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Our employees are ourmost valuable asset.Knowing that you are so important, that is why at Shentel, we are committed to a comprehensiveemployee benefits program that helps our employees stay healthy, feel secure, and maintain a work/lifebalance. This benefit summary will review the benefits available to employees effective January 1, 2020.STAY HEALTHY Medical Dental VisionMAINTAIN A WORK/LIFE BALANCE Employee Assistance Plan Flexible Spending AccountsFEELING SECURE Life and Accidental Death & Dismemberment Disability Insurance AccidentELIGIBILITYAll full-time employees are eligible for benefits the first of the month following 60 calendar days ofemployment. An employee is full-time as long as they hold a position classified as full-time and work atleast 32 hours in a work week.Employees can make changes to their benefit elections during the year only if they have a qualifying eventas defined by the Internal Revenue Service including: A change in your legal marital status A change in the number of your dependents A change in your or your spouse’s employment that affects benefits A change in the eligibility status of a dependent A loss of benefit coverageEmployees must be enrolled or make changes within 30 days from the qualifying event. If an employee failsto do so, their next opportunity to enroll or make changes will be during Open Enrollment for coverageeffective January 1 of the following year.2This guide is a high level summary of benefits only and not a guarantee of coverage. Please refer to the carrier provided plandocuments for all coverage details. In the event of a discrepancy, the insurance carrier documents will govern.SHENTEL EMPLOYEE BENEFITS SUMMARY PLAN YEAR 2020
Carrier Contact InformationPAGE 4Provider Name. AnthemProvider Phone Number.800-451-1527Provider Web Address. www.anthem.comPAGE 5Provider Name. Health EquityProvider Phone Number. 1-866-346-5800Provider Web Address. www.healthequity.comPAGE 6Provider Name.GuardianProvider Phone Number.877-500-2386Provider Web Address.www.guardiananytime.comPAGE 7Provider Name.GuardianProvider Phone Number.877-500-2386Provider Web Address.www.guardiananytime.comPAGE 8Provider Name.The StandardProvider Phone Number.888-937-4783Provider Web Address .www.standard.comPAGE 9Provider Name.The StandardProvider Phone Number.888-937-4783Provider Web Address .www.standard.comPAGE 9Provider Name.The StandardProvider Phone Number.888-937-4783Provider Web Address .www.standard.comPAGE 9Provider Name.The StandardProvider Phone Number.888-293-6948Provider Web Address .https://workhealthlife.com/standard3PAGE 10Provider Name. Health EquityProvider Phone Number. 1-866-346-5800Provider Web Address. www.healthequity.comPAGE 11Provider Name.GuardianProvider Phone Number.877-500-2386Provider Web Address.www.guardiananytime.comEmployees should refer to this list when they need to contact one of the benefitvendors. For general information contact, Human Resources.This guide is a high level summary of benefits only and not a guarantee of coverage. Please refer to the carrier provided plandocuments for all coverage details. In the event of a discrepancy, the insurance carrier documents will govern.SHENTEL EMPLOYEE BENEFITS SUMMARY PLAN YEAR 20203
Medical InsuranceMedical insurance is offered through Anthem. Employees have a choice of two plans. The table belowoutlines and compares the employee financial exposure under each plan.BenefitPPO PlanHDP with HSA PlanIn-NetworkIn-Network 1,000 2,000 3,000 6,00020% Member / 80% Anthem10% Member / 90% Anthem 4,000 8,000 5,000 10,000 15 LiveHealth Online 25 co-pay 50 co-pay 59 Live Health Online10% after deductible10% after deductibleDeductibleEmployee OnlyEmployee Dependent(s)CoinsuranceOut-of-Pocket MaxEmployee OnlyEmployee Dependent(s)LiveHealth Online VisitPhysician Office VisitPrimary Care SpecialistPreventive Care/Well BabyCovered at 100%Covered at 100%20% after deductible10% after deductible 50 co-pay10% after deductibleInpatient Hospital Stay20% after deductible10% after deductibleOutpatient Surgery20% after deductible10% after deductibleAdvanced Imaging(MRI, CT, PET)20% after deductible10% after deductibleMental HealthOutpatientInpatient20% after deductible20% after deductible10% after deductible10% after deductibleSubstance AbuseOutpatientInpatient20% after deductible20% after deductible10% after deductible10% after deductibleMandatory Generic/Mailorder* 10 / 30 / 50 / 20%** 25 / 75 / 125 / 20%*Mandatory Generic/Mailorder*After Deductible 10 / 30 / 50 / 20%**After Deductible 25 / 75 / 125 / 20%*Deductible: 1,500/ 3,000Coinsurance: 40% Member/60% AnthemOut-of-Pocket Maximum: 5,000/ 10,000Deductible: 6,000/ 12,000Coinsurance: 20%Out-of-Pocket Maximum: 10,000/ 20,000Emergency ServicesUrgent Care Center Office VisitPharmacy CoverageRetail Pharmacy Co-paysHome Delivery Co-paysOut-of-Network*Mandatory mail order on maintenance prescriptions after the second refill at a retail pharmacy. You must use the mail order program or aCVS Pharmacy location for the third refill to have the prescription covered by the insurance.**Up to 200 per prescription, per monthEmployee Medical Rates Per Pay Period4Employee OnlyEmployee OneFamilyPPO Plan 49.53 202.34 354.40HDHP with HSA Plan 4.59 74.78 153.50This guide is a high level summary of benefits only and not a guarantee of coverage. Please refer to the carrier provided plandocuments for all coverage details. In the event of a discrepancy, the insurance carrier documents will govern.SHENTEL EMPLOYEE BENEFITS SUMMARY PLAN YEAR 2020
Health Savings Account (HSA)If you participate in the high deductible health plan (HDHP) the IRS allows you to contribute to a HealthSavings account (HSA). The account is a tax-free medical IRA.All covered services, including prescriptions, are subject to the 3,000 deductible of the HDHP. Once anemployee meets the deductible, services will be covered by Anthem at 90% and the member is responsiblefor 10% co-insurance except for prescriptions. Prescriptions will be covered under four co-pay tiers of 10/ 30/ 50/20% up to 200 per month for retail and 25/ 75/ 125/20% up to 200 per month for mailorder, until the out-of-pocket maximum is met. Preventive maintenance prescriptions on the essentials list willbe covered at 0 cost to the participant in the medical plan. The list of preventive/maintenance prescriptionsthat are covered are listed on the last two pages of this booklet.The out-of-pocket maximum for the HDHP is 5,000 for employee only coverage and 10,000 for all othercoverage tiers. The deductible as well as the prescription co-pays go toward the out-of-pocket maximum.Shentel Contributions into the HSA for 2019Employee OnlyEmployee OneFamily 1,200 annually 46.15 per pay period 2,000 annually 76.92 per pay period 2,000 annually 76.92 per pay period*Shentel’s contribution will be deposited into the employee’s HSA account each pay period.Employees may also contribute to their Health Savings Account in addition to Shentel’s contribution.The IRS limits are the combined employee and employer contributions as shown below.HSA Contribution Limits for 2020Coverage TierIRS Contribution LimitShentel’s Contribution**Employee Contribution Limit**Employee Only 3,550 1,200 2,350Employee One 7,100 2,000 5,100Family 7,100 2,000 5,100*Catch up contributions of 1,000 can be made by employees, who are 55 years of age or will turn 55 in the plan year, and until they enroll in Medicare.Once an employee enrolls in Medicare, the employee can no longer contribute to an HSA.**Assumes full year of employmentContributions limits are based on a calendar basis, which means contributions are prorated by the number ofmonths individuals are eligible to contribute to an HSA. Employees may change their contribution to the HSAat any time during the year.Health Equity will administer the HSA and employees have the option of investing their funds in the market.Other key points: Investment income accumulates tax-free Any remaining balance in your HSA account at the end of each year may roll over to the following year Employees may use their debit card or check to pay for the qualified medical expenses Keep all related receipts and Explanation of Benefits for your records. You do not need to submitreceipts to be reimbursed from your HSA account.This guide is a high level summary of benefits only and not a guarantee of coverage. Please refer to the carrier provided plandocuments for all coverage details. In the event of a discrepancy, the insurance carrier documents will govern.SHENTEL EMPLOYEE BENEFITS SUMMARY PLAN YEAR 20205
Dental InsuranceDental insurance is offered through Guardian. Employees are given a choice of two plans. Both plans allowemployees to seek treatment from the dentist of their choice and services are based on the usual,reasonable and customary rates in your area; there is no dental network required. If you visit a dentistthat participates with Guardian’s National PPO Network, you may pay less out-of-pocket becauseservices are based on a negotiated contracted fee schedule. If you choose a non-participating provider, as inprevious years, the plan will continue to cover your services based on the usual, reasonable andcustomary rates in your area. Please see the chart below for a plan comparison and overview.Basic OptionHigh Option 50 Individual/ 150 Family 50 Individual/ 150 Family100% Covered100% Covered80% Covered by Guardian80% Covered by GuardianMajor Services: Crowns, Bridges, Dentures,Periodontics, EndodonticsNot Covered50% Covered by GuardianOrthodontic Services*Not Covered50% Covered by Guardian 1,000 per covered member 1,500 per covered memberType of ServiceDeductible(Applies to Basic and Major Services Only)Preventive Services: Exams, Cleanings,Bitewing X-rays, Fluoride, SealantsBasic Services: Amalgam Filings,Simple Extractions, Denture RepairDental Annual Maximum*Lifetime maximum for orthodontic services is 1,500 for a child under age of 18.Dental Rates per Pay Period – Basic OptionEmployee OnlyEmployee SpouseEmployee Child(ren)Family 4.10 8.72 9.43 14.34Dental Rates per Pay Period – High OptionEmployee OnlyEmployee SpouseEmployee Child(ren)Family 11.34 22.51 33.26 44.18New for 2020: Shentel is now contributing to the dental premiums!6This guide is a high level summary of benefits only and not a guarantee of coverage. Please refer to the carrier provided plandocuments for all coverage details. In the event of a discrepancy, the insurance carrier documents will govern.SHENTEL EMPLOYEE BENEFITS SUMMARY PLAN YEAR 2020
Vision PlanA vision plan is offered through Guardian and the network is through Davis Vision. The plan offers benefitsfor regular routine eye exams, lenses, frames, and contact lenses. Please see the chart below for a plancomparison and overview.Plan FeaturesPlan FrequenciesExam every 12 Months / Lenses every 12 Months / Frames every 24 MonthsCo-payment (each member)Exam 10 / Lenses and/or Frames 25Maximum AllowancesIn-NetworkOut-of-NetworkEye Exam 10 co-payment 50 maximum after 10 co-paymentLenses (per pair)SingleBifocalTrifocalLenticular 25 co-payment 25 co-payment 25 co-payment 25 co-payment 48 maximum after 10 co-payment 67 maximum after 25 co-payment 86 maximum after 25 co-payment 126 maximum after 25 co-payment 25 co-payment 210 maximum after 25 co-payment100% of amount up to 130, then member pays80% after 130 48 maximum after 25 co-paymentContact LensesMedically NecessaryFramesVision Rates per Pay PeriodEmployee OnlyEmployee SpouseEmployee Child(ren)Family 2.99 5.03 5.12 8.11This guide is a high level summary of benefits only and not a guarantee of coverage. Please refer to the carrier provided plandocuments for all coverage details. In the event of a discrepancy, the insurance carrier documents will govern.SHENTEL EMPLOYEE BENEFITS SUMMARY PLAN YEAR 20207
Basic Life Insurance& Accidental Death and DismembermentFull-time employees are provided with a Basic Life Insurance policy including Accidental Death andDismemberment paid by Shentel. Employees receive two times their annual salary up to a maximum of 600,000.Voluntary Life InsuranceFull-time employees may also choose to purchase voluntary life insurance benefits including AccidentalDeath and Dismemberment (AD&D) for themselves, their spouse and/or children when electing voluntary lifefor themselves. The coverage is provided through The Standard. Please see the plan overviews below.EMPLOYEE COVERAGEEmployees may elect coverage on themselves up to a maximum of 600,000. The guaranteed issue amountas a new hire is two times annual compensation up to 350,000, whichever is less. If the employee's salarychanges during the year, the coverage amount and pay period minimum will change too.SPOUSE COVERAGEEmployees may elect coverage on their spouse in 5,000 increments up to 50,000 not to exceed 100% ofthe employee election. The guaranteed issue amount as a new hire is up to 25,000.CHILD(REN) COVERAGEEmployees may elect coverage on their child(ren) in the amount of 5,000. The guaranteed issue amount asa new hire is 5,000.AgeMonthly Rate per 1,000Employee / SpouseLess than 30 0.074 / 0.07430-34 0.080 / 0.08035-39 0.100 / 0.10040-44 0.133 / 0.13345-49 0.196 / 0.19650-54 0.326 / 0.32655-59 0.498 / 0.49860-64 0.574 / 0.57465-69 1.136 / 1.13670-74 2.246 / 2.24675 ChildrenRate Per Pay PeriodAnnual Election Rateper 1,0001,000Monthly Amount 12 Months26 pay periods Per PayDeductionsExample: Employee elects 1 Salary and is 27 years of age.40,000 Salary .074 2.961,000 2.246 / 2.246 0.246 for 1,000 MonthlyAmounts2.96 12 35.5226 pay periods 1.37Rates include AD&D8This guide is a high level summary of benefits only and not a guarantee of coverage. Please refer to the carrier provided plandocuments for all coverage details. In the event of a discrepancy, the insurance carrier documents will govern.SHENTEL EMPLOYEE BENEFITS SUMMARY PLAN YEAR 2020
Disability InsuranceShentel provides full-time employees with short term and long term disability coverage through Standard.Employees are eligible for these benefits following 180 calendar days of employment. Employees arerequired to submit an application to The Standard to determine eligibility. In the event an employeebecomes disabled from a non work-related injury or sickness, disability income benefits are provided as asource of income. Please see the plan overviews below. Both benefits are 100% employer paid.Short Term DisabilityBenefits Begin8th Day*Maximum Benefit Period180 calendar daysPercentage of Income Replaced60% of weekly base salary*After Paid Time Off and other benefits have been exhausted, if applicableLong Term DisabilityBenefits Begin181st calendar dayMaximum Benefit PeriodSocial Security Normal Retirement AgePercentage of Income Replaced60% of weekly base salaryMaximum BenefitUp to 10,000 a monthEmployee Assistance ProgramThe Employee Assistance Program is offered to all employees and immediate family members throughThe Standard. The completely confidential counseling program covers covers issues such as marital andfamily concerns, depression, substance abuse, grief and loss, financial issues, and other personalstressors.888.293.6948This guide is a high level summary of benefits only and not a guarantee of coverage. Please refer to the carrier provided plandocuments for all coverage details. In the event of a discrepancy, the insurance carrier documents will govern.SHENTEL EMPLOYEE BENEFITS SUMMARY PLAN YEAR 20209
Flexible SpendingAccounts (FSA)FSA’s provide employees with an important tax advantage that can help an employee pay health care anddependent care expenses on a pre-tax basis. By anticipating one’s family’s health care and dependent carecosts for the next year, employees can actually lower their taxable income.HEALTH CARE SPENDING ACCOUNT (FSA)The FSA allows employees to pay for certain IRS-approved medical care not covered by their insuranceplan with pre-tax dollars.The Annual Maximum Contribution is 2,700. Employees may rollover amaximum of 500 at the end of the year.Some examples include: Hearing services, including hearing aids and batteries Vision services, including contact lenses, contact lens solution, eye examinations and eyeglasses Dental services and orthodontia Chiropractic services Acupuncture PrescriptionsAll participants in the Health Care Spending Account will receive a new debit card from Health Equity. Thiscard will make it easier to pay for services such as co-pays for physician office visits and prescription drugs.Employees may also purchase designated over-the-counter drugs. Employees need to save their receiptsfor validation purposes if the debit card is used for expenses other than prescription and office visitco-pays. For non-co-pay medical expenses, employees will be asked to send in a copy of their receipts tothe carrier to validate the expense.If a debit card is not used then a claims form detailing the expenses may be submitted by email, fax or mail.LIMITED PURPOSE SPENDING ACCOUNT (FSA)You may elect an FSA if you participate in the HSA; however, you can only be reimbursed for dental andvision expenses.DEPENDENT CARE SPENDING ACCOUNT (FSA)Employees can use pre-tax dollars toward qualified dependent care expenses such as caring for childrenunder the age 13 or caring for elders. The annual maximum amount an employee may contribute to theDependent Care FSA is 5,000 (or 2,500 if married and filing separately) per calendar year. Examplesinclude: 10The cost of child or adult dependent careThe cost for an individual to provide care either in or out of your house as long as the provider isclaiming the amount on taxesNursery schools and preschools (excluding kindergarten)This guide is a high level summary of benefits only and not a guarantee of coverage. Please refer to the carrier provided plandocuments for all coverage details. In the event of a discrepancy, the insurance carrier documents will govern.SHENTEL EMPLOYEE BENEFITS SUMMARY PLAN YEAR 2020
Benefit pays the employee, the employee’s spouse or child(ren) a daily benefit if he or she is in thehospital for a covered illness.The benefit amount is 150 per day up to 20 days per covered accident.RATES PER PAY PERIODEmployee OnlyEmployee SpouseEmployee Child(ren)Two Parent Employee FamilyAccident with 100 Wellness 5.19 8.96 9.37 13.14Sickness HospitalConfinement Benefit 5.47 9.50 9.78 13.80Sickness rider is guarantee issue for initial enrollment.Please see Guardian materials for further plan details and per pay period pricing for Employee, Spouse and Dependent Children coverage.This guide is a high level summary of benefits only and not a guarantee of coverage. Please refer to the carrier provided plandocuments for all coverage details. In the event of a discrepancy, the insurance carrier documents will govern.SHENTEL EMPLOYEE BENEFITS SUMMARY PLAN YEAR 202011
Premium Assistance UnderMedicaid and the Children’sHealth Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from youremployer, your state may have a premium assistance program that can help pay for coverage using fundsfrom their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, youwon’t be eligible for these premium assistance programs but you may be able to buy individual insurancecoverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below,contact your State Medicaid or CHIP office to find out if premium assistance is available.If you or your dependents are NOT currently enrolled in Medicaid or CHIP and you think you or any of yourdependents might be eligible for either of these programs, contact your state Medicaid or CHIP office, call1-877-KIDS NOW or visit www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state ifit has a program that might help you pay the premiums for an employer-sponsored plan.If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligibleunder your employer plan, your employer must allow you to enroll in your employer plan if you aren’t alreadyenrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60days of being determined eligible for premium assistance. If you have questions about enrolling in youremployer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).If you live in one of the following states, you may be eligible for assistance in paying your employerhealth plan premiums. The following list of states is current as of July 31, 2019. Contact your state formore information on eligibility.ALABAMA – MEDICAIDFLORIDA – MEDICAIDWebsite: http://myalhipp.com/Phone: 1-855-692-5447Website: http://flmedicaidtplrecovery.com/hipp/Phone: 1-877-357-3268ALASKA – MEDICAIDGEORGIA – MEDICAIDThe AK Health Insurance Premium Payment ProgramWebsite: http://myakhipp.com / Phone: 1-866-251-4861Email: CustomerService@MyAKHIPP.comMedicaid id/default.aspxWebsite: um-payment-program-hippPhone: 678-564-1162 ext. 2131ARKANSAS – MEDICAIDINDIANA – MEDICAIDWebsite: http://myarhipp.com/Phone: 1-855-MyARHIPP (855-692-7447)Healthy Indiana Plan for low-income adults 19-64Website: http://www.in.gov/fssa/hip/Phone: 1-877-438-4479All other MedicaidWebsite: http://www.indianamedicaid.comPhone: 1-800-403-0864COLORADO – HEALTH FIRST COLORADO(COLORADO’S MEDICAID PROGRAM) & CHILDHEALTH PLAN PLUS (CHP )IOWA – MEDICAIDHealth First ColoradoWebsite: https://www.healthfirstcolorado.com/Website: http://dhs.iowa.gov/HawkiPhone: 1-800-257-8563Health First Colorado Member Contact CenterCHP Website: plan-plusCHP Customer Service: 1-800-359-1991/ State Relay 71112This guide is a high level summary of benefits only and not a guarantee of coverage. Please refer to the carrier provided plandocuments for all coverage details. In the event of a discrepancy, the insurance carrier documents will govern.SHENTEL EMPLOYEE BENEFITS SUMMARY PLAN YEAR 2020
KANSAS – MEDICAIDNEW HAMPSHIRE – MEDICAIDWebsite: http://www.kdheks.gov/hcfPhone: 1-785-296-3512Website: https://www.dhhs.nh.gov/ombp/medicaid/Phone: 603-271-5218Toll free number for HIPP : 1-800-852-3345, ext. 218 (in NH only)KENTUCKY – MEDICAIDNEW JERSEY – MEDICAID AND CHIPWebsite: https://chfs.ky.govPhone: 1-800-635-2570 or (877) 524-4718TDD/TTY: (877) 807-4719Medicaid Website: /medicaidMedicaid Phone: 609-631-2392CHIP Website: http://www.njfamilycare.org/index.htmlCHIP Phone: 1-800-701-0710LOUISIANA – MEDICAIDNEW YORK – MEDICAIDWebsite: Phone: 1-888-695-2447 or 1-877-252-2447) TTY: 1-800-220-5404Website: https://www.health.ny.gov/health care/medicaidPhone: 1-800-541-2831MAINE – MEDICAIDNORTH CAROLINA – MEDICAIDWebsite: dex.htmlPhone: 1-800-442-6003TTY: Maine relay 711Website: https://dma.ncdhhs.govPhone: 919-855-4100MASSACHUSETTS – MEDICAID AND CHIPNORTH DAKOTA – MEDICAIDWebsite: th/Phone: 1-800-862-4840Website: d/Phone: 1-844-854-4825MINNESOTA – MEDICAIDOKLAHOMA – MEDICAID AND CHIPWebsite: -services/otherinsurance.jspPhone: 1-800-657-3739Website: http://www.insureoklahoma.orgPhone: 1-888-365-3742MISSOURI – MEDICAIDOREGON – MEDICAIDWebsite: htmPhone: 573-751-2005Website: : 1-800-699-9075MONTANA – MEDICAIDPENNSYLVANIA – MEDICAIDWebsite: Phone: 1-800-694-3084Website: hone: 1-800-692-7462NEBRASKA – MEDICAIDRHODE ISLAND – MEDICAIDWebsite: http://www.ACCESSNebraska.ne.govPhone: (855) 632-7633Lincoln: (402) 473-7000 Omaha: (402) 595-1178Website: http://www.eohhs.ri.govPhone: 855-697-4347 or 401-462-0311 (Direct RIte Share Line)NEVADA – MEDICAIDSOUTH CAROLINA – MEDICAIDMedicaid Website: http://dhcfp.nv.govMedicaid Phone: 1-800-992-0900Website: https://www.scdhhs.govPhone: 1-888-549-0820SOUTH DAKOTA – MEDICAIDWASHINGTON – MEDICAIDWebsite: http://dss.sd.govPhone: 1-888-828-0059Website: ne: 1-800-562-3022 ext.15473This guide is a high level summary of benefits only and not a guarantee of coverage. Please refer to the carrier provided plandocuments for all coverage details. In the event of a discrepancy, the insurance carrier documents will govern.SHENTEL EMPLOYEE BENEFITS SUMMARY PLAN YEAR 202013
TEXAS – MEDICAIDWEST VIRGINIA – MEDICAIDWebsite: http://gethipptexas.com/Phone: 1-800-440-0493Website: http://mywvhipp.com/Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)UTAH – MEDICAID AND CHIPWISCONSIN – MEDICAID AND CHIPMedicaid Website: https://medicaid.utah.gov/CHIP Website: http://health.utah.gov/chipPhone: 1-877-543-7669Website: https://www.dhs.wisconsin.gov/Phone: 1-800-362-3002VERMONT– MEDICAIDWYOMING – MEDICAIDWebsite: http://www.gre
Employees may also contribute to their Health Savings Account in addition to Shentel's contribution. The IRS limits are the combined employee and employer contributions as shown below. HSA Contribution Limits for 2020 Coverage Tier IRS Contribution Limit Shentel's Contribution** Employee Contribution Limit** Employee Only 3,550 1,200 2,350
