                                                                                 Jennifer, a 32-year-old female and long-time runner, is
               •     Organ transplants                                                           experiencing heel pain during her workouts. Jennifer’s
               •     Air ambulance transportation                                                physician has diagnosed her with Achilles tendonitis and has
               •     Certain outpatient surgeries and procedures:                                suggested anti-inflammatory medication and ten physical
                     −   Blepharoplasty                                                          therapy visits to reduce the inflammation and help strengthen
                     −   Breast surgeries (reduction, reconstruction,                            the tendon. Jennifer, her physician, a family member or a
                         except related to mastectomy, biopsy and                                friend must notify ENCOMPASS and receive approval prior to
                         lesions)                                                                receiving physical therapy services.
                     −   CAT scans
                     −   MRI                                                                     Jennifer has completed her initial ten physical therapy sessions
                     −   Nasal surgery (rhinoplasty and septoplasty)                             but her physical therapist thinks she would benefit from an
                     −   PET scans                                                               additional six sessions. Jennifer, her physician, physical
                     −   Sclerotherapy and Ligation, Vein Stripping                              therapist, family member or friend must notify ENCOMPASS
                     −   Sleep Studies                                                           and receive approval prior to receiving the additional physical
                                                                                                 therapy services.
               •     Hospice: inpatient and home
               •     Occupational therapy:            home and outpatient                        Example 2
                     treatment center
                                                                                                 Outpatient procedures: Caleb, a 7-year-old, has had
               •     Physical therapy: home and outpatient treatment
                                                                                                 numerous bouts of a sore throat and neck swelling over the
                     center
                                                                                                 past couple of years. During a recent examination, Caleb’s
               •     Speech therapy: home and outpatient treatment                               physician found a lump in Caleb’s neck. The lump was not
                     center                                                                      viewable with a normal x-ray so his physician has suggested
               •     Home nursing visits                                                         that Caleb have an MRI. Because Caleb is a minor his
                                                                                                 physician, the facility, or a family member parent or legal
               •     Private duty nursing
                                                                                                 guardian must notify ENCOMPASS prior to the scheduled date
               •     Durable medical equipment and supplies. For                                 of this outpatient procedure.
                     example:
                     −     Hospital beds                                                         Example 3
                     −     Oxygen and oxygen related equipment
                     −     Apnea monitors                                                        Inpatient Surgery and Hospital Admission: Francine, a 55-
                     −     Ventilators                                                           year-old with severe osteoarthritis, is scheduled to have knee
                     −     Prosthetics                                                           replacement. This surgery will require Francine to be in the
                     −     Other durable medical equipment that                                  hospital for several days. Francine, her physician, the facility,
                           costs $500 or more                                                    a family member or friend will need to notify ENCOMPASS as
                                                                                                 soon as the admission date is scheduled to pre-certify this
               •     Infertility treatment
                                                                                                 inpatient surgery and hospital admission.
               •     Enteral formula (life sustaining tubal feeding)
               •    All pregnancies (during the first three months                               If you don’t call: If you do not call for pre-certification as
                    or as soon as the pregnancy is confirmed                                     required or if you do not follow the program’s
                    and within two business days after admission                                 recommendations, you will be responsible for 50% of eligible
                    for delivery.)                                                               charges (capped at $1000 per individual/per event/per
                                                                                                 confinement). You will pay this penalty plus the co-insurance
                                                                                                 that applies. Also, benefits could be further reduced if it is
                                                                                                 determined that the treatment or admission is not medically
                                                                                                 necessary.




Note: The Benefits Overview is a brief description of CPS’ Plan is not e not meant to interpret, extend, or change the provisions of these programs. The plan documents shall govern if
there is a discrepancy between this document and the actual provisions of the Plan.
                               Planning Worksheet for Online Benefits Enrollment
                                    ELECTIONS MUST BE MADE ONLINE
     Employee user name ID#_________________________
     Employee Password_____________________

M E D I C AL C H O I C E S :                                 EMPLOYEE ONLY         E M P L O Y E E +O N E    FAMILY

The Blue Cross Blue Shield of Illinois PPO………………………..               □                         □               □
United Healthcare PPO………………………………………………                             □                         □               □
United Healthcare PPO with a health reimbursement account (“HRA”)   □                         □               □
BCBS HMO IL………………………………………………………………                                □                          □               □
Primary Care Physician Site Code: _______________ (required for HMOs)

UHC HMO…..……………………………………………………………….                               □                           □               □
Primary Care Physician Code: __________________ (required for HMOs)


DENTAL CHOICES:                                              EMPLOYEE ONLY         E M P L O Y E E +O N E    FAMILY

Delta Dental of Illinois PPO…………………………………………………..                   □                         □               □
CompBenefits Dental HMO…………………………………………………..                        □                         □               □
Primary Care Physician Facility Number Site: _______________ (required for HMOs)


VISION BENEFITS:                                             EMPLOYEE ONLY         E M P L O Y E E +O N E    FAMILY
Basic Vision Plan……………………………………………………… (Automatic, if you are enrolled in one of the Medical Plans)
Enhanced Vision Plan………… (Must be enrolled in a medical plan ………□                             □               □

LONG-TERM DISABILITY INSURANCE:
90-Day Wait Option……………………………………………………………. □

180-Day Wait Option……………………………………………...…                            □


F LEXIBLE S PENDING A CCOUNTS :
Flexible Spending-Health………………………………………………….Annual Contribution Amount
Flexible Spending-Dependent Care………………………………………Annual Contribution Amount


LIFE AND PERSONAL ACCIDENT INSURANCE (PAI)                                  1X       2X       3X        4X
Optional Term Life and/or PAI…………………………………………………     □   □  □   □
Spouse Life($50,000)…………………………………………………….........……………………………………………                                            □
PAI – Spouse……………………………………………………………………               □   □  □   □
Dependent Life ($10,000)……………………………………………………..…………………………………………...                                             □
Dependent PAI only ($10,000)………………………………….………………………………………………………….                                             □
GROUP LEGAL SERVICES
(ARAG Group)………………………………….…………………………………………………………. □
GROUP FINANCIAL SERVICES
PricewaterhouseCoopers (PwC)………………………………….…………………………………………………………. □
DEPENDENTS
In this space below, list your eligible dependents that you wish to enroll under your health coverage.

Dependent Name        Relationship              Date of Birth        Social Security         Medical Election        Dental Election




                                                      Don’t Wait Until
                                                      the Last Minute!



There are many Benefits of Starting Early
        •   Easier access to online computer systems.
            Employees who wait until the last few days, or even the last week may encounter delays.

        •   Calmer more thoughtful process. If you start your benefits enrollment early, you will have ample opportunity to consider
            all your options, and to see if your doctor is in your plan.

        •   Easier access to Benefits Employee Services Team Hotline (773) 553-2820. For best service, allow yourself ample time
            to call the hotline, because at times phones may be busy. One of our representatives will be happy to assist you.

        •   More time to deliver your documents after you’ve made your selections. – Remember, if you choose to add a spouse,
            dependent or same sex domestic partner to your benefits, proper documentation must be submitted by the 31st
            day after your date of hire (staffing) in order to complete processing

                                         Computer Systems Requirements for Enrollment

        Overview. Benefits enrollment is computer based only. Paper or telephone submissions are not accepted. Most modern
        computers purchased in the last seven or eight years, with internet access will work just fine, whether at CPS public school, at
        the public library, or in your own home. Exception: to view the training video, more strict requirements also apply and only
        Windows computers are supported. To view the video training, you will need a Windows computer, running Windows 2000, or
        XP. Your browser will need to be Internet Explorer, version 5.5 or later. A high speed-internet connection is recommended.

        Details. Benefits enrollment works with a Windows, Macintosh or even a Linux computer. Windows computers
        should be equipped with Windows 98, 2000 or XP and one of the following browsers:

            •    Internet Explorer 6 or later
            •    Netscape 7 or Later
            •    Mozilla 1.7 or later

        Macintosh computers should be running Mac OS X, and one of the following browsers:

            •    Safari 1.2, or 2.0 or later
            •    Mozilla 1.7 or later
            •    Firefox 1.0 or later
            •    Camino 1.0 or later
            •    Netscape 7.0 or later

        Linux computers should have one of the following browsers:
            •   Netscape 7.0 or later
            •   Firefox 1.0 or later
            •   Mozilla 1.7 or later
Documentation
Requirements
                                  Employee/ Dependent Documentation Requirements for Benefits

Please read the following document carefully and retain a copy for your records. You are responsible for providing the applicable
documentation as a new hire or during the annual Open Enrollment and for any subsequent changes to your enrollment in the health
benefits plan. COBRA participants must provide certified documents to establish that spouses and dependent children under a Chicago
Public Schools health benefit plan are eligible for coverage.

ELIGIBILITY
The following individuals are eligible for coverage under a CPS health benefits plan:
• Your legal spouse
• Your domestic partner
• Your unmarried children under the age of 19,
• Your unmarried children aged 19 to 23, who are either full-time students or tax dependents, and
• Your unmarried children aged 23 or older who are incapacitated due to physical handicap or mental retardation and incapable of
    self-support (proof must be provided before the child turns 19).

The term “children” includes:
• natural children,
• step children,
• legally adopted children, and
• children for which you have been appointed the legal guardian.

The following individuals are not eligible for coverage under a CPS health benefits plan:
• A spouse from whom you are divorced,
• A common law spouse, and
• Children for whom someone other than you or your spouse is named in a separate legal document such as a child support order or
    divorce decree as the person solely responsible for providing health insurance.

ACCEPTABLE DOCUMENTATION
All documents must be certified as having been filed by the governmental unit that has jurisdiction over issuing such
documents. Certified copies of documents generally have a raised or multi-colored seal, or are issued on multi-colored paper and
include the verbiage “this hereby certifies”.

Foreign documents must be issued by a governmental unit. If such documents are not in English, they must be accompanied by an
English translation that is:
• issued by a certified translator, or
• prepared by the Consulate of the foreign country which originally issued the document, or
• notarized by a notary who can read and write the language in which the document is prepared and swears that the translation is an
    accurate translation of the accompanying document.

DOCUMENTATION WHICH IS NOT ACCEPTABLE
• Altered documents are not acceptable.
• Photocopies of certified documents are not acceptable.
• Church certificates, hospital certificates, ceremonial certificates, abstracts or birth registration notifications are not acceptable.

All documents are subject to review and approval by the Benefits Employee Services Team, whose decision regarding documentation
is final.
DOCUMENTATION FOR YOUR SPOUSE
To establish your spouse’s eligibility for coverage, you must submit a certified copy of your marriage certificate. This certificate will
typically show the date that the marriage was recorded by the clerk of the governmental unit which issued the certificate. Ceremonial or
church certificates or certificates which are issued by a justice of the peace are not acceptable. Marriage licenses are only acceptable if
they also contain a certification of the date that the marriage was recorded by the county clerk. A marriage license, which is signed by
the official who performed the marriage ceremony, but which does not have the date that the marriage was recorded with the county
clerk, is not acceptable.

A person from whom you are divorced is not eligible for coverage. If you provide a certified copy of your marriage certificate, you are
certifying that you are currently married to the individual named in the marriage certificate.

DOCUMENTATION FOR A DOMESTIC PARTNER
Proof of domestic partnership is required. To determine if your Partner qualifies for enrollment, the following eligibility requirements
must be met:
• First you, the employee, must be enrolled in a CPS sponsored medical or dental plan;
• You must submit a completed Affidavit of Domestic Partnership and meet the eligibility requirement for a Domestic Partner.
• You must submit certified Birth Certificates and copies of your Illinois driver’s licenses or State of Illinois Identification Cards for both
   you and your partner.

Employee Benefits will review your affidavit to determine if you meet the minimum requirements listed below:
• You and your partner are each other’s sole domestic partner, responsible for each other’s common welfare;
• Neither you nor your Partner are married (if you or your partner were previously married proof of
  dissolution of marriage is required)
• You and your Partner are not related by blood closer than would bar marriage in the
   State of Illinois;
• You and your Partner are at least 18 years of age, are the same sex and reside at the same residence; and

At least two of the following four conditions must apply:

(1)      You and your Partner have been residing together for at least twelve (12) months prior to filing the Affidavit of Domestic
         Partnership.

(2)      You and your Partner have common or joint ownership of a residence.

(3)      You and your partner have at lest two of the following arrangements:
         a. Joint ownership of a motor vehicle;
         b. A joint credit account;
         c. A joint checking account;
         d. A lease for residence identifying both you and your Partner as tenants.

(4)      You declare your partner as a primary beneficiary in your will.


If the Benefits Employee Services Team accepts your request, you may enroll by:

1. Submitting the Imputed Income Acknowledgement Form within 31 days of approval.

You are eligible to add a Domestic Partner as a newhire or during the annual Open Enrollment period.
COVERAGE TERMINATION FOR DOMESTIC PARTNER

If at any time your Partner becomes ineligible for benefits, it is your responsibility to notify Employee Benefits in writing. Certain
limitations exist in regard to continuing coverage for a domestic partner. Contact Employee Benefits for more information.

Following the termination of a domestic partnership, a minimum of twelve (12) months must elapse before a new domestic partner may
be designated.


DOCUMENTATION FOR YOUR DEPENDENT CHILDREN
To establish your child’s eligibility for coverage, you must provide:
• a certified copy of the child’s birth certificate ( See Section 1, below); and
• proof of your relationship (or in the case of a stepchild, your spouse’s relationship) to the child’s other parent (See Section 2); and
• for a child who is over the age of 18, additional documentation is required as outlined in the sections regarding “Children Aged 19
    - 23” (See Section 3); and
• for a child over the age of 23 who is incapable of self-support due to a physical handicap or mental retardation, proof of
    incapacitation as outlined in the section “Children Who Are Physically Handicapped or Mentally Disabled” (See Section 4).

NAME CHANGES
The names of parents and children must be the same on the birth certificates, marriage certificates, divorce decrees, child support
orders and notarized statements. Further, the names as recorded on these documents will be used in records of the Chicago Public
Schools. If names do not match, certified court orders of name change must be provided to show the change in identity of the
respective parties.

SECTION 1 - BIRTH CERTIFICATES
A certified copy of a birth certificate is issued by a municipality, county or state. The certificate must contain parental information and
the birth registration number. Your name must appear on the birth certificate, unless you are the child’s legal guardian. If the child is
your stepchild, then your spouse’s name must appear on the birth certificate.

Adopted Children
If the child is your adopted child and the birth certificate has not yet been amended to name you and other adoptive parent as the
child’s parents, then the letter issued by the governmental agency placing the child in your home will suffice for documentation, until
such reasonable time as the amended birth certificate can be issued.


SECTION 2 - PROOF OF RELATIONSHIP TO THE CHILD’S OTHER PARENT
You must be able to establish that the child is legally your dependent, and that no outside documents exist which name another person
as solely responsible for providing the child’s health insurance. Different documents are required for natural children (Section 2A),
stepchildren (Section 2B), and children for whom you are the legal guardian (Section 2C).

Section 2A - Natural Children
If you are currently married to the child’s other parent, you must provide a copy of your marriage certificate, as outlined in the
section called “Documentation For Your Spouse”. This document must be provided even if you are not covering your spouse under
the CPS health benefits plan.

If the child’s other parent is deceased, you must provide a certified copy of his/her death certificate.
If you are divorced from the child’s other parent:
• You must provide a copy of the divorce decree that is certified by the clerk of the court in which the divorce was filed, including the
     portion of the divorce decree that deals with financial arrangements for the child. The divorce decree must name either you only, or
     both you and your former spouse, as responsible for providing the child’s health insurance in order for the child to be covered
     under the CPS health benefits plan.
• If the divorce decree does not say who is responsible for providing health insurance, and reserves the issue of child support, you
     must provide a copy of any and all later child support orders.
• If there is no child support order, you must provide a notarized affidavit stating that although the issue of child support was
     reserved, no child support order has ever been entered in the court.
• If neither the divorce decree nor the child support order state who is responsible for health insurance, then the child can be
     covered under the CPS health benefits plan if the CPS employee claims the child as a dependent for Federal Tax purposes. You
     must submit a notarized Affidavit to Establish Dependency which is provided by the Benefits Employee Services Team.

If you were never married to the child’s other parent, you must provide a copy of any and all child support orders requiring either
you or the other parent to provide support. If no such document exists, you must provide a notarized affidavit stating that you were
never married to the child’s other parent, that no outside child support order requiring the other parent to provide health insurance
exists, and that the child is your dependent for Federal Income Tax purposes.

If you are the child’s father, but are not named as the father on the birth certificate, then the child cannot be covered as a
dependent under the CPS health benefits plan without a certified copy of the child support order requiring the child to be placed on the
father’s insurance. As an alternative, you may also provide an amended birth certificate and proof of relationship to the child’s other
parent.

Section 2B - Stepchildren
If the child’s other parent is deceased, you must provide a certified copy of his/her death certificate.

If the dependent is your stepchild and your spouse is divorced from the child’s other parent:
• You must provide a copy of your spouse’s divorce decree that is certified by the clerk of the court in which the divorce was filed,
     including the portion of the divorce decree that deals with financial arrangements for the child. The divorce decree must name your
     spouse alone, or both your spouse and his/her former spouse jointly, as responsible for providing the child’s health insurance in
     order for the child to be covered under the CPS health benefits plan.
• If the divorce decree does not say who is responsible for providing health insurance, and reserves the issue of child support, you
     must provide a copy of any and all later child support orders requiring either your spouse or the other parent provide health
     insurance.
• If there is no child support order, you and your spouse must provide a notarized Affidavit to Establish Dependency stating that
     although the issue of child support was reserved, no child support order has ever been entered in the court.
• If neither the divorce decree nor the child support order states who is responsible for health insurance, then the child can be
     covered under the CPS health benefits plan if the you and/or their spouse claim the child as a dependent for Federal Tax
     purposes. You must submit a notarized Affidavit to Establish Dependency signed by both you and your spouse. This document is
     provided by the Benefits Employee Services Team.


If the dependent is your stepchild and your spouse was never married to the child’s other parent, you must provide a copy of
any and all child support orders requiring either your spouse or the other parent to provide support. If no such document exists, you
and your spouse must provide a notarized affidavit stating that your spouse was never married to the child’s other parent, that no
outside child support order requiring the other parent to provide health insurance exists, and that the child is your dependent for
Federal Income Tax purposes.

Section 2C - Children for whom you are the legal guardian
You do not need to prove your relationship to the child’s parents if you are the child’s legal guardian. You must provide a copy of the
guardianship appointment certified by the clerk of the court in which the appointment occurred.
Section 3 - CHILDREN AGED 19 - 23
A child aged 19 to 23 can be covered as a dependent under the CPS health benefits plan if he or she otherwise meets the criteria of
dependency established for children under the age of 19. Therefore, birth certificates and proof of parental relationship must be
established in the same manner as outlined above.

In addition, the child must be either:
• a full-time student at a high school or an accredited college or university (See Section 3A), or
• claimed by you as a dependent on your Federal Income Tax return (See Section 3B).

Section 3A - Proof of full-time student status
To establish that a child is a full-time student, and in high school, provide a statement from the school clerk or principal verifying that
the child is a student. If the child is enrolled at an accredited college or university, provide a letter from the office of the registrar stating
that the child is enrolled as a full-time student with 12 or more credit hours of enrollment.

Section 3B – Federal Income Tax Dependency
If the child aged 19 to 23 is not a full-time student, the child is eligible for coverage under a CPS health benefits plan if he or she meets
the Tax Dependency requirements and you complete an Affidavit to Establish Dependency. In order to meet the Tax Dependency
requirements:
• the child must be claimed by you or your current spouse as a dependent on the most recently filed tax return on file with the IRS;
• the child must continue to qualify as a dependent for tax purposes as of the date you add the child as a dependent under your
      CPS health benefits plan; and
• You must notify the Benefits Employee Services Team in writing if the child no longer qualifies as your dependent for tax purposes.

The Affidavit to Establish Dependency can be obtained from the Benefits Employee Services Team.


SECTION 4 - CHILDREN WHO ARE PHYSICALLY INCAPACITATED OR MENTALLY DISABLED
In addition to the birth certificate and proof of parental relationship, a completed Statement of Dependent Incapacitation must be
submitted to establish eligibility of children who are over the age of 23 and either physically handicapped or mentally Disabled, and
incapable of self-support. Forms can be obtained from the Benefits Employee Services Team. Proof of incapacitation must be provided
prior to the child’s 19th birthday, except at the point of hire. The determination of incapacitation will be made by the Benefits Employee
Services Team, under the advisement of an outside medical review firm, whose decision will be binding.


FRAUDULENT ACTS
It is a fraudulent act to provide documentation to establish the eligibility of a person who is not eligible for coverage or if you
fail to notify the Benefits Employee Services Team that a formerly eligible person is no longer eligible within 31 days of the
date on which that person becomes ineligible. Suspected acts of fraud will be reported to the Office of the Inspector General,
and are grounds for termination. The employee will also be held responsible for any PPO claims or HMO premiums paid on
behalf of an ineligible person. To ensure proper identification of your documents, you must include your name and employee
identification number on a separate piece of paper along with any documents you send to the Benefits Employee Services
Team. Your spouse or dependent cannot be enrolled if identifying information is not included with your documents.
All required documents can be walked in or mailed to:
                Chicago Public Schools
            Department of Human Resources
        The Benefits Employee Services Team
          320 North Elizabeth Street, 1st Floor
                  Chicago IL. 60607
                  Mail Run/ GSR# 38
                    (773) 553-2820

				
DOCUMENT INFO
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