The University of Texas System - Office of Employee Benefits
Cost Worksheet



Benefits Cost Worksheet
Plan Year

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

Download a printable version of the cost worksheet for employees.
Download a printable version of the cost worksheet for retirees.

Please remember this form only provides you (the subscriber) with an estimate of your total out-of-pocket cost per month based on state-appropriated funds and contracted premium rates. Be sure to review available benefits information and provider directories for more information on the plans listed. Evidence of Insurability may be required to enroll in some of these coverages. For details, see your UT Group Benefits Handbook or contact your Institution Benefits Office.

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The correct plan year / status costs must be loaded BEFORE calculating your total monthly out-of-pocket.

Medical out-of-pocket cost PER MONTH:

Decline medical coverage
Plan Subscriber Only Subscriber & Spouse Subscriber & Child(ren) Subscriber & Family
UT SELECT TIERED - BLUE RPPO $ 0.00 $ 214.22 $ 224.05 $ 421.86
TOBACCO USER DECLARATION:

Why is the Health / Medical Insurance deduction on my pay stub different than the out-of-pocket cost listed on this worksheet?

Health Basic Coverage is inclusive of Subscriber Only Medical coverage plus $6,000 Basic Life coverage for retired employees or $20,000 Basic Life coverage and $20,000 Basic Accidental Death and Dismemberment (AD&D) coverage for active employees. Premium Sharing pays for your Basic Life and Basic AD&D coverage along with the Subscriber's Medical coverage and a portion of your Dependent Medical coverage.

Premium Sharing is the portion of your benefits that the University pays for and is listed in a separate category. Premium Sharing shows up as an addition to your gross pay. The costs of your coverages show up as deductions. The total cost of your coverages minus Premium Sharing should equal the total at the bottom of this worksheet.

All U.T. Medical Plan subscribers must declare Covered Tobacco Users, up to a maximum of 3 users (you, your spouse, and at least one child age 16 or older). Your Covered Tobacco Users must be declared before access to the Benefits Summary and Dependents tabs is granted. As a result, you must make your Tobacco User Declaration and click the "Record My Elections" button before you can review your coverage and update your dependents on these tabs. For more information, please refer to the OEB Tobacco Premium Program.

You must make a Tobacco User Declaration every year.

Dental out-of-pocket cost PER MONTH:

Decline dental coverage
Plan Subscriber Only Subscriber & Spouse Subscriber & Child(ren) Subscriber & Family
UT SELECT DENTAL (DELTA) $ 30.86 $ 58.58 $ 64.57 $ 91.81
UT SELECT DENTAL PLUS (DELTA) $ 53.19 $ 101.01 $ 111.46 $ 158.80
DELTACARE DHMO $ 8.55 $ 16.25 $ 17.96 $ 25.65

Vision out-of-pocket cost PER MONTH:

Decline vision coverage
Plan Subscriber Only Subscriber & Spouse Subscriber & Child(ren) Subscriber & Family
SUPERIOR VISION PLAN $ 6.80 $ 10.76 $ 10.96 $ 17.40
SUPERIOR VISION PLAN PLUS $ 10.80 $ 16.76 $ 17.96 $ 25.40

Provide a Salary and Ages for Life, AD&D, LTD, and STD Coverages

Enter your basic annual earnings or contract salary:   (whole dollars only, no cents)
Select your age on September 1 of the upcoming plan year:
Select your spouse's age on September 1 of the upcoming plan year:
Check this box if you are on a 9-month contract:

Voluntary Group Term Life (GTL) out-of-pocket cost PER MONTH

Subscriber coverage amount:
Spouse coverage amount:
Check this box for Family Coverage:
Voluntary Group Term Life (GTL) out-of-pocket cost:

Employee Voluntary GTL coverage is selected in one to six times earnings/salary increments of $1,000.

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

Employee coverage amount:
Spouse coverage amount:
Check this box for Dependent child(ren) coverage:
Voluntary Accidental Death and Dismemberment (AD&D) out-of-pocket cost:
Voluntary AD&D coverage is available up to 10 times your basic annual earnings or contract salary. Basic annual earnings and contract salary are rounded up to the next $1,000 increment (e.g. $21,323 would be rounded to $22,000, with a maximum coverage amount of $220,000). Total employee Voluntary AD&D coverage cannot exceed $1,000,000.

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

Dependent child(ren) coverage is limited to $10,000 per child for one monthly premium. Employee must have at least $20,000 in Voluntary AD&D coverage to elect dependent Voluntary AD&D coverage.

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

Decline STD coverage
Accept STD coverage
Short Term Disability (STD) out-of-pocket cost:  
Your out-of-pocket cost for STD is not redirected from your check before taxes. The cost is deducted from your pay after taxes. Maximum benefit based on maximum monthly salary of $5,000.

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

Decline LTD coverage
Accept LTD coverage
Long Term Disability (LTD) out-of-pocket cost:  
Your out-of-pocket cost for LTD is not redirected from your check before taxes. The cost is deducted from your pay after taxes unless otherwise elected. Maximum benefit based on maximum monthly salary of $20,042.

Long Term Care (LTC) out-of-pocket cost PER MONTH

Subscriber coverage:
Spouse coverage:
Long Term Care (LTC) out-of-pocket cost:
PLAN A is the Basic Benefit with Guaranteed Benefit Increase Option
PLAN B is the Basic Benefit with Lifetime Automatic Benefit Increase Option (Inflation Protection)
Although other dependents are eligible for LTC coverage, only the subscriber and spouse coverage is deducted from your check after taxes.

UT FLEX monthly salary deductions (Employees Only):

PayFlex Savings Calculator

Medical Expense Reimbursement Account
Minimum Maximum Enter desired monthly deduction in dollars
$15.00 $208 with a 12-month contract
$277 with a 9-month contract
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A $12 annual administrative fee is deducted from your first account contribution in the new plan year. If you enroll during the plan year, the administrative fee is prorated.

Day Care Reimbursement Account
Minimum Maximum Enter desired monthly deduction in dollars
$15.00 $416 if single or married filing jointly with a 12-month contract
$555 if single or married filing jointly with a 9-month contract
$208 if married and filing separately with a 12-month contract
$277 if married and filing separately with a 9-month contract
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UT System Retirement Programs (Employees Only):

Retirement Account Enter desired monthly deduction in dollars
UT 403b UTSaver TSA
UT 457 DCP (Deferred Contribution Plan)

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