Manual Claim Reimbursements
Have you had to pay for a claim out-of-pocket that may be covered under the plan? If you need to request reimbursement for a claim, please use the following forms.

CBA Blue
Medical Claim Submission Form

Magellan Rx 
Prescription Claim Submission Form 

Delta Dental
Dental insurance is provided through Delta Dental. The City covers the full dental insurance premium, so there is no premium cost to employees. Coverage levels for city employees are single, two-person, and family.

Member Portal Registration
Delta Dental Registration - Please contact Maddi Sousa, HR Generalist for your Subscriber ID Number.
Link to Delta Dental Portal (bookmark me!)

Summary of Benefits
Outline of Coverage
Summary of Enhanced Benefits

Forms
Delta Dental Enrollment/Change Form
1557 Nondiscrimination Notice
Delta Dental Eye Med Vision Discount

EyeMed
Vision insurance is provided to city employees through EyeMed. Vision insurance premium costs are shared by the city and its employees. Employees share in the cost of premiums at a 10% rate. Annual costs for each employee coverage level are included below:

• Single: $5.20 per year
• Two-person: $10.40 per year
• Family: $15.08 per year

EyeMed Discounts Through Delta Dental

Health Savings Account (HSA)
Employees enrolled on the City's CBA Blue medical insurance plan are eligible to contribute to a Health Savings Account (HSA). The City makes an annual contribution to the HSA accounts of employees enrolled through the City's CBA Blue medical insurance plan. The City's contribution amount is based on the coverage level of the employee. Please see the annual contribution rates of the City below:

• Single: $925.00 per year
• Two-person: $1,925.00 per year
• Family: $1,350.00 per year

Employees may also contribute to an HSA account on a pre-tax basis through payroll deductions. Employees can contribute up to the annual maximum amount as determined by the IRS. Please note that this amount includes the City's annual contribution. The 2023 maximum contribution limits are outlined below: 

• Single: $4,150.00 per year (Individuals age 55+ may contribute an additional $1,000.00)
• Family: $8,300.00 per year (Individuals age 55+ may contribute an additional $1,000.00)

Limited Purpose Flexible Spending Accounts (LPFSA)
Employees enrolled in an HSA-qualifying, High Deductible Health Plan are eligible to enroll in a Limited Purpose Flexible Spending Accounts (LPFSA). This type of FSA allows you to set aside pre-determined amount of money to pay for qualifying dental and vision expenses on a pre-tax basis. The maximum contribution election amount is set by the IRS, and it is $3,200.00 for 2024.

Forms
FSA Enrollment Form
FSA Worksheet
Consumer Portal Instructions

Dependent Care Flexible Spending Accounts (DCFSA)
Employees enrolled in an HSA-qualifying, High Deductible Health Plan are also eligible to enroll in a Dependent Care Flexible Spending Accounts (DCFSA). This type of FSA allows you to set aside pre-determined amount of money to pay for qualifying dependent care expenses on a pre-tax basis. The maximum contribution election amount is set by the IRS, and it is $5,000.00 for 2024.

Forms
FSA Enrollment Form
FSA Worksheet
Consumer Portal Instructions

Life and AD&D Insurances
The City provides life insurance and AD&D coverage to employees at no cost. Optional insurance can be purchased at an additional cost to the employee when they are hired, or, during open enrollment annually. These insurances 

Summary of Benefits
Class 6 - All Police Department Employees
Class 1 - All Full-Time Employees

Forms
Unum Privacy Statement
Group Beneficiary Form

Short Term Disability Insurance
Short Term Disability Insurance is provided at no cost to employees. This insurance is managed by UNUM, and may cover a variety of conditions and injuries, and can help pay for your groceries, out-of-pocket medical expenses, rent, mortgage, and more! 

Summary of Benefits
Class 1 - Police
Class 2 - All full-time employees (excluding Public Safety employees)

Forms
How to File a Disability Claim with UNUM

Long Term Disability Insurance
Long Term Disability Insurance is provided at no cost to eligible employees. Eligible employees include all full-time employees, excluding Public Safety employees. This insurance is managed by UNUM, and may cover a variety of conditions and injuries, and can help pay for your groceries, out-of-pocket medical expenses, rent, mortgage, and more! 

Summary of Benefits
Long Term Disability Insurance

Forms
How to File a Disability Claim with UNUM

MissionSquare
Police, City Hall, Public Works, and all other non-union, full-time employees may enroll in a 457(b) Deferred Compensation Plan through MissionSquare Retirement. A 457(b) plan is a tax-deferred retirement savings plan where funds are withdrawn from an employee’s income without being taxed and are only taxed upon withdrawal, which is typically at retirement. The City offers up to a 5.5% contribution match for all City Hall, Public Works, and non-union employee contributions. 

Member Portal
MissionSquare Participant Portal Registration
Link to MissionSquare Portal (bookmark me!)

Forms & Resources
MissionSquare Retirement Education Center
Get to know your 457(b) Plan
MissionSquare 457(b) Enrollment & Contribution Change Form

For more information, contact our MissionSquare Retirement Plans Specialist:
Michael Savage, Retirement Plan Specialist
Appointment link for Mike Savage
Phone: 888-803-2721
Email: MSavage@missionsq.org

Nationwide
Fire Department employees may enroll in a 457(b) Deferred Compensation Plan through Nationwide Retirement. A 457(b) plan is a tax-deferred retirement savings plan where funds are withdrawn from an employee’s income without being taxed and are only taxed upon withdrawal, which is typically at retirement. This account is fully funded by the employee

Member Portal
Nationwide Participant Portal Registration
Link to Nationwide Portal (bookmark me!)

Forms & Resources
Link to Nationwide Resource Center

SEI
SEI manages the City's Defined Benefit Pension Plan. This plan is only for those employees who have been legacied into the plan. If you have questions on your eligibility into this plan, please reach out to Maddi Sousa, at msousa@southburlingtonvt.gov. 

Forms & Resources
SEI Summary Plan Document
Description of Plan Provisions for Non-Public Safety Employees
Description of Plan Provisions for Public Safety Employees
Beneficiary Form

Vermont Municipal Employees' Retirement System (VMERS)
The Vermont Municipal Employees' Retirement System (VMERS) is the public pension plan provided by the State of Vermont for participating municipalities' employees. Enrollment into this plan is mandatory for all new employees. The City covers the employee contribution amount for all employees except those employed in the Fire or Police Departments. 

Member Portal
VMERS Member Portal Registration

Forms & Resources
VMERS Contribution Rates for Fiscal Year 2024
VMERS Beneficiary Form