Monroe County School District Employee Benefit Guide
2015 Monroe County School District Employee Benefit Guide Monroe County School District Dear Monroe County School District Employee, It’s benefit enrollment time once again and we have some exciting changes for the coming year. We have partnered with new providers for 2015 which means new opportunities for you and your family. The School District recognizes the importance of benefits for you and your family, that’s why we take the time to carefully select providers that can best serve our employees. We know you don’t make your benefit decisions lightly, which is why we are dedicated to partnering with providers who offer quality benefits. Your benefit enrollment will be for all core (Medical/Dental/Vision/Disability Income Protection/Life/Medical Flexible Spending Account and Dependent Flexible Spending Account) plus supplementary benefits. This year we have a new life insurance carrier, Minnesota Life. Minnesota Life is offering up to $100,000 guaranteed issuance on life insurance for the employee, guaranteed issuance up to $25,000 for Spouse and $10,000 for Children. For 2015, we are proud to partner with American Fidelity Assurance Company for the following supplementary benefits: Disability Income Insurance Term Life Insurance Accident Insurance Cancer Insurance Critical Illness Insurance Keep in mind that the supplementary benefits that are being offered by American Fidelity Assurance Company is not a mandatory enrollment. These benefits are being offered to you at your discretion and you are not obligated to enroll. Enrollment counselors will be available throughout the open enrollment process to assist you in enrolling in all of your benefits and to answer any questions you may have. To see a complete schedule of this year’s open enrollment sessions, please see page 6. The Employee Benefits Department developed the following benefit guide to provide you with information about your benefit options for the new plan year, explain the enrollment and change process, and serve as a valuable resource for information about all the benefits available to you. It’s a good idea to take some time to read this guide before attending open enrollment and/or completing your enrollment forms. Thank you in advance for taking the time to review this benefit guide and we look forward to seeing you during open enrollment. Sincerely, Wanda Menendez Employee Benefits & Risk Management Specialist Table of Contents 2015 Benefits Enrollment Annual Enrollment........................................................................................................5 Section 125 Cafeteria Plan .........................................................................................5 How to Enroll ..................................................................................................................6 Enrollment Schedule....................................................................................................6 Insurance Plans SMART................................................................................................................................8 Eligibility Requirements..............................................................................................9 Prescription Plans........................................................................................................11 Medical Benefit Summaries.....................................................................................12 Dental/Vision Rates.....................................................................................................16 Dental Plan.....................................................................................................................17 Vision Plan......................................................................................................................25 Group Term Life Insurance........................................................................................28 Disability Income Protection ..................................................................................30 Critical Illness/Disability Income Insurance........................................................33 Accident Only/Hospital GAP Insurance ..............................................................34 Cancer/Permanent Portable Life Insurance ......................................................35 Life Insurance................................................................................................................36 Flexible Spending Accounts (FSA) Health Flexible Spending Account (FSA)............................................................38 Flex Debit Card.............................................................................................................39 Dependent Care FSA..................................................................................................40 Filing a Flex Claim........................................................................................................41 Accessing Your FSA.....................................................................................................41 Other Information Cigna Will Center..........................................................................................................43 Vista 401(k).....................................................................................................................45 COBRA Q&A ..................................................................................................................47 Beyond Your Benefits.................................................................................................48 Marketplace Notice.....................................................................................................49 Benefits Directory........................................................................................................52 2015 BENEFITS ENROLLMENT Annual Enrollment Section 125 Cafeteria Plan How to Enroll Enrollment Schedule Your Annual Enrollment Important Dates to Remember Your Open Enrollment Dates are: November 12, 2014 - December 6, 2014 Your Plan Year is: January 1, 2015 - December 31, 2015 Note: Changes to insurance plans will go into effect January 1st. Annual Open Enrollment Before you meet with your American Fidelity Representative, take time to evaluate your current coverage and decide how well it serves the needs of you and your family. Important Points To Consider • Figure an estimate of child care expenses. • Review your beneficiaries. • Review American Fidelity’s options of portable insurance plans that you can keep if your employment changes. • Evaluate your need for life insurance. • Consider increasing your Disability Income Insurance policy amount to match your current salary. Each year Open Enrollment provides you an opportunity to change plans and modify dependent coverage. Your election deductions begin in June and will remain in effect through the plan year (January 1, 2015 - December 31, 2015) for your Voluntary benefits. NOTE: If eligibility changes during the year you must notify Human Resources within 31 days of the qualifying event. Your Section 125 Plan Save Money With Section 125 If there was a program available that could dramatically save money on your taxes, would you take advantage of it? That’s exactly what the Section 125 Plan does—reduces your taxes and increases your spendable income! Plus, the Plan is available to you at no cost* and you’re already eligible, all you have to do is enroll. The Plan works like this: You are allowed to deduct needed benefits from gross earnings before taxes are computed. This means that current after-tax expenses, such as insurance products and benefits, can be paid for with pre-tax dollars. The advantage of this Plan is simple: The eligible premiums you pay under the Plan are paid on a pre-tax basis. You could be on your way to increased savings, just by signing up and taking advantage of this Plan! Benefits Eligible For The Section 125 Cafeteria Plan • Group Medical, Dental and Vision Insurance • Accident Insurance • Cancer Insurance • Flexible Spending Accounts 5 How Can This Plan Help Me? The sample paycheck below shows the benefits under the Section 125 Plan compared to benefits outside of the Plan. In this example, the employee gained $55 more spendable income per month! Pre-Tax Example After-Tax Example $1,500.00 Monthly Gross Salary $1,500.00 - $150.00 Pre-Tax Medical Insurance $0.00 - $25.00 Pre-Tax Disability Insurance $0.00 - $25.00 Pre-Tax Accident Insurance $0.00 $1,300.00 Adjusted Monthly Gross Salary $1,500.00 - $260.00 Estimated Federal Tax (20%) - $300.00 - $99.45 Estimated FICA (7.65%) - $114.75 $0.00 After-Tax Medical Insurance - $150.00 $0.00 After-Tax Disability Insurance - $25.00 $0.00 After-Tax Accident Insurance - $25.00 Take-Home Pay $885.25 $940.55 * Taxes are a sample average of State, Federal and FICA taxes. Your own average tax rate may vary. How to Enroll Monroe County makes it easy for you to enroll in your 2015 benefits. Employees can enroll on-site with your American Fidelity representative. Don’t Miss It! • Have you recently received a pay increase? • Have you or are you planning on getting married, having children, or buying a home? • What would happen if you were suddenly ill or disabled? Enroll On-site See your American Fidelity’s Representative during your enrollment to complete your benefit election form and discuss the options that are available to you. What To Bring To Your Appointment • Driver’s license. • Bank account information (to sign up for direct deposit) • Spouse and children’s DOB and Social Security number if considering coverage for them. • Beneficiary information, including (if a trust) full name and date of trust. These questions and others will be addressed during your benefit consultation to make sure you are properly covered. It takes just a few moments to review your coverage and protect the welfare of you and your family. By enrolling on-site you can enroll in: • Dental Insurance • Accident Only Insurance • Vision Insurance • Life Insurance • Group Life Insurance • Health Flex Spending Account • Disability Income Insurance • Dependent Care FSA • Cancer Insurance 6 INSURANCE PLANS SMART Choices Eligiblity Requirements Prescription Plans Florida Blue Dental Vision Group Life Insurance Disability Insurance Term Life Insurance Long-Term Disability Insurance Accident Insurance Hospital GAP PLAN Insurance Cancer Insurance Texas Life Insurance Critical Illness Insurance AF Permanent Life Insurance Life Insurance The SMART Choices Plan Advantage The SMART Choices Plan Advantage TheMonroeCountySchoolDistrictprovidesallemployeeswith: • $10,000 Life and AD&D Insurance • Partially paid medical coverage for employees who choose medical insurance and • $450 a year contribution, which is applied to your medical coverage. If you do not have medical insurance through the school board, the contribution may be used to purchase voluntary benefits,excluding401(k).Anyunusedbalances will revert back to the school board. DualSpouseProvision:TheDualSpouseEnrollmentOptionisavailable for both instructional and non-instructional employees. Employees shouldcalltheEmployeeBenefitsandRiskManagementDepartmentat (305)293-1400,ext.53342,orseeWandaMenendezduringenrollment for details. HowDoestheSMARTChoicesPlanWork? 1. The $450 a year contribution is applied to your school board medical coverage. If you do not have medical insurance through the school board, the contribution may be used to purchase voluntary benefits, excluding 401(k). Any unused balances will revert back to the school board. 2. Youchooseanyvoluntarybenefitsyouandyourfamilyneedand the premium costs are deducted tax free from your gross pay before incomeandSocialSecuritytaxesarecalculated. 3. Taxes are calculated on the amount of your salary remaining after allpremiumshavebeendeducted.Then,anyotherafter-taxpayroll deductions you may have are taken out of your paycheck. 4. Theamountremaininginyourpaycheckisyourtake-homepayfor eachpayperiod.Sinceyouhavepaidlesstax,youhavemoreincome to spend. Appeals Process If you have a request for a mid-plan year election change, FSA reimbursement claim or other similar request denied, in full or in part, you have the right to appeal the decision by sending a written request within 180 days of the denial for review Your appeal must include: • the name of your employer • the date of the services for which your request was denied • a copy of the denied request • the denial letter you received • why you think your request should not have been denied and • any additional documents, information or comments you think may have a bearing on your appeal. Your appeal will be reviewed upon receipt and its supporting documentation. You will be notified of the results of this review within 60 business days from receipt of your appeal. In unusual cases, such as when appeals require additional documentation, the review period may then be extended by an additional 30 days. We will notify you in writing if an extension is necessary. If we request additional information, you will have 45 days to respond. If you do not respond within 45 days, we may conclude our review of your claim based on the information we have received. If your claim is denied on appeal, you have the right to bring a civil action for benefits under Section 502(a) of ERISA. If your appeal is approved, additional processing time is required to modify your benefit elections. Note: Appeals are approved only if the extenuating circumstances and supporting documentation are within your employer’s, insurance provider’s and IRS regulations governing the plan. American Fidelity believes in making it easy for you. You can call our Flex Department Colleagues to speak with a live representative for claim questions or status. Our customer service representatives are ready to assist you from 7:00 a.m. – 6:00 p.m. CST with any questions you may have. Call us today at 1-800-325-0654. 8 Eligiblity Requirements Eligibility Requirements WhenDoesMyPeriodofCoverageBegin? Current Employees: Your period of coverage is January 1, 2015 through December31,2015. New Employees: Ifyouareanewfull-timeemployee,youareeligible fortheSMARTChoicesPlanonthefirstdayofthemonthfollowing 15calendar days of active employment. If you do not enroll before your period of coverage begins, you will not be able to do so until the next plan year or until you experience a valid change in status. If you enroll during open enrollment, your period of coverage is the sameastheplanyear (January1,2015throughDecember31, 2015). WhoIsEligibletoEnrollintheFlexible BenefitsPlan? Ifyouareafull-timeinstructionalornon-instructionalemployeeofthe school board who works at least 51 percent of the average time required foryourposition,youareeligibletoenrollintheSMARTChoicesPlan. Upon certain triggering events, spouses, ex-spouses, children and employeesgoingfromfull-timetopart-timestatusmaybeeligiblefor coverageundertheConsolidatedOmnibusBudgetReconciliationAct (COBRA).PleasecontactyourEmployeeBenefitsandRiskManagement Department for additional information. WhoAreEligibleDependents? Eligible dependents are: • your legal spouse • your own unmarried children • children for whom you have been appointed legal guardian; and • stepchildrenandlegallyadoptedchildren(providedtheyresidein yourhouseholdandprimarilydependonyouforsupport). IntheStateofFloridaanyoneuptotheageof30maybeconsidereda dependent for the purposes of health insurance eligibility and access. Forallhealthcoverageofferedunderyouremployer’splan,youmay continue to cover your dependent child until the end of the calendar year in which the child reaches the age of 30 if the child: • is unmarried and does not have a dependent of his or her own • isaresidentofFloridaorafull-timeorpart-timestudentand • is not provided coverage as a named subscriber, insured, enrollee, or covered person under any other group, blanket, or franchise health insurancepolicyorindividualhealthbenefitsplan,orisnotentitled tobenefitsunderTitleXVIIIoftheSocialSecurityAct. WhatBenefitsAmIEligibleforIfI TerminateEmployment? During the plan year, except as otherwise provided by law and in accordance with your employer’s plan(s), terminating employees are covered until the last day of the month following 31 days after termination, provided you make necessary contributions. If termination occurs in the month of December, then coverage will cease no later than December31,2015.Youcancontinuecertainbenefitsbycontacting thefollowing within 30 days of your termination of employment*: • EmployeeBenefitsandRiskManagementDepartmentforbenefits continuationandtoobtaininformationontheFamilyMedicalLeave Act(FMLA). HowWillRetiringAffectmyEligibility? During the plan year, except as otherwise provided by law and in accordancewithyouremployer’splan(s),anemployeewho retiresiscovered until the last day of the month following 31 days of retirement. Someplansmaybecontinuedatthesamepremiumrates whileothersrequire conversion to an individual policy and may have an increase in premiumrates.Duringthe90daysprecedingyour scheduledretirement,it’simportantthatyoucontactcustomercarefor continuationofflexiblebenefits.You may not continue disability income protection or adependentcareFSAuponretirement. A retiree is a former full-time employee of the school board who iscurrentlyreceivingincomeundertheFloridaRetirementSystem (FRS). Note: In order to continue medical coverage for dependents between the pages 27-30, additional contribution is required, as set forth by Monroe County School District. Note: The extension of coverage up to age 30 does not apply to accident only, specified disease, disability income, Medicare supplement, or long-termcareinsurancepolicies.Thepremiumsforsuchcontinued coveragemustbeonapost-taxbasis.Youremployerisresponsiblefor ensuring the proper tax treatment for any dependent coverage elected under these provisions. * Youremployer’smedicalexpenseFSAplanisnotsubjecttoCOBRAcontinuationbeyondtheend of the plan year in which a COBRA-qualifying event occurs. Disability income protection and dependentcareFSAsmaynotbecontinued. 9 Eligiblity Requirements Eligibility Requirements How Does Employee Leave Affect My Eligibility? Employees on leave of absence are eligible for certain types of coverage depending on the type of leave (A or B). A. Board-Approved Paid Leave–Theschoolboardcontinuestopay the $450 a year contribution up to one year if you go on medical leavebecauseofyourowndisability(whichincludespregnancyand disabilitiesresultingfrompregnancycomplications).Yourpremium deductionswillcontinuethroughtheSMARTChoicesPlanaslong asyoureceiveasalary.TheFamilyMedicalLeaveActmayaffect yourrightsconcerningthecontinuationofyourhealthbenefitswhile on unpaid leave. Consult with your Employee Benefits and Risk Management Department for further information. B. Board-Approved Nonpaid Leave–Theschoolboarddoesnotpay foryourbenefits.Youcancontinuetoreceivecoverageunderyour benefitsforuptooneyearifyoupaytheschoolboardcontribution and your premiums directly to the school board.The Family and Medical Leave Act may affect your rights concerning the continuation of your health benefits while on unpaid leave. Consult with your Employee Benefits and Risk Management Department for further information. Ifyougoonboard-approvedleaveforanyreason,youmaypayyour premiumstotheschoolboardtomaintainyourbenefitsexceptforVISTA 401(k).Ifyouhavenotmaintainedacurrentpremiumstatuswhileon leave,youwillberequiredtore-satisfyeligibilityrequirementswhen you return to active status, except as otherwise provided by law. HowDoestheFlexibleBenefitsPlanAffect OtherBenefits? Yourcontributionstotheflexiblebenefitsplandonotreduceyourfuture Florida Retirement System (FRS) benefits or current contributions to FRS.Anysalarydirectedtoyourflexiblebenefitsplanisincludedinthe compensationreportedtotheFloridaRetirementSystem. 10 Prescription Plans Prescription Plans The Monroe County School District Prescription Benefit Program providesoutpatientprescriptiondrugbenefitsforitsmembersandis administered by Envision Rx. Covered services include prescription drugs purchased from a participating pharmacy pursuant to a prescription orderfromaphysicianorotherlicensedpractitioner.Effective8/1/12 theMonroeCountySchoolDistrictofferstwo(2)healthinsuranceplans, thecurrentplanwhichisnowcalledthe“TheBuyUpPlan”andan optionalplanwhichiscalledthe“CorePlan.”Thefollowingarethe benefitsforeachplan: Quantity Allowed: 30-daysupplyatretail,90-daysupplyatmailorder Generic Substitution: Patientwillpaythebrandco-paymentplusthe cost difference between the branded product and the generic if they receivethebrandedproductwhenanFDAapprovedgenericisavailable. Prior Authorizations:Certainproductsarecoveredonlywhendefined conditions have been met. Products requiring prior approval include: • injectablemedications • MultipleSclerosismedications • growth hormone. Mail Order Program: The mail order program is designed for those who take maintenance medications on a long term basis. Prescriptions are triple checked and screened by licensed pharmacists with personal medical history for quick, reliable, and safe dispensing. This program will provide the following: • • • • firsttimeprescriptionsandrefills 90 day supply delivery to the member’s home nocomplicatedclaimformtofile. Exclusions • Non-prescriptionmedications(overthecounter“OTC”products) • AnymedicationthathasnotbeenapprovedbytheFoodandDrug Administration(FDA) • Bloodandplasmarelatedproducts • Oxygen • Immunization agents or biological sera • Allergy desensitization agents or allergy serum • MedicationsobtainedoutsidetheU.S. • Professional charges in connection with compounding, administering, orinjectingmedications • Durable or disposable medical equipment, devices, appliances and supplies • Emergency contraceptive kits/diaphragms and other intrauterine devicesimplants/other • Infertility medications • Impotencemedications/allforms • Appetite suppressants • Nicotinereplacements/smokingcessationproducts • Medications for cosmetic purposes • Prescriptionmulti-vitamins/prescriptionmultivitaminswithfluoride • Medications for foreign travel • Influenzamedications Customer Service:ContactEnvisionRxCustomerServiceHelpDesk at1-800-361-4542withquestionsregardingyourprescriptionbenefit. The website is www.envisionrx.com Shouldyouhaveanyfurtherquestions,pleasedonothesitatetocontact theEmployeeBenefitsDepartment,MonroeCountySchoolDistrict,at 305-293-1400,ext.53340. Buy-up Plan - Deductible: $100/individual, $200/family Co-payment Retail: Mail order: Generic $10 $20 Preferred Brands $35 $70 Non-preferred brand $50 $100 Core Plan - Deductible: $100/individual, $200/family Co-payment Retail: Mail order: Generic $15 $30 Preferred Brands $45 $90 Non-preferred brand $65 $130 High Deductible Plan - Deductible: $100/individual, $200/family Co-payment Retail: Mail order: Generic $15 $30 Preferred Brands $50 $100 Non-preferred brand $75 $150 11 12 Allergy Injections In-Network Family Physician In-Network Specialist Out-of-Network E-Office Visit Services In-Network Family Physician In-Network Specialist Out-of-Network Office Services In-Network Family Physician In-Network Specialist Out-of-Network Family Physician Out-of-Network Specialist Provider Services at Hospital In-Network Family Physician In-Network Specialist Out-of-Network Family Physician Out-of-Network Specialist Provider Services at ER In-Network Family Physician In-Network Specialist Out-of-Network Family Physician Out-of-Network Specialist Provider Services at Other Locations In-Network Family Physician In-Network Specialist Out-of-Network Family Physician Out-of-Network Specialist Radiology, Pathology and Anesthesiology Provider Services at Ambulatory Surgical Center In-Network Specialist Out-of-Network COST SHARING Maximums shown are Per Benefit Period (BPM) unless noted Deductible (DED) (Per Person/Family Agg) In-Network Out-of-Network Coinsurance (Member Responsibility) In-Network Out-of-Network Out of Pocket Maximum (Per Person/Family Agg) In-Network Out-of-Network Lifetime Maximum Predictable Cost 03559 CORE PLAN $1,000 / $2,000 Combined with In-Network Predictable Cost 03768 BUY UP PLAN $500 / $1,000 Combined with In-Network $10 $10 $10 $10 $10 DED + 40% $40 $50 $50 $70 $50 $50 $50 $50 $50 $50 $50 $50 $40 $50 DED + 40% DED + 40% $75 $75 $10 $10 $10 $10 $10 DED + 40% $30 $30 $40 $40 $50 $50 $50 $50 $50 $50 $50 $50 $30 $30 DED + 40% DED + 40% $45 $45 1 25% 25% 40% 40% Includes DED, Coins and all Copays Includes DED, Coins and all Copays (Excludes Rx) (Excludes Rx) $6,350 /$12,700 $6,350 /$12,700 Combined with In-Network Combined with In-Network No Maximum No Maximum PROFESSIONAL PROVIDER SERVICES BlueOptions BlueOptions Benefit Summaries Monroe County School District -1/1/2015 DED + 25% DED + 40% DED + 25% DED + 25% DED + 40% DED + 40% DED + 25% DED + 25% In-Ntwk DED + 25% In-Ntwk DED + 25% DED + 25% DED + 25% DED + 40% DED + 40% $50 DED + 25% $60 DED + 40% $10 $10 DED + 40% $10 $10 $10 25% 40% Includes DED, Coins, & Copays(Excludes Rx) $6,350 / $12,700 Combined with In-Network No Maximum $1,500 / $3,000 Combined with In-Network Plan 05360 HIGH DEDUCTIBLE BlueOptions Medical Benefit Summaries Florida Blue $0 $0 $0 $0 $0 / $0 $0 / $0 $40 $50 $40 $70 EMERGENCY / URGENT / CONVENIENT CARE No per Day Maximum No per Day Maximum DED + 25% DED + 25% In-Ntwk DED + 25% In-Ntwk DED + 25% $0 / $0 $50 $70 Age 50+ then Frequency Schedule Applies $0 $0 Predictable Cost 03559 CORE PLAN BlueOptions $0 / $0 $40 $40 Age 50+ then Frequency Schedule Applies $0 $0 PREVENTIVE CARE Predictable Cost 03768 BUY UP PLAN BlueOptions 2 Plan 05360 HIGH DEDUCTIBLE BlueOptions DED + 25% DED + 25% DED + 40% DED + 40% DED + 25% DED + 40% DED + 25% DED + 40% DED + 25% DED + 40% DED + 25% In-Ntwk DED + 25% DED + 25% DED + 40% No per Day Maximum DED + 25% In-Ntwk DED + 25% $0 / $0 DED + 40% DED + 40% $0 $0 $0 / $0 DED + 40% DED + 40% Age 50+ then Frequency Schedule Applies $0 $0 Ambulance Maximum (per day) In-Network Out-of-Network Convenient Care Centers (CCC) In-Network $20 $20 Out-of-Network DED + 40% DED + 40% Emergency Room Facility Services In-Network $100 $200 Out-of-Network $100 $200 Urgent Care Centers (UCC) In-Network $50 $50 Out-of-Network DED + 40% DED + 40% FACILITY SERVICES – HOSPITAL / SURGICAL / LAB / INDEPENDENT DIAGNOSTIC TESTING FACILITY Ambulatory Surgical Center In-Network $200 $250 Out-of-Network DED + 40% DED + 40% Independent Clinical Lab In-Network $0 $0 Out-of-Network DED + 40% DED + 40% Independent Diagnostic Testing Facility Xrays and AIS (Includes Physician Services) In-Network - Advanced Imaging Services (AIS) $200 $200 In-Network - Other Diagnostic Services $50 $50 Out-of-Network-Advanced Imaging (AIS) $200 $200 Out-of-Network-Other Diagnostic Services DED + 40% DED + 40% In-Network Out-of-Network Mammograms (Routine ) In-Network Out-of-Network Well Child Office Visits (No BPM) In-Network Family Physician / Specialist Out-of-Network Family Physician Out-of-Network Specialist Adult Wellness Office Services In-Network Family Physician / Specialist Out-of-Network Family Physician Out-of-Network Specialist Colonoscopies (Routine) COST SHARING MAXIMUMS SHOWN ARE PER BENEFIT PERIOD (BPM) UNLESS NOTED Medical Benefit Summaries Florida Blue 13 14 Out-of-Network Provider Services at Hospital In-Network Family Physician In-Network-Specialist Out-of-Network Family Physician Out-of-Network-Specialist Provider Services at ER In-Network Family Physician In-Network-Specialist Out-of-Network Family Physician Out-of-Network-Specialist Physician Office Visit In-Network Family Physician In-Network-Specialist Out-of-Network Family Physician Out-of-Network Specialist Emergency Room Facility Services (per visit) In-Network Out-of-Network Provider Services at Locations other than Hospital and ER In-Network Family Physician / Specialist Out-of-Network Family Physician Out-of-Network Specialist Out-of-Network Outpatient Hospitalization (per visit) In-Network Inpatient Hospitalization In-Network Out-of-Network Out-of-Network Therapy at Outpatient Hospital In-Network Out-of-Network Inpatient Rehab Maximum Outpatient Hospital (per visit) In-Network Cost Sharing Maximums shown are Per Benefit Period (BPM) unless noted Inpatient Hospital (per admit) In-Network Option 1 – DED + 25% Option 2 – DED + 25% DED + 40% 30 Days Option 1 – DED + 25% Option 2 – DED + 25% DED + 40% Option 1 – DED + 25% Option 2 – DED + 25% DED + 40% 30 Days Option 1 – DED + 25% Option 2 – DED + 25% DED + 40% Option 1 – DED + 25% Option 2 – DED + 25% DED + 40% $40 $50 $50 $70 $40 $50 $50 $70 $40 $50 $50 $70 $200 $200 $40/ $50 $50 $70 Option 1 – DED + 25% Option 2 – DED + 25% DED + 40% $30 $30 $40 $40 $30 $30 $40 $40 $30 $30 $40 $40 $100 $100 $30 / $30 $40 $40 3 Option 1 – DED + 25% Option 2 – DED + 25% DED + 40% Option 1 – DED + 25% Option 2 – DED + 25% DED + 40% Option 1 – $45 Option 1 – $50 Option 2 -- $60 Option 2 -- $70 DED + 40% DED + 40% MENTAL HEALTH AND SUBSTANCE ABUSE BlueOptions Predictable Cost 03559 CORE PLAN BlueOptions Predictable Cost 03768 BUY UP PLAN DED + 25%/DED + 25% DED + 40% DED + 40% DED + 25% In-Ntwk DED + 25% $50 DED + 25% $60 DED + 40% DED + 25% DED + 25% In-Ntwk DED + 25% In-Ntwk DED + 25% DED + 25% DED + 25% DED + 40% DED + 40% Option 1 - DED + 25% Option 2 - DED + 25% DED + 40% Option 1 - DED + 25% Option 2 - DED + 25% DED + 40% Option 1 - DED + 25% Option 2 - DED + 25% DED + 40% Option 1 - DED + 25% Option 2 - DED + 25% DED + 40% Option 1 - DED + 25% Option 2 - DED + 25% DED + 40% 30 Days Plan 05360 HIGH DEDUCTIBLE BlueOptions Medical Benefit Summaries Florida Blue BlueOptions BlueOptions Predictable Cost 03559 CORE PLAN $50 $70 Covered Covered $30 $40 Covered Covered DED + 25% DED + 40% $2,500 Maximum DED + 25% DED + 40% 30 visits DED + 25% DED + 40% No Maximum DED + 25% DED + 40% 122 Visits (Includes up to 26 Spinal Manipulations) DED + 25% DED + 40% $2,500 Maximum DED + 25% DED + 40% 30 visits DED + 25% DED + 40% No Maximum DED + 25% DED + 40% 122 Visits (Includes up to 26 Spinal Manipulations) $50 $40/ $50 $50 / $70 DED + 40% 60 days DED + 25% DED + 40% DED + 25% DED + 40% No Maximum DED + 25% DED + 40% No Maximum $30 $30 / $30 $40 / $40 DED + 40% 60days DED + 25% DED + 40% $200 $200 $200 $200 $200 $200 OTHER SPECIAL SERVICES AND LOCATIONS Predictable Cost 03768 BUY UP PLAN DED + 25% DED + 40% Covered Covered DED + 25% DED + 25% DED + 40% DED + 40% 60 Days DED + 25% DED + 40% DED + 25% DED + 40% $2,500 Maximum DED + 25% DED + 40% 30 Visits DED + 25% DED + 40% No Maximum DED + 25% DED + 40% 122 Visits (Includes up to 26 Spinal Manipulations) DED + 25% DED + 40% No Maximum DED + 25% DED + 25% DED + 40% Plan 05360 HIGH DEDUCTIBLE BlueOptions 4 The information contained in this Summary of Benefits includes benefit changes required as a result of the Patient Protection And Affordable Care Act (PPACA), otherwise known as Health Care Reform (HCR). Please note that plan benefits are subject to change and may be revised based on guidance and regulations issued by the Secretary of Health and Human Services (HHS) or other applicable federal agency. Additionally, Interim rules released by the Federal Government February 2, 2010 require BCBSF to test all benefit plans to ensure compliance with the Mental Health Parity and Addiction Equity Act (MHPAE). Diabetic Supplies (lancets, strips, etc.) are available through DME. Diabetic Equipment (insulin pumps, tubing) are covered under the medical benefits. In-Network Free Standing Rehabs In-Network Family Physician / Specialist Out-of-Network Family Physician / Specialist Out-of-Network-All Other Locations Skilled Nursing Facility BPM In-Network Out-of-Network Acupuncture (Cover up to 28 visits per CYM) In-Network Out-of-Network Bariatric Surgery Removal of Impacted Wisdom Teeth Advanced Imaging Services in Physician's Office In-Network Family Physician In-Network Specialist Out-of-Network Birthing Center In-Network Out-of-Network Durable Medical Equipment, Prosthetics, Orthotics BPM In-Network Out-of-Network Enteral Formulas In-Network Out-of-Network Home Health Care BPM In-Network Out-of-Network Hospice (In-Patient, Out-Patient & Home) In-Network Out-of-Network Outpatient Therapy (PT, OT, ST, Cardiac and Spinal Manipulations) Cost Sharing Maximums shown are Per Benefit Period (BPM) unless noted Medical Benefit Summaries Florida Blue 15 Dental/Vision Rates Dental Plans Managed Care Elite Preferred 605 PPO (DHMO) Plan C150 Dental Plan Coverage 20 pay periods 20 pay periods Employee$11.32 $12.38 Employee + 1 Employee & family $21.28 $29.33 $24.61 $36.62 Vison Plan Coverage20 pay periods Employee$2.99 Employee + 1$5.98 Employee + 2$8.97 Employee + 3$11.96 Employee + 4 or more $14.95 16 Dental Plan Summary Save Money with Elite Preferred 605. Because we specialize in dental, we can bring you benefits and service that other companies can’t match! Quick Claims Turnaround CompBenefits’ state of the art claims center provides fast reimbursement of your claims. Access To Information Our toll-free customer service number at 1-(800)-342-5209 has Member Services Representatives who can provide the answers you need quickly and thoroughly. Total Freedom Of Choice The plan provides you with total freedom of choice by allowing you to use any licensed dentist for treatment. The plan reimburses a percentage of eligible expenses based on the plan you have chosen. Any way you add it up, CompBenefits really is the benefits company of choice! MAJOR RESTORATIVE LIMITATIONS The charges for Major Restorative services will be Covered Dental Expenses subject to the following: 1. the denture or partial denture must replace a Natural Tooth extracted while insured for Dental Benefits under this policy; 2. the fixed bridge (including a resin bonded fixed bridge) must replace a Natural Tooth extracted while insured for Dental Benefits under this policy; 3. the replacement of a partial denture, full denture, or fixed partial denture (including a resin bonded bridge), or the addition of teeth to a partial denture if: (a) replacement occurs at least five years after the initial date of insertion of the current full or partial denture or resin bonded bridge; (b) replacement occurs at least five years after the initial date of insertion of an existing implant or fixed bridge; (c) replacement prosthesis or the addition of a tooth to a partial denture is required by the necessary extraction of a Functioning Natural Tooth while insured for Dental Benefits under this policy; or (d) replacement is made necessary by a Covered Dental Injury to a partial denture, full denture, or fixed partial denture (including a resin bonded bridge) provided the replacement is completed within 12 months of the injury; 4. the replacement of crowns, cast restorations, inlays, onlays or other laboratory prepared restorations if: (a) replacement occurs at least five years after the initial date of insertion; and (b) they are not serviceable and cannot be restored to function; 5. the replacement of an existing partial denture with fixed bridgework, only if upgrading to fixed bridgework is essential to the correction of the person’s dental condition; and 6. the replacement of teeth up to the normal complement of 32. EXCLUSIONS Benefits will not be paid for: 1. procedures which are not included in the Schedule of Benefits; which are not medically necessary; which do not have uniform professional endorsement; are experimental or investigational in nature; for which the patient has no legal obligation to pay; or for which a charge would not have been made in the absence of insurance; 2. any procedure, service, or supply which may not reasonably be expected to successfully correct the patient’s dental condition for a period of at least three years, as determined by CompBenefits Insurance Company; 3. crowns, inlays, cast restorations, or other laboratory prepared restorations on teeth which may be restored with an amalgam or composite resin filling; CompBenefits Insurance Company Voluntary+ PPO – Ortho 4. appliances, inlays, cast restorations or other laboratory prepared restorations used primarily for the purpose of splinting; 5. any procedure, service, supply or appliance, the sole or primary purpose of which relates to the change or maintenance of vertical dimension; the alteration or restoration of occlusion including occlusal adjustment, bite registration, or bite analysis; 6. pulp caps, adult fluoride treatments, athletic mouthguards; myofunctional therapy; infection control; precision or semi-precision attachments; denture duplication; oral hygiene instruction; separate charges for acid etch; broken appointments; treatment of jaw fractures; orthognathic surgery; completion of claim forms; exams required by third party; personal supplies (e.g. water pik, toothbrush, floss holder, etc.); or replacement of lost or stolen appliances; 7. charges for travel time; transportation costs; or professional advice given on the phone; 8. procedures performed by a Dentist who is a member of Your immediate family; 9. any charges, including ancillary charges, made by a hospital,ambulatory surgical center, or similar facility; 10. charges for treatment rendered: (a) in a clinic, dental or medical facility sponsored or maintained by the employer of any member of Your family; or (b) by an employee of the employer of any member of Your family; 11. any procedure, service or supply required directly or indirectly to diagnose or treat a muscular, neural, or skeletal disorder, dysfunction, or disease of the temporomandibular joints or their associated structures; 12. charges for treatment performed outside of the United States other than for emergency treatment. Benefits for emergency treatment which is performed outside of the United States are limited to a maximum of $100 (US dollars) per year; 13. the care or treatment of an injury or sickness due to war or an act of war, declared or undeclared; 14. treatment for cosmetic purposes. Facings on crowns or bridge units on molar teeth will always be considered cosmetic; 15. any services or supplies which do not meet the standards set by the American Dental Association or which are not reasonably necessary, or customarily used, for dental care; 16. procedures that are a covered expense under any other medical plan (established by the employer) which provides group hospital, surgical, or medical benefits whether or not on an insured basis; 17. a sickness for which the patient can receive benefits under a workers’ compensation act or similar law; 18. an injury that arises out of or in the course of a job or employment for pay or profit; 19. charges to the extent that they are more than the Prevailing Fee. If the amount of the Prevailing Fee for a service cannot be determined due to the unusual nature of the service, CompBenefits Insurance Company will determine the amount. CompBenefits Insurance Company will take into account: (a) the complexity involved; (b) the degree of professional skill required; and (c) other pertinent factors; or 20. orthodontic plan benefits for persons 19 years of age or older. PREDETERMININATION If Covered Dental Expenses for a procedure are expected to be more than $200 it is recommended that you send a Dental Treatment Plan in prior to beginning treatment, send preauthorization to CompBenefits, P.O. Box 8236 Chicago, IL 60680–8236. You and/or your dentist will be notified of the benefits payable based upon the Dental Treatment Plan. This brochure contains a brief description of the plan. A complete description of the coverage, including limitations on certain procedures is found in the Schedule of Benefits and Certificate of Group Dental Insurance. 17 Dental Plan Summary CompBenefits Insurance Company Voluntary+ PPO – Ortho Summary of Benefits In Network Reimbursements Out-of- Network Reimbursements Type I Diagnostic & Preventive Oral Examination (once per six months) Prophylaxis (cleaning, once per six months) Topical Fluoride (children under 16, once per 12 months X-Rays (limitations may apply) Sealants (once per 3 years for children under age 16, for non carious molars only) Partial Listing of Covered Services* 100% No Deductible 75% Type II Basic Services Simple Restorative (amalgam, synthetic, or composite fillings) Space Maintainers (for children under age 16) Non-Surgical Tooth Extractions Non-Surgical Periodontics 75% After Deductible 50% After Deductible Type III Major Services (12 month waiting period**) Major Restorative (crowns/inlays/onlays) Bridge, Denture Repair Prosthetics (bridges and dentures) Emergency Palliative Treatment Endodontics (root canals) Surgical Tooth Extractions Surgical Periodontics 50% After Deductible 25% After Deductible Group’s plan may include Orthodontics Coverage for an additional fee. Not all plans have Type IV coverage. Type IV Orthodontics (Optional) (12 month waiting period**) Dependent children 18 years of age or younger MAXIMUM BENEFITS Insured Individual and Dependents Lifetime Type I, II and III Type IV Calendar Year Type I, II and III Type IV Deductible*** Type I Type II, III and IV 50% 50% Unlimited Unlimited $1,000 $1,000 $1,500 $1,500 $500 $500 None $50 None $50 *Coverage based on contracted fees for the Preferred Provider Network. **Time served on the employer’s immediately preceding group dental plan may be credited towards this plan’s waiting periods, subject to Underwriting approval. ***Maximum of 3 per family. 18 Dental Plan Summary 150 CompBenefits InsuranceC Company Voluntary+ PPO – Ortho CompBenefits Family of Companies schedule of benefits and subscriber copayments ADA CODE PROCEDURE PATIENT PAYS ADA CODE PROCEDURE APPOINTMENTS PREVENTIVE CARE (cont.) 9310 1510 9430 9440 9999 9999 Consultation (diagnostic service provided by dentist other than practitioner providing treatment) ................$15.00 Office Visit (normal hours) ..........................$5.00 Office Visit (after regularly scheduled hours) ....................................$35.00 Emergency visit during regularly scheduled hours, by report .......................$20.00 Broken appointments (without 24 hr notice, per 15 min) Maximum $40 per broken appointment. No charge will be made due to emergencies ................................$10.00 DIAGNOSTIC 120 Periodic oral evaluation ..................NO CHARGE 140/150/160 Limited/Comprehensive oral evaluation ..............................NO CHARGE 180 Comprehensive periodontal evaluation .............................................$10.00 210 X-Ray Intraoral - complete series including bitewings ........................NO CHARGE 220 X-Ray Intraoral - periapical first film ........................................NO CHARGE 230 X-Ray Intraoral - periapical each additional film .......................NO CHARGE 270 X-Ray Bitewing single film .....................................NO CHARGE 272 X-Ray Bitewings two films ......................................NO CHARGE 274 Bitewings - four films .......................NO CHARGE 330 Panoramic film ..............................NO CHARGE 460 Pulp vitality tests .............................NO CHARGE 470 Diagnostic casts .............................NO CHARGE PREVENTIVE CARE 1110/1120 Prophylaxis-adult/child-routine (once every 6 months) ....................NO CHARGE 1110/1120 Prophylaxis-adult/child- (additional) ...........$20.00 1201 Topical application of fluoride (including prophylaxis) child (up to 16 years of age) ..................NO CHARGE 1203 Topical application of fluoride (not including prophylaxis) child (up to 16 years of age) ..................NO CHARGE 1330 Oral hygiene instruction ..................NO CHARGE 1351 Sealant - per tooth ..................................$10.00 C150 03/03 005C1504 1515 1520 1525 1550 PATIENT PAYS Space Maintainer - fixed unilateral .....................................$45.00 + LAB Space Maintainer - fixed bilateral ......................................$45.00 + LAB Space Maintainer - removable unilateral .....................................$85.00 + LAB Space Maintainer - removable bilateral ......................................$85.00 + LAB Recementation of space maintainer ...........$10.00 RESTORATIVE 2140 2150 2160 2161 2940 2999 Amalgam - one surface, primary or permanent .....................NO CHARGE Amalgam - two surfaces, primary or permanent .....................NO CHARGE Amalgam - three surfaces, primary or permanent .....................NO CHARGE Amalgam - four or more surfaces, primary or permanent .....................NO CHARGE Sedative filling .......................................$15.00 Sedative base (under fillings), by report ......................................NO CHARGE RESIN RESTORATION 2330 2331 2332 2391 2392 2393 2394 2510 2520 2530 Resin - one surface, anterior .....................$35.00 Resin - two surfaces, anterior ....................$40.00 Resin - three surfaces, anterior ..................$50.00 Resin - based composite one surface, posterior .............................$60.00 Resin - based composite two surfaces, posterior ............................$80.00 Resin - based composite three surfaces, posterior .........................$100.00 Resin - based composite four or more surfaces, posterior ...............$120.00 Inlay - metallic - one surface .....................$95.00 Inlay - metallic - two surfaces ..................$105.00 Inlay - metallic - three or more surfaces ......................................$130.00 CROWN & BRIDGE 2740 2750* 2751 2752* Crown - porcelain/ceramic substrate ...$280 + LAB Crown - porcelain fused to high noble metal ..................................$280.00 Crown - porcelain fused to predominantly base metal ......................$280.00 Crown - porcelain fused to noble metal .........................................$280.00 Current Dental Terminology © 2004 American Dental Association. All rights reserved. 19 Dental Plan Summary C 150 CompBenefits Insurance Company Voluntary+ PPO – Ortho CompBenefits Family of Companies schedule of benefits and subscriber copayments ADA CODE PROCEDURE PATIENT PAYS ADA CODE CROWN & BRIDGE (cont.) PROSTHODONTICS 2790* 2791 5110 5120 5130 5140 5211 2792* 2910 2920 2930 2950 2951 2952 2953 2954 2962 Crown - full cast high noble metal ...........$280.00 Crown - full cast predominantly base metal ..........................................$280.00 Crown - full cast noble metal ..................$280.00 Recement inlay ......................................$15.00 Recement crown ....................................$15.00 Prefabricated stainless steel crown primary tooth .........................................$75.00 Core buildup, including any pins ..............$45.00 Pin retention - per tooth ...........................$15.00 Cast post and core in addition to crown .....................................$90.00 + LAB Each additional cast post same tooth ...................................$90.00 + LAB Prefabricated post and core in addition to crown ..................................$90.00 Labial veneer (porcelain laminate) laboratory ......................................$280 + LAB 5212 5213 5214 5410 5411 5421 5422 REPAIRS TO PROSTHETICS 3220 3221 5510 3320 3330 3410 Therapeutic pulpotomy ............................$35.00 Pulpal debridement, primary and permanent teeth ...................................$100.00 Root canal therapy - anterior (excluding final restoration) .....................$100.00 Root canal therapy - bicuspid (excluding final restoration) .....................$200.00 Root canal therapy - molar (excluding final restoration) .....................$250.00 Apicoectomy/periradicular surgery anterior ..............................................$125.00 5520 5610 5630 5640 5650 5730 5731 PERIODONTICS (Gum treatment) 4210 4211 4341 4342 4355 4381 4910 Gingivectomy/gingivoplasty 4+ teeth per quad ...............................$125.00 Gingivectomy/gingivoplasty 1-3 teeth per quad .................................$40.00 Periodontal scaling and root planing 4+ teeth per quad .................................$50.00 Periodontal scaling and root planing 1-3 teeth per quad .................................$50.00 Full mouth debridement to enable eval and diagnosis .................................$45.00 Localized delivery of chemotherapeutic agents (per tooth) ...................................$45.00 Periodontal maintenance .........................$50.00 C150 03/03 005C1504 5740 5741 5750 5751 5760 5761 5850 5851 PATIENT PAYS Complete denture - maxillary .........$300.00 + LAB Complete denture - mandibular ......$300.00 + LAB Immediate denture - maxillary ........$300.00 + LAB Immediate denture - mandibular .....$300.00 + LAB Maxillary partial denture resin base .................................$300.00 + LAB Mandibular partial denture resin base .................................$300.00 + LAB Maxillary partial denture cast metal framework, resin denture bases .....................$300.00 + LAB Mandibular partial denture cast metal framework, resin denture bases .....................$300.00 + LAB Adjust complete denture - maxillary ...........$15.00 Adjust complete denture - mandibular ........$15.00 Adjust partial denture - maxillary ...............$15.00 Adjust partial denture - mandibular ............$15.00 ENDODONTICS 3310 20 PROCEDURE Repair broken complete denture base ................................$15.00 + LAB Replace missing or broken teeth complete denture (each tooth) .........$15.00 + LAB Repair resin denture base ...............$15.00 + LAB Repair or replace broken clasp ........$15.00 + LAB Replace broken teeth - per tooth ......$15.00 + LAB Add tooth to existing partial denture ..............................$30.00 + LAB Reline complete maxillary denture (chairside) .............................................$50.00 Reline complete mandibular denture (chairside) .............................................$50.00 Reline maxillary partial denture (chairside) .............................................$50.00 Reline mandibular partial denture (chairside) .............................................$50.00 Reline complete maxillary denture (laboratory) ..................................$35.00 + LAB Reline complete mandibular denture (laboratory) ..................................$35.00 + LAB Reline maxillary partial denture (laboratory) ..................................$35.00 + LAB Reline mandibular partial denture (laboratory) ..................................$35.00 + LAB Tissue conditioning - maxillary ..................$30.00 Tissue conditioning - mandibular ...............$30.00 Current Dental Terminology © 2004 American Dental Association. All rights reserved. Dental Plan Summary C 150 CompBenefits Insurance Company Voluntary+ PPO – Ortho CompBenefits Family of Companies schedule of benefits and subscriber copayments ADA CODE PROCEDURE PATIENT PAYS ADA CODE PROCEDURE PROSTHODONTICS (Fixed) ADJUNCTIVE GENERAL SERVICES 6210* 6211 6212* 6240* 9215 9230 6241 6242* 6750* 6751 6752* 6790* 6791 6792* 6930 Pontic - cast high noble metal .................$280.00 Pontic - cast predominantly base metal .....$280.00 Pontic - cast noble metal ........................$280.00 Pontic - porcelain fused to high noble metal ..................................$280.00 Pontic - porcelain fused to predominantly base metal ......................$280.00 Pontic - porcelain fused to noble metal .........................................$280.00 Crown - porcelain fused to high noble metal ..................................$280.00 Crown - porcelain fused to predominantly base metal ......................$280.00 Crown - porcelain fused to noble metal .........................................$280.00 Crown - full cast high noble metal ...........$280.00 Crown - full cast predominantly base metal ..........................................$280.00 Crown - full cast noble metal ..................$280.00 Recement fixed partial denture (per unit) .....$10.00 EXTRACTIONS/ORAL AND MAXILLOFACIAL SURGERY 7111 7140 7210 7220 7230 7240 7250 7310 7311 7320 7321 7510 Coronal remnants, deciduous tooth ...NO CHARGE Extraction, erupted tooth or exposed root .................................NO CHARGE Surgical removal of erupted tooth ..............$40.00 Removal of impacted tooth - soft tissue .......$50.00 Removal of impacted tooth partially bony ........................................$70.00 Removal of impacted tooth completely bony ....................................$85.00 Surgical removal of residual tooth roots ......$35.00 Alveoloplasty in conjunction with extractions - per quadrant ........................$35.00 Alveoplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant .......................$35.00 Alveoloplasty not in conjunction with extractions - per quadrant ..................$70.00 Alveoplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant .......................$70.00 Incision and drainage of abscess intraoral ...............................................$25.00 C150 03/03 005C1504 9450 9951 9952 PATIENT PAYS Local anesthesia ............................NO CHARGE Analgesia (nitrous oxide per 15 minutes) .....................................$15.00 Case presentation, detailed and extensive treatment planning ............NO CHARGE Occlusal adjustment - limited ....................$25.00 Occlusal adjustment - complete ...............$150.00 * THE ABOVE COPAYMENTS DO NOT INCLUDE THE ADDITIONAL COST OF PRECIOUS (HIGH NOBLE) AND SEMI-PRECIOUS (NOBLE) METAL. THE ADDITIONAL COST OF PRECIOUS METAL SHALL NOT EXCEED $125 PER UNIT AND $75 PER UNIT FOR SEMI-PRECIOUS METAL. NOTE: 1. NOT ALL PARTICIPATING DENTISTS PERFORM ALL LISTED PROCEDURES, INCLUDING AMALGAMS. PLEASE CONSULT YOUR DENTIST PRIOR TO TREATMENT FOR AVAILABILITY OF SERVICES. 2. UNLISTED PROCEDURES ARE AT THE DENTIST’S USUAL FEE LESS 25%. 3. WHEN CROWN AND/OR BRIDGEWORK EXCEEDS SIX UNITS IN THE SAME TREATMENT PLAN, THE PATIENT MAY BE CHARGED AN ADDITIONAL $50.00 PER UNIT. SPECIALIST SERVICES Should you need a specialist, (i.e., Endodontist, Orthodontist, Oral Surgeon, Periodontist, Pediatric Dentist), you may be referred by your Participating General Dentist, or you may refer yourself to any Participating Specialist. Upon identification of yourself as a CompBenefits member, you will receive a 25% reduction from usual and customary fees for services performed. Specialist services are available only in areas where the dental plan has a Participating Specialist. Current Dental Terminology © 2004 American Dental Association. All rights reserved. 21 Dental Plan Summary 150 CompBenefits InsuranceC Company Voluntary+ PPO – Ortho CompBenefits Family of Companies schedule of benefits and subscriber copayments LIMITATIONS AND EXCLUSIONS 1. 2. 3. No service of any dentist other than a Participating General Dentist or Participating Specialist will be covered by Company, except out-of-area emergency care as provided in Section VIII, Paragraph C of the Certificate. Whenever any Contributions or Copayments are delinquent, Member will not be entitled to receive Benefits, transfer Dental Facilities, or enjoy any of the other privileges of a Member in good standing. Company does not provide coverage for the following services: a) Cost of hospitalization and pharmaceuticals, drugs or medications. b) Services which in the opinion of the Participating General Dentist or Participating Specialist are not Necessary Treatment to establish and/or maintain the Member’s oral health. CompBenefits CompBenefits Company CompBenefits Insurance Company CompBenefits of Georgia, Inc. 22 C150 03/03 005C1504 c) Any service that is not consistent with the normal and/or usual services provided by the Participating General Dentist or Participating Specialist or which in the opinion of the Participating General Dentist or Participating Specialist would endanger the health of the Member. d) Any service or procedure which the Participating General Dentist or Participating Specialist is unable to perform because of the general health or physical limitations of the Member. e) Any dental treatment started prior to the Member’s effective date for eligibility of benefits. f) Services for injuries and conditions which are paid or payable under Workers’ Compensation or Employers’ Liability laws. g) Treatment for cysts, neoplasms and malignancies. h) General anesthesia. CompBenefits Dental, Inc. CompBenefits of Alabama, Inc. American Dental Plan of North Carolina, Inc. Current Dental Terminology © 2004 American Dental Association. All rights reserved. Dental Plan Summary Insurance Company Dental PlansCompBenefits Voluntary+ PPO – Ortho Foranupdatedlistofproviders,pleaseregisteratmycompbenefits.comorcallmemberservicesat1-800-342-5209formoreinformation. PPO Provider Directory GENERAL DENTISTS MONROE COUNTY ISLAMORADA Jeffers, Janis, DMD PA 81990OverseasHwy 33040(305)664-4282 KEY WEST Backer,Abraham 802TrumanAve 33040(305)293-1660 #183699 Ong, DMD, James N KeyWestDentalAssociates 3146NorthsideDrSte101 33040-8014(305)293-9490 #193826 Lindner, DMD, George W Old Town Dental Group, PA 1215SimontonSt 33040-3158(305)296-8541 Weith,CarolC,DDS 1010KennedyDr.Ste.307 33040-4134(305)292-6422 MARATHON #31507 Buitrago,DDS,JuanC SmilePlusoftheKeys 11399OverseasHwy 33050-3403(305)743-0401 #31507 Gil,DDS,Lester SmilePlusoftheKeys 11399OverseasHwy 33050-3403(305)743-0401 Rangel,DeniseV. (Pedodontist) 9713OverseasHwy 33050(305)743-4670 Tinsley,LeanneK,DMD 2901OverseasHwySte.2 33050-2235(305)289-8915 KEY LARGO #452702 Gonzalez,DDS,MariaF Tooth Place 99105OverseasHwy 33037-4254(305)451-2616 Hayes, Norys, DMD 103400OverseasHwy.Ste.234 33037-2849(305)453-9105 #191312 Bennett,DMD,TravisW Everyone Loves a Gentle Dentis 102965OverseasHwy 33037-4690(305)451-2616 Lesperance,DDS,Lawrence Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 Azar,Francisco Gomara, Luis Salcines,Damaris Martinez, Milton Blanco,Diana Davis,Stephanie DeVera,Vanessa Jaramillo, Gabriel Delgado, Ligming Saladriga,Lisa Valdes,Marylin Shayan,Maria Cruz,Karen Morgado, Aracello Knopf,Kenneth 100750OverseasHwy 33037(305)460-7060 Rodriguez,DMD,AdrianaM Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 Soleymani,DMD,Kameran Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 Ruiz,DMD,Eliseo Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 Chiu,DDS,GordonB Dental Associates of Homestead 925NE30thTerSte118 33033-7614(305)247-0910 #3920 Plasky,DDS,PaulE. KeyLargoDentalAssociates 99198OverseasHwySte12 33037-2437(305)451-3204 Vazquez,DMD,JorgeE Dental Associates of Homestead 925NE30thTerSte118 33033-7614(305)247-0910 SUMMERLAND KEY #995507 TycolizJr.,DDS,WilliamL. SummerlandDental 24986OverseasHwy 33042(305)745-1522 Silvestry,DDS,Elvin Dental Associates of Homestead 925NE30thTerSte118 33033-7614(305)247-0910 Sander,Michael (orthodonticonly) SummerlandDental 24986OverseasHwy 33042(305)745-1522 #17655 GarciaCastellos,DMD,Jacqueline Dental Associates of Homestead 925NE30thTerSte118 33033-7614(305)247-0910 TAVERNIER Green,Anne,DDS 91555OverseasHwy 33070(305)735-4218 #17655 Guilarte,DMD,RhonaE Dental Associates of Homestead 925NE30thTerSte118 33033-7614(305)247-0910 MIAMI-DADE HOMESTEAD Chiu,DDS,GordonB Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 #17655 Gurreonero,DMD,CarlosJ Dental Associates of Homestead 925NE30thTerSte118 33033-7614(305)247-0910 Silvestry,DDS,Elvin Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 #17655 Lesperance,DDS,Lawrence Dental Associates of Homestead 925NE30thTerSte118 33033-7614(305)247-0910 Rodriguez,DMD,EstebanJ Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 #17655 Rodriguez,DMD,EstebanJ Dental Associates of Homestead 925NE30thTerSte118 33033-7614(305)247-0910 Felipe,DMD,Veronica Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 #17655 Landa, DMD, Jorge E Dental Associates of Homestead 925NE30thTerSte118 33033-7614(305)247-0910 #183574 Sanchez,DDS,ZoraidaT Sanchez,DDS,PA,ZoraidaT. 1619NE8thSt 33033-4603(305)247-9292 #995548 Muro Jr., DMD, Thomas Muro Jr., DMD, PA, Thomas 311NE8thStSte204AB 33030-4738(305)242-5336 #183953 Azar,DDS,FranciscoJ Family&CosmeticDentistry 125NE8thStSte1 33030-4676(786)243-2438 #183953 Gomara, DMD, Luis A Family&CosmeticDentistry 125NE8thStSte1 33030-4676(786)243-2438 #183953 Salcines,DMD,DamarisG Family&CosmeticDentistry 125NE8thStSte1 33030-4676(786)243-2438 #29103 Paz,DDS,LidiaM Paz,DDS,LidiaM 950NKromeAve 33030-4400(305)247-5264 #25848 Gil,DDS,Lester SmilePlus 963NKromeAve Homestead,FL33030-4408 (305)247-5161 #191452 Buitrago,DDS,JuanC SmilePlus 963NKromeAve 33030-4408(305)247-5161 #183887 Puente,DMD,Katia The Tooth Place 8PalmPlz 33030-6046(305)245-7974 # 426413 Buitrago,DDS,JuanC Tooth Place 8PalmPlz 33030-6046(305)245-7974 * Not accepting new patients. 13 23 www.myFBMC.com Dental Plan Summary Insurance Company Dental PlansCompBenefits Voluntary+ PPO – Ortho # 426413 Saenz,DDS,ReginaH Tooth Place 8PalmPlz 33030-6046(305)245-7974 # 426413 Gonzalez,DDS,MariaF Tooth Place 8PalmPlz 33030-6046(305)245-7974 # 426413 Barrera,DDS,MarthaE Tooth Place 8PalmPlz 33030-6046(305)245-7974 #5079 Rosen,DDS,HowardB. Rosen,DDS,Howard 30NW15thSt 33030-4262(305)245-9691 #183888 Molina,DDS,RolandoJ. Molina,DDS,PA,RolandoJ. 45NW8thStSte101 33030-4452(305)242-5223 #995577 Senk,DDS,GaryP* Senk,DDS,PA,GaryP.* 381NKromeAveSte209 33030-6047(305)247-2143 # 32343 Chakalov,DMD,BoyanB Homestead Dental Inc 83NW8thSt 33030-4404(305)248-0027 FLORIDA CITY #994658 Estrada,DDS,Javier TheFamilyDentalCareInc 646WPalmDrSte200 33034-3210(305)242-1200 #994658 DeLacruz,DDS,Alejandro TheFamilyDentalCareInc 646WPalmDrSte200 33034-3210(305)242-1200 #994658 GonzalezRubio,DMD,Eduardo TheFamilyDentalCareInc 646WPalmDrSte200 33034-3210(305)242-1200 * Not accepting new patients. 24 www.myFBMC.com Managed Care Provider Directory GENERAL DENTISTS MONROE COUNTY KEY LARGO #3920 Plasky,DDS,PaulE. KeyLargoDentalAssociates 99198OverseasHwySte12 33037-2437(305)451-3204 Hayes, Norys, DMD 103400OverseasHwy.Ste.234 33037-2849(305)453-9105 Azar,Francisco Gomara, Luis Salcines,Damaris Martinez, Milton Blanco,Diana Davis,Stephanie DeVera,Vanessa Jaramillo, Gabriel Delgado, Ligming Saladriga,Lisa Valdes,Marylin Shayan,Maria Cruz,Karen Morgado, Aracello Knopf,Kenneth 100750OverseasHwy 33037(305)460-7060 Dieudonne,DDS,Stephanie SouthDadeFamilyDentistry 18435SDixieHwy 33157-6815(305)259-9130 Kablawi,DMD,FadiM Kablawi,DMD,FadiY 27501SDixieHwySte300 33032-8219(305)245-7733 Nguyen, DMD, Diep H SouthDadeFamilyDentistry 18435SDixieHwy 33157-6815(305)259-9130 Azar,DDS,FranciscoJ Family&CosmeticDentistry 125NE8thStSte1 33030-4676(786)243-2438 Gonzalez-Zamora,DDS,Maria SouthDadeFamilyDentistry 18435SDixieHwy 33157-6815(305)259-9130 Gomara, DMD, Luis A Family&CosmeticDentistry 125NE8thStSte1 33030-4676(786)243-2438 Mendoza,DDS,Irenia SouthDadeFamilyDentistry 18435SDixieHwy 33157-6815(305)259-9130 Salcines,DMD,DamarisG Family&CosmeticDentistry 125NE8thStSte1 33030-4676(786)243-2438 HOMESTEAD Chiu,DDS,GordonB Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 Vazquez,DMD,GeorgeA GeorgeAVazquezDMD 127NE8thSt 33030-4607(305)245-0306 Vazquez,DMD,JorgeE Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 KEY WEST #183699 Ong, DMD, James N KeyWestDentalAssociates 3146NorthsideDrSte101 33040-8014(305)293-9490 Silvestry,DDS,Elvin Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 Rodriguez,DMD,EstebanJ Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 Stone,Ira (oralsurgeon) 3146NorthsideDr.#B 33040(305)294-4661 Felipe,DMD,Veronica Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 SUMMERLAND KEY #995507 TycolizJr.,DDS,WilliamL. SummerlandDental 24986OverseasHwy 33042(305)745-1522 Lesperance,DDS,Lawrence Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 Sander,Michael (orthodonticonly) SummerlandDental 24986OverseasHwy 33042(305)745-1522 MARATHON Rangel,DeniseV. (Pedodontist) 9713OverseasHwy 33050(305)743-4670 MIAMI-DADE CUTLER BAY Alvarez,DMD,NolyrisK SouthDadeFamilyDentistry 18435SDixieHwy 33157-6815(305)259-9130 Buitrago,DDS,JuanC SmilePlus 963NKromeAve 33030-4408(305)247-5161 Gil,DDS,LesterO SmilePlus 963NKromeAve 33030-4408(305)247-5161 Puente,DMD,Katia The Tooth Place 8PalmPlz 33030-6046(305)245-7974 Rosen,DDS,HowardB. Rosen,DDS,Howard 30NW15thSt 33030-4262(305)245-9691 Molina,DDS,RolandoJ. Molina,DDS,PA,RolandoJ. 45NW8thStSte101 33030-4452(305)242-5223 Rodriguez,DMD,AdrianaM Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 FLORIDA CITY Estrada,DDS,Javier TheFamilyDentalCareInc 646WPalmDrSte200 33034-3210(305)242-1200 Soleymani,DMD,Kameran Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 DeLacruz,DDS,Alejandro TheFamilyDentalCareInc 646WPalmDrSte200 33034-3210(305)242-1200 Ruiz,DMD,Eliseo Dental Assoc. of Homestead Inc 925NE30thTerSte118 33033-7614(305)247-0910 GonzalezRubio,DMD,Eduardo TheFamilyDentalCareInc 646WPalmDrSte200 33034-3210(305)242-1200 * Not accepting new patients. 14 Vision Plan HumanaVision HumanaVision Florida Vision Care Plan Monroe County School Board See a participating provider See a nonparticipating provider Exam with dilation as necessary Lenses 100% after $10 copay $35 allowance • Single • Bifocal • Trifocal 100% after $15 copay 100% after $15 copay 100% after $15 copay $25 allowance $40 allowance $60 allowance Frames Contact lenses2 $35 wholesale allowance $45 retail allowance $100 allowance 100% $100 allowance $210 allowance Once every 12 months Once every 12 months Once every 24 months Once every 12 months Once every 12 months Once every 24 months 1 3 • Elective (conventional and disposable) 4 • Medically necessary (limit one pair) Frequency (based on date of service) • Examination • Lenses or contact lenses • Frame Additional plan discounts • Members may benefit with fixed pricing for most lens options including anti-reflective and scratch-resistant coatings. • Members may also be eligible to receive up to a 20 percent retail discount on a second pair of eyeglasses, which is available for 12 months after the covered eye exam through the participating provider who sold the initial pair of eyeglasses. • After copay, standard polycarbonate available at no charge for dependents less than 19 years old. 1 2 3 4 Material copay is required for a complete pair of eyeglasses, lenses or frames. If a member prefers contact lenses, the plan provides an allowance for contacts in lieu of all other benefits (including frames) (Vision Care Plan only). The contact lens allowance applies to professional services (evaluation and fitting fee) and materials. Members may be eligible to receive up to a 15 percent discount on in-network professional services, which is available for 12 months after the covered eye exam. Benefit provides coverage for professional services and one pair of medically necessary contact lenses with prior plan authorization. 25 Vision Plan HumanaVision Vision Care Plan HumanaVision Lasik discount We have contracted with many well-known facilities and eye doctors to offer Lasik procedures at substantially reduced fees. You can take advantage of these low fees when procedures are done by network providers. The network locations listed below offer the following prices (per eye): Conventional / Traditional** Custom** TLC 888-358-3937 (designated locations only) LasikPlus 866-757-8082 QualSight LASIK 855-456-2020 $895 $695* LasikPlus free enhancements for 1 year $1,395* LasikPlus free enhancements for life $895 QualSight free enhancements for 1 year $1,295 with QualSight Lifetime Assurance Plan $1,295 $1,895* $1,895* LasikPlus free enhancements for life You may receive a 10% discount from retail prices at certain independent Lasik participating providers and pay no more than $1,800 per eye for Conventional Lasik and $2,300 per eye for Custom Lasik. $1,995* with QualSight Lifetime Assurance Plan $1,320 *with IntraLaseTM **Pricing varies by section procedure offered by the provider you choose and options in your area. Not all locations offer fixed pricing. Please call the provider for details How does the wholesale frame allowance work? Benefits include a wholesale frame allowance. If the wholesale cost exceeds the frame allowance, members pay twice the wholesale difference. They never pay full retail. Retail price* Wholesale price Wholesale allowance Member pays Savings $125 $50 $50 $0 $125 $187.50 $75 $50 $50 ($75-$50=$25x2=$50) $137.50 * Retail costs may differ and are based on 2½ times the wholesale cost. Actual savings may vary. Use your HumanaVision benefits How it Works HumanaVision options have you covered and make eye care affordable. You have access to one of the largest vision networks in the United States, with more than 35,000 participating optometrist, ophthalmologists, and national retail locations, including LensCrafters®, Pearle Vision®, Sears® Optical, Target® Optical, and JCPenney® Optical. In addition you’ll enjoy: 1. After signing up for your vision plan, you will receive an ID card in the mail 2. Prior to scheduling your appointment, select a network provider through the Customer Care Center, automated information line, or www.HumanaVisionCare.com HumanaVisionCare.com 3. Schedule an appointment, providing your name, the patient’s name and employer 4. Sign your provider’s form after your exam, you’ll pay any copayments and/or costs of any upgrades at this time • The same benefits at all participating providers, no matter where they’re located • Wholesale pricing on frames, avoiding high retail markups • Simple access to plan information, provider search, Customer Care and other automated services at HumanaVisionCare.com www.HumanaVisionCare.com JCPenney Optical ® 26 Vision Plan HumanaVision Know what your plan covers Attached is a summary of HumanaVision benefits that are described in detail in your certificate. You can www.HumanaVisionCare.com or call find your certificate on HumanaVisionCare.com 1-866-537-0229. Here’s what you can expect: • Quality routine eye health care from independent eye care professionals and national retail locations. • Services and materials provided on a prepaid basis, and the plan pays in-network providers directly, you also have the freedom to use out-of-network providers if you prefer • Life without claim forms! With HumanaVision, you pay your eye care professional directly for copayments and any extra cosmetic options selected at the time of service • Select a vision provider from our network simply by visiting www.HumanaVisionCare.com HumanaVisionCare.com, if you prefer, call us at 1-866-537-0229 Vision health impacts overall health Routine eye exams can lead to early detection of vision problems and other diseases such as diabetes, hypertension, multiple sclerosis, high blood pressure, osteoporosis, and rheumatoid arthritis.1 Know what your plan doesn’t cover Some items and services not included in HumanaVision are: • Orthoptics or vision training, subnormal vision aids or Plano (non-prescription) lenses • Replacement of lost or broken lenses, except at the regularly-scheduled plan intervals • Medical or surgical treatment of eyes • Care provided through or required by any government agency or program, including Workers’ Compensation or a similar law 1 Thompson Media Inc. This is not a complete disclosure of plan qualifications and limitations. Check with your local Humana or HumanaDental sales office to verify product availability. Insured by Humana Insurance Company or CompBenefits Insurance Company or CompBenefits Company 27 Group Term Life Insurance Minnesota Life Monroe County District School Board Welcome to Minnesota Life - Administered by Ochs, Inc. Monroe County District School Board is pleased to introduce Minnesota Life as the new Group Life Insurance carrier, effective January 1, 2015. ONE-TIME OPPORTUNITY Nov. 12 - Dec. 5, 2014 All basic and supplemental life will be carried over to Minnesota Life. NEW - SPOUSE AND CHILD LIFE Benefit eligible employees now have a chance to purchase additional Spouse Term Life and Child Life through a Supplemental Term Life Program. This Program gives employees and their families a way to keep their life insurance coverage in line with their changing needs. Review your benefit plan options below and find the excellent rates, enhanced plan features and value-added services on the reverse side. GUARANTEED ISSUE (GI) OPPORTUNITY For a limited time, employees can enroll for up to $100,000 of Supplemental Life; up to $25,000 of Spouse Life; and $10,000 of Child Life - no health questions asked. Take advantage of this special opportunity because enrolling at any other time will require proof of good health. Guaranteed coverage elections will be effective January 1, 2015. No Health Questions Employees - elect up to $100,000* Spouses - elect up to $25,000 Children - elect $10,000 *GI limit includes amounts currently in force. Amounts greater than the GI limit require evidence of insurability. Your plan at a glance Coverage Basic Term Life Employer Paid Amount Additional Information Amount varies according to job classification (ask your employer or see certificate for details) All coverage is Guaranteed - no health questions Includes a matching AD&D benefit Age reductions apply beginning at age 65 or 70 depending on job classification (ask your employer or see certificate for details) Supplemental Term Life $10,000 increments Employee Paid Maximum $300,000 Spouse Term Life Employee Paid Child Term Life Employee Paid 28 $5,000 increments Maximum $150,000 (not to Up to $100,000 is Guaranteed - no health questions (GI limit includes amounts currently in force) Includes a matching AD&D benefit Elections greater than $100,000 require evidence of insurability ceed 100% of employee total basic and supplemental coverage amount) ex- $10,000 14 days to 6 months receive a $1,000 benefit Up to $25,000 is Guaranteed - no health questions Includes a matching AD&D benefit A spouse is not eligible, if also eligible as an employee Elections greater than $25,000 required evidence of insurability All coverage is Guaranteed - no health questions Covers all eligible children from 14 days to 26 years A child may only be covered by one parent, if both are employees Group Term Life Insurance Minnesota Life Employee or Spouse Supplemental Life Age Monthly Cost/$1,000 (includes AD&D) Under 25 $0.108 25 -29 $0.108 30 - 34 $0.132 35 - 39 $0.132 40 - 44 $0.204 45 - 49 $0.324 50 - 54 $0.564 55 - 59 $0.924 60 - 64 $1.020 65 - 69 $1.980 70 - 74 $3.588 75* $3.588 Rates increase with age each January 1st. *Additional rates beyond age 75 are available upon request. Child Life - Covers all eligible children Benefit Monthly Cost $10,000 $ 1.60 Plan Features Waiver of Premium - If you become totally disabled your life insurance premiums may be waived. Accelerated Death Benefit - If you become terminally ill with a life expectancy of 12 months or less, you may request early benefit payment of up to 100% of the life insurance amount. Accidental Death and Dismemberment (AD&D) Provides an additional insurance benefit if death results from an accident, or pays a benefit if there is a loss from an injury as defined in the plan. Portability - If you leave or retire, prior to age 70, you may be eligible to take your Term Life coverage with you and pay premiums directly to Minnesota Life. Premiums may be higher than those paid by active employees. Conversion Rights - If you leave employment or retire, you can convert existing coverage to an individual policy. No health questions will be asked at conversion, as long as you apply within 31 days after leaving your job. Premiums will be higher than those paid by active employees. Additional Services Convenient Payroll Deductions Premiums are automatically deducted from your paycheck. No Cost to Access the Following Resources: Travel Assistance - Access to emergency travel assistance service provided by Global Rescue. More information is available at www.lifebenefits.com/travel or by calling 1-855516-5433. Legal Services and Will Preparation - Services provided by Ceridian LifeWorks. Additional information is available at www.lifeworks.com: Username: will, Password: preparation or by calling 1-877-849-6034. Legacy Planning - Final arrangement resources provided by Minnesota Life. More information available online at www.LegacyPlanningResources.com. Beneficiary Financial Counseling - Beneficiaries may choose to use independent beneficiary counseling services from PricewaterhouseCoopers LLP (PwC). Supplemental Life Monthly Premium Calculation Example A 40 year old employee elects $50,000 of Supplemental Term Life Insurance: Coverage elected: Total number of units: Rate per $1,000 (age 40): Rate times # of units: $50,000 $50,000 / 1,000 = 50 $0.204 (from table above) $0.204 x 50 = $10.20 Monthly Cost = $10.20 Complete a Beneficiary Form Your employer is requesting that all benefit eligible employees update their beneficiary designations currently on file. Please complete and turn in the attached beneficiary designation form to your Benefits Office. Take Action - Enroll Now! Be sure to take advantage of this enrollment opportunity. Forms must be turned in to your Benefits Office by December 5, 2014. Questions: Contact your Benefits Office; or call Ochs, Inc. at 1-800-3927295 M-F 9:00 am to 5:30 pm EST; or email your questions to [email protected] [email protected]. A representative is available to help you. Services provided by Ceridian, Global Rescue LLC, and PricewaterhouseCoopers LLP are their sole responsibility. The services are not affiliated with Minnesota Life or its group contracts and may be discontinued at any time. Certain terms, conditions and restrictions may apply when utilizing the services. To learn more, visit the appropriate website. This is a summary of plan provisions related to the insurance policy issued by Minnesota Life to the policyholder. In the event of a conflict between this summary and the policy and/or certificate, the policy and/or certificate shall dictate the insurance provisions, exclusions, all limitations, and terms of coverage. 10-2014 400 Robert Street North Suite 1880 St. Paul, MN 55101 www.ochsinc.com 29 Disability Income Protection Disability Income Protection Cigna Disability A disability can put a lot of things in your life on hold. Unfortunately, expenses aren’t one of those things. They keep right on coming. If you become disabled, this insurance plan can help you keep up by providing a stable monthly income, up to a maximum of $1,500 a month, or 60 percent of your monthly salary, whichever is less. PlanFeatures • Benefitsstartafteryouaredisabledfor90consecutivedays. • For employees working 30 or more hours per week, benefits are payable monthly up to age 65, if you are disabled before age 63. If youbecomedisabledbetweentheagesof63and69,benefitsare payableonadecreasingscale,withamaximumoneyearbenefit periodfordisabilitiesthatcommenceatage69orolder. • Foremployeesworkinglessthan30hoursperweek,benefitsare payable monthly for a maximum period of 5 years if disabled before age63.Ifdisabilityoccursbetweenages63and69,benefitsare payableonadecreasingscalewithamaximumoneyearbenefitat age69orolder. • BenefitscoordinatewithSocialSecurityDisabilityBenefits,orany othergroupbenefits,toensureyoureceiveupto60percentofyour monthly income. • Theminimummonthlybenefitforemployeesworking30ormore hoursperweekis$300permonth.Theminimummonthlybenefitfor employees working less than 30 hours per week is $100 per month. Theminimummonthlybenefitistheminimumamountpayable,once allotherincomebenefitshavebeenapplied. • Premiums are waived while you receive payments under this plan. Mental Illness, Alcoholism, Drug Abuse Limitation You can receive payments for a covered disability which does not require hospitalization that results from mental illness, alcoholism or drugabuseforamaximumof24months.After24months,thebenefit willcontinueonlywhilethedisabledemployeeisconfinedforatleast 14 consecutive days in a hospital licensed to provide care and treatment for the condition causing the disability. WorkIncentiveBenefit Thisbenefitoffersaneffectiveincentiveforemployeeswhoarereadyto return to work, but not full time. If you are covered for work incentive benefits, you may return to work while disabled and your disability benefitswillcontinue. Forthefirst12monthsyoureturntowork,if,foranymonthduring thatperiod,thesumofyourdisabilitybenefit,yourincomefromthe rehabilitativeworkandanyadditionalotherincomebenefitsexceed 100percentofyourindexedcoveredearnings,yourdisabilitybenefit will be reduced by the excess amount. After12months,yourdisabilitybenefitwillbereducedby50percent of your income received during any month of rehabilitative work. If the sumofyourdisabilitybenefit,yourincomefromtherehabilitativework andanyadditionalotherincomebenefitsexceeds80percentofyour earnings,yourdisabilitybenefitwillbereducedbytheexcessamount. 30 CatastrophicDisabilityBenefitRider “CIGNA’sCatastrophicDisabilityBenefitRider”paysanadditional15 percent of your monthly salary, up to a maximum of $2,500 a month, when CIGNA determines that the covered employee’s disability is consideredcatastrophicandisduetothesamesicknessorinjuryfor which long-term disability benefits are payable under the policy.A catastrophic disability is determined by an inability to perform at least two activities of daily living, which include bathing, dressing, continence, toileting, feeding oneself, and the ability to transfer oneself without substantialassistance(e.g.,movefromone’sbedtoawheelchair).This benefitwillnotbereducedbyanyothersourceofincome. Life Assistance Program CIGNA’s LifeAssistance Program offers basic work/life services for “employees and family members,” providing access to in-person behavioral health assistance, telephonic counseling and online tools. The program offers coverage for employees and their families. • Professional counseling from licensed behavioral health providers (includes 24/7 telephonic counseling, and up to 3 free in person sessions). • Life event referrals and research (research and up to 3 qualified referrals within 12 business hours for services, and 30 minute free legalconsultationsformostlegalissues). • HealthyRewards®discountprogram(upto60percentdiscountson healthandwellnessproductsandservices). • Personal Stress Navigator (interactive tool to help evaluate stress sourcesandsymptomsinordertomakeeffectivebehavioralchanges). Eligibility Waiting Period For employees hired after the policy effective date: Thefirstofthemonthfollowing15calendardaysofactiveemployment. Termination of Insurance The insurance on an employee will end on the earliest date below: • the date the employee is eligible for coverage under a plan intended to replace this coverage • the date the policy is terminated • the date the employee is no longer in an eligible class • the day after the period for which premiums are paid • the date the employee is no longer in active service. DisabilityDisability Income Protection Income ProtectionCigna Disability RehabilitationDuringPeriodofDisability A Rehabilitation Plan is a written agreement between you and the insurance company in which the insurance company agrees to provide, arrange or authorize vocational and physical rehabilitation services. The Rehabilitation Plan may, at the insurance company’s discretion, allow for payment of your medical expenses, education expenses, moving expenses, accommodation expenses or family care expenses while you participate in the program. If, while you are disabled, the insurance company determines that you are a suitable candidate for rehabilitation, you may participate in aRehabilitationPlan.Youandtheinsurancecompanymustmutually agreeuponthetermsandconditionsoftheRehabilitationPlan.The insurance company may require that you participate in a rehabilitation assessment with you, your employer, your physician and others, as appropriate, to develop a rehabilitation plan. If you refuse to participate intherehabilitationeffortsdisabilitybenefitswillnotbepayable. SurvivorBenefit If death occurs after the employee has been receiving the monthly benefitsforatleastsixmonths,hisorhereligiblesurvivorwillreceive sixmonthlypayments,nottoexceedatotalbenefitof$1,000. Definitionof“Disability” The plan considers you disabled if you: • cannot perform all the material and substantial duties of your regular occupation, and • areunabletoearnmorethan80percentofyourindexedcovered earnings,solelyduetoinjuryorsickness. After monthly benefits have been payable for 24 months, the plan considers you disabled if you cannot perform the material and substantial duties of any occupation or employment for which you may reasonably become qualified based on your education, training or experience andareunabletoearnmorethan80percentofyourindexedcovered earnings,solelyduetoinjuryorsickness. Pre-ExistingConditions Ifyourdisabilityresults,directlyorindirectly,fromapre-existingsickness orinjuryforwhichyouincurredexpenses,receivedmedicaltreatment, took prescribed drugs or consulted a physician in the three months before the most recent effective date of your insurance, you will receive no monthlybenefitsforthatcondition.However,thislimitationdoesnot apply to a total disability which begins more than 12 months after the most recent effective date of your insurance. ConversionPrivilege If you terminate employment or if your coverage ends for any reason except non-payment of premium, you can convert this plan to an individual policy by applying for conversion within 62 days of termination. To be eligible for conversion, you must have been insured for disability benefits and actively at work for at least 12 months. Contact Fringe Benefits Management Company Customer Care at 1-855-5MYFBMC (1-855-569-3262), to request a LINA Conversion Application. Coverage Employeeonly 20 pay periods $9.87 OtherIncomeBenefits Whenanemployeeisdisabled,heorshemaybeeligibleforbenefits from other income sources. If so, the insurance company may reduce the disabilitybenefitspayablebytheamountofsuchotherincomebenefits. Theextenttowhichotherincomebenefitswillreduceanydisability benefitspayableunderthepolicyisshowninthescheduleofbenefits. Otherincomebenefitsinclude: 1. any amounts that the employee or any dependents, if applicable, receive(orareassumedtoreceive)under: • theCanadaandQuebecPensionPlans • theRailroadRetirementAct • any local, state, provincial or federal government disability or retirement plan or law as it pertains to the employer • any sick leave plan of the employer; • anyworklossprovisioninmandatory“no-fault”autoinsurance • any workers’ compensation, occupational disease, unemployment compensation law or similar state or federal law, including all permanentaswellastemporarydisabilitybenefits.Thisincludes any damages, compromises or settlement paid in place of such benefits,whetherornotliabilityisadmitted. 2. anySocialSecuritydisabilitybenefitstheemployeeoranythirdparty receives(orisassumedtoreceive)ontheemployee’sbehalforfor hisorherdependents,orthathisorherdependentsreceive(orare assumedtoreceive)becauseoftheemployee’sentitlementtosuch benefits. 3. anyretirementplanbenefitsfundedbytheEmployer.“Retirement plan” means any defined benefit or defined contribution plan sponsored or funded by an employer. It does not include an individual deferred compensation agreement, a profit sharing or any other retirementorsavingsplanmaintainedinadditiontoadefinedbenefit orotherdefinedcontributionpensionplan,oranyemployeesavings plan including a thrift, stock option or stock bonus plan, individual retirementaccountor401(k)plan. 4. any proceeds payable under any franchise or group insurance or similar plan. If there is other insurance that applies to the same claim for disability and contains the same or similar provision for reduction because of other insurance, the insurance company will pay its pro ratashareofthetotalclaim.“Proratashare”meanstheproportionof thetotalbenefitthattheamountpayableunderonepolicy,without otherinsurance,bearstothetotalbenefitsunderallsuchpolicies. 5. any amounts paid on account of loss of earnings or earning capacity throughsettlement,judgment,arbitrationorotherwise,whereathird party may be liable, regardless of whether liability is determined. 6. any wage or salary for work performed. If an employee is covered forworkincentivebenefits,theinsurancecompanywillonlyreduce 31 Disability Income Protection Disability Income ProtectionCigna Disability disabilitybenefitstotheextentprovidedundertheworkincentive benefitinthescheduleofbenefits. What’sNotCovered? The plan will not pay disability benefits for a disability that results, directly or indirectly, from: • suicide,attemptedsuicideorwheneveranemployeeinjureshimself or herself on purpose • war or any act of war, whether or not declared • servingonfull-timeactivedutyinanyarmedforces* • active participation in a riot • commission of a felony or • revocation, restriction or non-renewal of an employee’s license, permitorcertificationnecessarytoperformthedutiesofhisorher occupation,unlessduesolelytoinjuryorsicknessotherwisecovered by the policy. * If the Employee sends proof of military service, the insurance company will refund the portion of the premium paid to cover the employee during a period of such service. The plan will not pay disability benefits for any period of disability during which the employee: • is incarcerated in a penal or corrections institution • is not receiving appropriate care • fails to cooperate with the insurance company in the administration of the claim including, but not limited to, providing any information ordocumentsneededtodeterminewhetherbenefitsarepayableor theactualbenefitamountdue • refuses to participate in rehabilitation efforts required by the insurance company or • refuses to participate in a work transition arrangement or other modifiedworkarrangement. Important Notice This information is a brief description of the important features of this plan. It is not a contract. Terms & conditions of the coverage are set forth ingrouppolicyNo.LK006441,onpolicyformTL-004700,issuedin Floridaandsubjecttoitslaws.Theavailabilityofthisoffermaychange. Pleasekeepthismaterialasareference,andfileitwithyourcertificate, should you become insured. Plan Provider CoverageunderwrittenbyLifeInsuranceCompanyofNorthAmerica. 32 Critical Illness Insurance Disability Income Insurance American Fidelity Assurance Company Critical Illness Insurance* Surviving a critical illness, such as a heart attack or stroke, can come at a high price. Even with medical insurance, the out-of-pocket expenses associated with a critical illness can affect anyone’s finances. American Fidelity’s Limited Benefit Critical Illness Insurance plan can assist with the expenses that may not be covered by standard medical insurance, allowing you and your family to focus on what matters the most – your recovery. How tHe Plan works If you are diagnosed with a covered Critical Illness, such as a heart attack or stroke, this plan is designed to pay a lump sum benefit amount to help cover expenses. Features: • Health screening Benefit Receive an annual benefit for undergoing one covered health screening test per year, such as a stress test, echo cardiogram, blood glucose testing, or up to five other routine tests. • three Benefit amount options Choose from a coverage amount of $15,000, $20,000, or $25,000 at the time of application. • Benefit Paid Directly to You Use your benefit for any expense you wish. *This product may be referred to by a different name. Limitations, exclusions, and waiting periods may apply. Not generally qualified benefits under Section 125 Plans. This product is inappropriate for people who are eligible for Medicaid coverage. SB-29446-0114 Disability Income Insurance If your paycheck suddenly stopped today, could you afford to pay for your mortgage, car payments, food, and other monthly expenses? How could you maintain your current lifestyle? American Fidelity knows one of the most important assets a person possesses is their ability to earn an income. Our Disability Income Insurance is a cost-effective solution designed to help protect you if you become disabled and cannot work due to a covered injury or sickness. How tHe Plan works If you become disabled due to a covered injury or sickness, Disability Income Insurance will pay a percentage of your gross monthly income once you have satisfied the elimination period. Disability benefits will be payable up to the benefit period stated in your policy. Features • Multiple elimination Periods Based on your individual need, you can select from multiple elimination periods. • waiver of Premium Benefit Premiums are not required while you are disabled based on the length of your disability. • return to work Benefit This allows you to return to work, on a part-time basis, and still receive a portion of the benefit. • accidental Death Benefit Your beneficiary will receive a lump sum payment if you die within the period stated in your policy as a result of an accidental injury. These products may contain limitations, exclusions, and waiting periods. Applicant’s eligibility for this program may be subject to insurability. SB-29447-0114 33 Accident Only Insurance Hospital GAP PLAN Insurance American Fidelity Assurance Company Accident Only Insurance Whether you are a weekend warrior with an active lifestyle or the stay-at-home type, accidents can happen anytime, anywhere, without warning. Being prepared for the unexpected can make all the difference. American Fidelity’s Limited Benefit Accident Only Insurance plan is designed to help cover some of the expenses that can result from a covered accident, and benefit payments are made directly to you. How tHe Plan works This plan provides 24-hour coverage for accidents that occur both on and off the job. With more than 25 available benefits, this plan pays for a wide range of benefits and can help offset the financial cost of medical expenses. Features: • Four Coverage options Choose the coverage that best fits your lifestyle and financial needs. • wellness Benefit The plan pays an annual Wellness Benefit for one Covered Person to receive their routine physical exam, including immunizations and preventive testing. • accidental Death and Dismemberment Benefit The plan pays a benefit when an Accidental Death or Dismemberment occurs within 90 days of a covered accident. 104521457 Limitations, exclusions, and waiting periods may apply. Not all products and benefits may be available in all states. This product is inappropriate for people who are eligible for Medicaid coverage. SB-29441-0114 Hospital GAP PLAN® Insurance Many people think that basic health insurance is enough to cover their medical needs, but the reality is that many plans only cover a portion of overall expenses. It’s important to protect yourself in case of a sudden hospitalization. American Fidelity’s Hospital GAP PLAN® Insurance may help cover certain out-of-pocket costs such as copayments, coinsurance, and deductibles not covered by traditional insurance. How tHe Plan works Our plan pays benefits directly to you and is specially designed to help supplement your standard medical insurance plan and cover certain out-of-pocket expenses. Features • In-Patient Benefit Benefits assist in paying for out-of-pocket expenses, such as copayments and deductibles. • out-Patient Benefit Benefits help pay for emergency room, out-patient surgery, and diagnostic testing expenses. • Doctor Bill Benefit Benefits help pay for treatment at a doctor’s office, out-patient treatment, hospital emergency room, or clinic. These products may contain limitations, exclusions, and waiting periods. This product is inappropriate for people who are eligible for Medicaid coverage. 34 SB-29449-0114 Cancer Insurance Permanent, Portable Life Insurance American Fidelity Assurance Company Cancer Insurance The expenses associated with a cancer diagnosis can be overwhelming. Even with a good medical plan, the out-of-pocket costs of cancer treatment, such as travel, child care, and loss of income, can be expensive. American Fidelity’s Limited Benefit Cancer Insurance offers a solution to help so you can focus your attention on your treatment and healing. We offer a plan that may assist with out-of-pocket costs often associated with a covered cancer diagnosis, and we provide the money directly to you, to be used however you see fit. How tHe Plan works This plan is specially designed to help with a portion of the costs of cancer, with more than 25 plan benefits available for cancer treatment. Features • Preventative Care Benefit Receive an annual benefit for undergoing a routine cancer screening test, which can help with early detection. • three Coverage options Choose from Individual, Single Parent Family, and Family coverage. You choose the coverage that best fits your lifestyle and financial needs. • Plan enhancements* You may be able to enhance your base plan by adding optional riders, such as a Critical Illness Rider. *Not all riders may be available in every state. Limitations, exclusions, and waiting periods may apply. This product is inappropriate for people who are eligible for Medicaid coverage. SB-29445-0114 Permanent, Portable Life Insurance Your employer may provide you with group life insurance, but do you have permanent portable life insurance that you can take with you after employment? Life insurance at retirement can be very costly. Secure your life insurance premium today with a permanent and portable plan. How tHe Plan works Permanent life insurance is a policy that is effective to age 121. You own the policy, so you take it with you after your employment ends. Features • Minimal Cash Value Premiums are dedicated primarily to the purchase of life insurance. • Multiple Coverage options Policies are available for you, your spouse/domestic partner, children, and grandchildren.1 • Portable A policy that you own. Take it with you if you leave employment or retire.2 Policy Form: PRFNG-NI-10 / 14M020-C AF 1017 (expires 2/2016) See brochure for details. 1 Coverage and spouse/domestic partner eligibility may vary by state. Coverage not available for children and grandchildren in Washington. Texas Life complies with all state laws regarding marriages and legally recognized familial relationships. 2 As long as you pay the necessary premium. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. Not generally qualified benefits under Section 125 Plans. PureLife-plus not available in NJ, NY, or PA. Underwritten by SB-29479-0114 35 Life Insurance American Fidelity Assurance Company Life Insurance It is impossible for life insurance to emotionally compensate for a loss, but it may help ease the financial obligations placed on your loved ones. American Fidelity’s portable, individual life insurance policies may help your family in the event of your death. They have a simplified application process, minimal health questions*, and no required medical exams.* How tHe PlanS work term life Insurance offers protection during your peak earning years and allows you choose from a 10, 20, or 30 year benefit. Permanent life Insurance provides lifelong protection and the ability to accumulate cash values on a tax-deferred basis**. FeatureS • Guaranteed Death Benefit Your death benefit is guaranteed for the life of the policy, provided premiums are paid. • accelerated Death Benefit You can receive a portion of the chosen death benefit if you are diagnosed with a terminal condition. • non-taxable Death Benefit A death benefit amount that is generally tax free.** *Issuance of the policy may depend upon the answers to the health questions. **Please consult your tax advisor for your specific situation. Limitations, exclusions, and waiting periods may apply. Not generally qualified benefits under Section 125 Plans. SB-29457-0114 36 FLEXIBLE SPENDING ACCOUNTS Health FSA Debit Card Dependent Care FSA Filing a Claim Accessing Your FSA 37 Flexible Spending Accounts American Fidelity Assurance Company American Fidelity Assurance Company Flexible Spending Accounts are a great cost savings tool to help with common medical and/or dependent care expenses not covered by your insurance. You can elect a portion of your pay to be deducted, on a pre-tax basis, from each paycheck to use for reimbursements of qualified out-of-pocket expenses throughout the plan year. Health Flexible Spending Account (FSA) Flexible Spending Account Savings Example Maximum Annual Deposit: $2,500 With FSA Without FSA $30,000 Annual Gross Income - $2,400 Health FSA Deposit $0 - $2,500 Dependent Care Account Deposit $0 $25,100 Taxable Gross Income $30,000 - $5,020 Estimated Federal Tax (20%) - 6,000 - $1,920.15 Estimated FICA (7.65%) - 2,295 $18,159.85 Annual Net Income $21,705 Cost of Recurring Medical Expenses - $2,400 $0 $0 Cost of Recurring Dependent Care Expenses $18,159.85 Spendable Income $30,000 - $2,500 $16,805 With an FSA you have a potential annual savings of: $1,354.85 By using an FSA to pay for eligible recurring expenses, you can cut down on your taxable income which will result in additional spendable income. A Health FSA allows you to allocate money on a pre-tax basis to reimburse yourself for qualified medical expenses for you and your family. Qualified expenses include anything from co-payments, medical deductibles, prescriptions and much more. Partial List of Eligible Expenses for Health FSA Copays/coinsurance Deductibles Dental treatments Diabetic supplies Prescription drugs and medicines Eye exams, eyeglasses, contact lenses, contact lens solution and enzyme Flu shots Immunizations Lab fees Laser/Lasik/RK surgery Medical exams Orthodontia Psychiatric care Wheelchair X-rays For a complete list of eligible expenses, please visit www.americanfidelity.com Carryover Provision for Health Flexible Spending Accounts The Internal Revenue Service (IRS) gives employers the ability to allow Health Flexible Spending Account (Health FSA) participants to carry over up to $500 of unused contributions from one plan year to the next. This is called the Carryover Provision. This carryover amount may then be used to reimburse eligible medical expenses incurred anytime during the next plan year. 23 38 Flexible Spending Accounts Health FSA Debit Card American Fidelity will provide a Debit Card to all employees who elect to participate in a Health FSA. The debit card gives immediate, convenient access to Health FSA funds at the point of sale for prescriptions, copays, and other common qualified medical expenses. The card can only be used for the Health FSA and is not available for the Dependent Care Account. Using Your Debit Card Simply swipe your Health FSA debit card like you would with any other credit card. Whether at the doctor’s office or the dentist, the amount of your eligible expenses will be automatically deducted from your Health FSA account. Health FSA Debit Card Activating Your Card You will receive your card at your home address and can begin using your card at the beginning the first day of your plan year. Your card will be automatically activated when you use it for the first time for an eligible expense. Guidelines for Your Health FSA Debit Card • Keep your receipts. Claims not approved automatically will need to be submitted manually. • If a provider does not accept the Debit Card, you can request reimbursement by completing the Health FSA Expense Reimbursement Voucher and submit with the required documentation. Health FSA reimbursement vouchers can be found online at www.americanfidelity.com. • If debit card “swipes” do not match up with pre-set benefits from your employer, or, we do not receive all the necessary information electronically from the debit card vendors to automatically approve the flex debit card “swipe”, manual claims substantiation will be requested. • If you cannot provide the substantiation requested, that claim will be determined to be ineligible and funds for that claim must be reimbursed back to the plan. Acceptable substantiation to accompany the request is a professional bill or receipt that includes the provider of service, type of service rendered, charges for the service, and original date of service; insurance company explanation of benefits; pharmacy statement that includes Prescription number and name of prescription. Debit Cards for Health FSAs can be used at: • Healthcare related facilities which include: hospitals, physician offices, dental offices, vision offices; and, • Merchants participating in the Inventory Information Approval System (IIAS). Your debit card claim will be automatically approved without further information requested for: • Copay Amounts – If your employer provides the necessary information for your medical carrier, the copay amounts can be automatically approved if your copay is stated as a flat dollar amount. If your medical coverage is stated as a coinsurance percentage, additional information will be necessary to approve the expenses. • Recurring expenses – You will need to submit your first claim manually and state this will be a recurring claim from the same provider at the same dollar amount. It will be noted on your account that this will be a recurring expense, and additional substantiation will not be required for that plan year. 39 Flexible Spending Accounts Dependent Care Account A Dependent Care Account allows you to allocate money on a pre-tax basis to reimburse yourself for dependent care services such as after school care and dependent daycare centers. Maximum Annual Deposit: $5,000 Partial List of Eligible Dependent Care Expenses After-school care or extended day programs Nanny expenses Baby-sitter inside or outside participant’s household Custodial or elder care expenses if the qualifying individual still spends at least 8 hours each day in the employee’s household Dependent care center* expenses/pre-kindergarten/nursery school expense if primary purpose is to care for the child so the parent can work Expenses paid to a non-dependent relative of participant Summer day camp if the primary purpose of the expense is custodial in nature and not educational For a complete list of eligible expenses, please visit www.americanfidelity.com. *A Dependent Care Center is a place that provides care for more than six persons (other than persons who live there) and receives a fee, payment or grant for providing services for any of those persons, regardless of whether the center is run for profit. Regardless of whether you participate in the dependent care plan under Section 125 or claim the credit on your income tax, you must provide the IRS with the name, address and taxpayer identification number (TIN) or Social Security number of your dependent care provider(s) by completing either Schedule 2 of Form 1040A or Form 2441 and attaching it to your annual income tax return. Be sure that you follow the current instructions given by the IRS for preparing your annual income tax return. Failure to provide this information to the IRS could result in loss of the pre-tax exemption for your dependent care expenses. 40 American Fidelity Assurance Company FSA Fund Availability Health FSA Account Your full annual election is available to you on June 1st of the plan year. Dependent Care Account Unlike the Health FSA, the entire elected amount is not available on the first day of the plan year, but rather as contributions are received and services have been provided. Important FSA Notes: • Participants are allowed a 90-day run-off period after the plan year ends in which to submit claims that occurred during the plan year but were not yet submitted. • If you are a new employee entering the plan during a plan year, services must be provided after you are eligible to participate in the plan. • If you are enrolled in the Health FSA and take a leave of absence during the plan year, you may: 1.Prepay the contributions pre-tax, or 2.Continue the contributions on an after-tax basis (pre-tax contributions may continue when you return to work), or 3.Prorate the unpaid contributions over the remaining pay periods when you return to work. • Failure to make all elected contributions will result in termination of your account as of the date contributions ceased. • Health FSAs must comply with COBRA and offer COBRA continuation rights to qualified beneficiaries who lose their Health FSA coverage as a result of termination of employment. This may only be offered upon termination of employment if you have a balance remaining in your Health FSA. The balance is calculated by subtracting the reimbursements made from the contributions received. You may choose to continue your contributions by either sending your contributions to your employer on an after-tax basis each pay period, or, you can choose to pre-tax the remaining contributions for the plan year from your severance pay. Expenses incurred while contributions are being made are eligible for reimbursement. The coverage may not continue beyond the current plan year. If you do not elect to continue the contributions on an after-tax basis, only expenses incurred during the period of employment will be reimbursed. Coverage under the Health FSA ceases when the contributions cease. Flexible Spending Accounts Filing a Claim 1. Complete an Expense Reimbursement Voucher, along with the thirdparty documentation of the expense. Health FSA and Dependent Care vouchers can be found online at www.americanfidelity.com. 2. Submit your completed form and documentation to American Fidelity’s Flex Department. You can either mail it to the address located on the bottom of the voucher or fax it toll-free to 1-888-543-3539. 3. Your claim will be processed on an average of 5-7 business days from the date all required claim information is received. The Health FSA reimbursement check will be for the expenses claimed up to the annual election for the plan year minus any previously reimbursed amounts. The Dependent Care expense reimbursement will be for the services provided limited to the amount you have in your account. If the Dependent Care expense claim is in excess of your account balance, the balance of the claim will be paid to you as additional contributions are received. Filing a Claim Accessing Your FSA By visiting American Fidelity’s web site www.americanfidelity.com you will have a wealth of information available to you without the use of any customer IDs or passwords. Through the public site you have access to: • Claim forms • Section 125 Flex Reimbursement Forms • Customer FAQs • Contact information Secure Account Management Tools American Fidelity’s Online Service Center is a convenient, secure web site that gives you access to information regarding your American Fidelity account. Available any time of day from home, work or any computer with Internet access, the Online Service Center provides valuable options. • Check claim status • Review detailed insurance policy information • Access Health FSA information and balances • Submit address changes Direct Deposit By selecting to have your reimbursements directly deposited to your bank account you can get your reimbursements faster without having to wait for the check to arrive in the mail. Each time a reimbursement is deposited into your bank account, you will be mailed an Explanation of Benefits that shows the deposit as well as a summary of your account. 41 OTHER INFORMATION Cigna Will Center Vista 401(k) COBRA Q&A Beyond Your Benefits 42 Cigna Will Center Cigna Life Insurance Cigna will preparation program Difficult legal decisions JUST GOT A LITTLE EASIER. Preparing a will is a critical step to protecting your family’s financial future. That’s why we offer will preparation services at no additional cost if you have a Cigna life, accident, disability, critical illness or accidental injury plan. The death of a family member can be a confusing and conflicting time. There are many tasks and decisions to make – all when emotions and stress are high, time limited and energy may be low. Planning in advance helps relieve these uncertainties for family members left behind and ensures that your wishes are known. Not sure how to get started? Don’t worry. Cigna’s Will Center is secure, easy to use and available to you and your spouse seven days a week, 365 days a year. Phone representatives are also available to assist you via a toll-free number.1 Once you’re registered on the site, you can: • Follow an intuitive, interactive, question-and-answer process to create state-specific legal documents tailored to your needs • Create and maintain your personalized legal documents in an estate plan • Preview, edit, download and print your legal documents for execution • Access resources and tools to help with the funeral planning process 859684 12/12 Offered by: Connecticut General Life Insurance Company, Life Insurance Company of North America and Cigna Life Insurance Company of New York. 43 Cigna Will Center Cigna Life Insurance CignaWillCenter.com Visit www.CignaWillCenter.com CignaWillCenter.com to register and immediately start building your own personalized estate and funeral plan, including: Last will and testament: Determine what’s to be done with your property when you die, and name the executor of your estate and a guardian for your minor children Living will: Outline your wishes regarding the use of extraordinary life support or other life-sustaining medical treatment To access all these valuable tools and services, go to CignaWillCenter.com Health care power of attorney: Allow someone to make medical decisions if you are unable Financial power of attorney: Allow someone to make financial decisions on your behalf if you are unable Medical authorization for minors: Empower medical personnel to treat your child if you are not present Funeral planning resources: • Informational guidebooks – in-depth, easy-tounderstand information to help you prepare your or a loved one’s end-of-life wishes • Personal information organizer tool – keep important personal data, account information, contacts, and end-of-life wishes all in one place 1. Legal advice is not provided. Registrations and customized documents are maintained for two years, which allows individuals to easily make revisions to their legal documents as their personal situation changes. Will preparation services are independently administered by ARAG®. Cigna does not provide legal services and makes no representations or warranties as to the quality of the information on the ARAG website or the services of ARAG. “Cigna” is registered service marks, and the “Tree of Life” logo and “GO YOU” are service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including Life Insurance Company of North America, Cigna Life Insurance Company of New York and Connecticut General Life Insurance Company, and not by Cigna Corporation. All models are used for illustrative purposes only. 859684 12/12 © 2012 Cigna. Some content provided under license. Vista 401(k) Supplemental Vista 401(k)Plan Supplemental RetirementVista Plan 401(k) Retirement Plan Features WhoCanJoin? Allfull-timeemployeesareeligibletoparticipateintheVista401(k) SupplementalRetirementPlan. HowDoesthePlanWork? 401(k) enrollment forms can be downloaded from www.vista401k.com or contact. The basic processes are simple: • Contributions to the plan are made through regular payroll deductions. • Selectionsfromover30mutualfundsareavailable. • No taxes are paid on any contributions or earnings until they are withdrawn. ParticipantStatement How to Enroll You can also obtain daily information from our website or through the IVRat1-800-213-2310. To enroll in yourVista 401(k) Plan simply visit our website at www.vista401k.com or complete an enrollment form indicating: • The per pay period amount you want to contribute. • Howyouwantyourmoneyinvested(youmaydeferthatdecision untilafteryouhaveenrolledbutbeforethefirstpayrolldeductions arereceived).Ifnodecisionismade,yourcontributionswillbemade tothetargetretirementfundclosesttoyourretirement(age62). • Thebeneficiarywhowillreceiveyouraccountintheeventofyour death. MailyourcompletedformtoVista401(k)atP.O.Box1878,Tallahassee, Florida32302-1878. HowtoChangeYourInvestments YoucanchangeyourinvestmentsbygoingtotheVista401(k) websiteat www.vista401k.com • Changehowyourfuturecontributionswillbeinvested. • Transfer your existing account balance among the fund choices. You will receive personal account statements on a quarterly basis. Your statement will show activity in your account including contributions, sharespurchased,gains/losses,fundtransfersanddistributions.Youmay also create a statement for any time period by visiting our website at www.vista401k.com. Contributions Contribution Limits The minimum annual contribution is $500. The maximum amount is indexedonanannualbasisbytheIRS.Pleasevisitwww.vista401k.com for current annual amount. Tax Savings Each contribution defers your federal income taxes. Additionally, no taxes are paid on any earnings in the plan until they are withdrawn. Yourcontributionsare,however,subjecttoSocialSecuritytaxes.Visit our website at www.vista401k.com and perform an investment analysis. Contribution Changes Achangeisdefinedasanincreaseordecreaseinyourcontribution amount. You are allowed to make two changes per year. You can stop your contributions at any time even if you have made a change during the year. There is no minimum time period before transfers or exchanges are allowed. 45 Vista 401(k) Supplemental Vista 401(k) Supplemental RetirementVista Plan 401(k) Retirement Plan FeesandExpenses Vista401(k)planexpensesareasfollows: • OverallManagement-A“wrap”feeof0.5%isassessedfromyour assetbalances • administration-$1.00permonthisassessedtoparticipantsnolonger activelycontributingtotheir401(k)account • MutualFund-Thereareinvestmentfeesthataredifferentforeach fund as described in their prospectus. A detailed summary is available at www.vista401k.com • $20 check writing fee for distributions and loan checks. • Front-endorloadingcharge-none. • Surrendercharge-none. • Fees and/or restrictions on transferring plan assets between funds-none. • Othercharges-none. • Loanfee-$65. Loans Note: Some of these funds normally charge a sales charge from contributions by individual investors. All of those charges have beenwaivedbyeachfundfortheVista401(k)Plan.Therefore,your contributionspurchasesharesatNetAssetValue(NAV). Your401(k)planhasaloanprovisiontogiveyouaccesstoyourmoney The following rules apply: • You must have a minimum of $2,000 in your account. • Youcanborrowupto50%ofyouraccountbalance,withamaximum of $50,000. Employer contributions and any earnings are not eligible for a loan. • The minimum loan amount is $1,000. • You have a choice of paying your loan back, with interest, in 1, 2, 3 or 4 years. • You pay back your loan through equal payroll deductions. • There are no penalties if you prepay your loan, but if you want to pay it off early, you must pay it off in one lump sum. • Youcanonlyhaveoneloanatatime;thereisa30-daywaitingperiod between loans. • Theinterestratewillbe2%overtheprimerate. • Yourtotalpayment(principalandinterest)willbedepositedback into your account. • Thereisa$65feeforloanprocessing,whichincludesStateofFlorida DocumentaryStamppayment. RestrictionsonPlanDistributions Hardship Withdrawal Provisions Your401(k)accountisalong-terminvestment,designedspecifically foryourretirementneeds.Becauseofthis,theIRSrestrictswhenyou can withdraw your money. You are able to withdraw your money when you reach age 59½, retire, terminate employment, become totally andpermanentlydisabled,orhaveafinancialhardship(seehardship withdrawalprovisions).Federallawimposestheselimitations. Taxes on Distributions YoupaytaxesonyourVista401(k)plancontributionsandyourearnings when you withdraw them. If a check is written to you, your distribution willhave20%federalincometaxwithheld.Ifyouwanttoavoidpaying taxesonyourwithdrawal,youmaydoadirectrollovertoanIRAoryour newemployer’s401(k)plan. Anadditional10%penaltytaxwillbeimposedfordistributionsmade beforetheageof59½exceptforthefollowingcircumstances: • distributions if you have reached age 55 and retired early • hardship distributions • distributionstoanalternatepayeeunderaqualifieddomesticrelations order, issued by the court in the divorce or dissolution of marriage proceeding • distributions made due to an employee’s death or disability • adirectrollovertoanotherqualifiedplan • purchaseofservicecreditsforadefinedbenefitplan. TheIRSconsidersyour401(k)accounttobealast resort for money. Youmustmeetspecificcriteriatoqualifyforafinancialhardship.The IRSallowsthefollowingsixreasonsforhardshipwithdrawalofyour 401(k)funds.Thewithdrawalcannotexceedthecostofyourhardship. ($1,000.00minimum) • Purchaseofaprimaryresidence(excludingmortgagepayments). • Tuition expenses and related educational fees for you or your dependent’snext12monthsofpost-secondaryeducation. • Expenses incurred by you or your dependents to obtain medical services. • Payments to prevent eviction or foreclosure on your primary residence. • Payments for burial or funeral expenses for the employee's deceased parent, spouse, children or dependents. • Expenses for the repair of damage to the employee's principal residencethatqualifiesforthecasualtydeductionundercodesection 165. You must complete a hardship withdrawal application that details your financialsituationandprovidewrittendocumentationforalleligible expenses. Also, you may be asked to provide proof that a commercial lender has denied you a loan and that you are ineligible for a loan from your401(k)plan. Your contributions to theVista 401(k) plan and any other retirement plan,suchasa403(b)tax-deferredannuity,mustbesuspendedforsix months after the withdrawal. Rollovers All investments involve risks. You should carefully consider all of your options before investing. 46 Youmayrollover,onatax-freeexchangebasis,fundsfromaprevious employer's 401(a), 401(k), 403(b), 457 or IRA plans into yourVista 401(k)plan. CallVista401(k)toll-freeat1-866-325-1278forinformation. COBRA Q&A COBRA Q&A WhatIsContinuationCoverage? ForMoreInformation Federal law requires that most group health plans, including medical flexible spendingaccounts(medicalexpenseFSAs),giveemployeesandtheirfamiliesthe opportunity to continue their health care coverage when there is a “qualifying event”thatwouldresultinalossofcoverageunderanemployer’splan. This COBRA Q&A section does not fully describe continuation coverage or other rights under the plan. More information about continuation coverage and your rights under the plan is available from your employer. FormoreinformationaboutyourCOBRArights,theHealthInsurancePortability andAccountabilityAct (HIPAA) and other laws affecting group health plans, contacttheU.S.DepartmentofLabor’sEmployeeBenefitsSecurityAdministration (EBSA)inyourareaorvisittheEBSAWebsiteatwww.dol.gov/ebsa. HowLongWillContinuationCoverageLast? For Medical Expense FSAs: IfyoufundyourmedicalexpenseFSAentirely,youmaycontinueyourmedical expenseFSA(onapost-taxbasis)onlyfortheremainderoftheplanyearinwhich your qualifying event occurs, if you have not already received, as reimbursement, themaximumbenefitavailableunderthemedicalexpenseFSAfortheyear.For example,ifyouelectedamedicalexpenseFSAbenefitof$1,000fortheplanyear and have received only $200 in reimbursement, you may continue your medical expenseFSAfortheremainderoftheplanyearoruntilsuchtimethatyoureceive themaximummedicalexpenseFSAbenefitof$1,000. Keep Your Address Updated In order to protect your family’s rights, you should keep AFA informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to your employer and AFA. If your employer funds all or any portion of your medical expense FSA, you may be eligible to continue your medical expense FSA beyond the plan year in which your qualifying event occurs and you may have Open Enrollment rights at the next Open Enrollment period. There are special continuation rules for employer-funded medical expense FSAs. If you have questions about your employer-funded medical expense FSA, you should call our customer service representatives. We are ready to assist you from 7:00 a.m. – 6:00 p.m. CST with any questions you may have. Call us today at 1-800-325-0654 47 www.myFBMC.com 30 Beyond Your Benefits Beyond Your Benefits TaxableBenefitsandtheIRS Insuranceplan(s)aresetforthfromtimetotimeinthehealthinsuranceplan(s).Allclaims toreceivebenefitsunderthehealthinsuranceplan(s)shallbesubjecttoandgovernedby thetermsandconditionsofthehealthinsuranceplan(s)andtherules,regulations,policies and procedures from time to time adopted. Certainbenefitsmaybetaxedifyoubecomedisabled,dependingonhowthepremiums were paid during the year of the disabling event. Payments, such as disability, from coveragespurchasedwithpre-taxpremiumsand/ornontaxableemployercredits,will besubjecttofederalincomeandemployment(FICA)tax.Ifpremiumswerepaidwitha combinationofpre-taxandafter-taxdollars,thenanypaymentsreceivedundertheplan willbetaxedonaproratabasis.Ifpremiumswerepaidonapost-taxbasis,youwillnot be taxed on the money you receive from the plan. You can elect to have federal income taxwithheldbytheproviderjustasitiswithheldfromyourwages.Consultyourpersonal tax adviser for additional information. AFA Privacy Statement As a provider of products and services that involve compiling personal—and sometimes, sensitive—information, protecting the confidentiality of that information has been, and will continue to be, a top priority of AFA. We collect only the customer information necessary to consistently deliver responsive services. AFA collects information that helps serve your needs, provide high standards of the service center and fulfill legal and regulatory requirements. The sources and types of information collected generally varies depending on the products or services you request and may include: Inaddition,FICAandMedicaretaxeswillbewithheldfromanydisabilitypaymentspaid through six calendar months following the last calendar month in which you worked prior tobecomingdisabled.ThereafternoFICAorMedicaretaxwillbewithheld. • Information provided on enrollment and related forms - for example, name, age, address,SocialSecuritynumber,e-mailaddress,annualincome,healthhistory,marital statusandspousalandbeneficiaryinformation. YouwillberequiredbytheIRStopayFICA,Medicare,andfederalincometaxeson certainotherbenefitpayments,suchasthosefromHospitalIndemnityInsurance,Personal CancerExpenseInsuranceandHospitalIntensiveCareInsurance,thatexceedtheactual Healthcaresyouincur,ifthesepremiumswerepaidwithpre-taxdollarsand/ornontaxable employer credits. If you have questions, consult your personal tax adviser. • Responsesfromyouandotherssuchasinformationrelatingtoyouremploymentand insurance coverage. • Information about your relationships with us, such as products and services purchased, transaction history, claims history and premiums. AccordingtoIRSregulations,youcanpaylifeinsurancepremiumstaxfreeonyourfirst $50,000 of life insurance. You must pay tax on premiums for coverage exceeding $50,000. • Information from hospitals, doctors, laboratories and other companies about your health condition, used to process claims and prevent fraud. Notice of Administrator's Capacity This notice advises insured persons of the identity and relationship among the contract administrator, the policyholder and the insurer: We maintain safeguards to ensure information security and are committed to preventing unauthorized access to personal information. 1. AFA has been authorized by your employer to provide administrative services for your employer’s insurance plans offered herein. In some instances, AFA may also be authorized by one or more of the insurance companies underwriting the benefits offered herein to provide certain services, including (but not limited to) marketing, underwriting, billing and collection of premiums, processing claims payments, and other services. AFA is not the insurance company or the policyholder. We limit how, and with whom, we share customer information. We do not sell lists of our customers, and under no circumstances do we share personal health information for marketing purposes. With the following exceptions, we will not disclose your personal information without your written authorization. We may share your personal information with insurance companies with whom you are applying for coverage, or to whom you are submitting a claim. We also may disclose personal information as permitted or required by laworregulation.Forexample,wemaydiscloseinformationtocomplywithaninquiry by a government agency or regulator, in response to a subpoena or to prevent fraud. 2. The policyholder is the entity to whom the insurance policy has been issued. The policyholder is identified on either the face page or schedule page of the policy or certificate. NotethisprivacystatementisnotmeanttobeaprivacynoticeasdefinedbytheHealth InsurancePortabilityandAccountabilityAct(HIPAA).Youmayreceiveaprivacynotice from your employer or from the providers of various health plans in which you enroll. You should read these statements carefully to assure you understand your rights under HIPAA. 3. The insurance companies noted herein have been selected by your employer, and are liable for the funds to pay your insurance claims. If AFA is authorized to process claims for the insurance company, we will do so promptly. In the event there are delays in claims processing, you will have no greater rights to interest or other remedies against AFA than would otherwise be afforded to you by law. AFA is not an insurance company. SocialSecurity SocialSecurityconsistsoftwotaxcomponents:theFICAorOASDIcomponent(thetax forold-age,survivors’anddisabilityinsurance)andtheMedicarecomponent.Aseparate maximum wage to which the tax is assessed applies to both tax components. There is no maximum taxable annual wage for Medicare. The maximum taxable annual wage for FICAissubjecttofederalregulatorychange.Ifyourannualsalaryaftersalaryreduction isbelowthemaximumwagecapforFICA,youarereducingtheamountoftaxesyoupay andyourSocialSecuritybenefitsmaybereducedatretirementtime. However,thetaxsavingsrealizedthroughtheflexiblebenefitsplangenerallyoutweighthe SocialSecurityreduction.Calltheservicecenterat1-855-569-3262foranapproximation. Disclaimer - Health Insurance Benefits Provided UnderHealthInsurancePlan(s) HealthInsurancebenefitswillbeprovidednotbyyouremployer’sflexiblebenefitsplan, butbythehealthinsuranceplan(s).Thetypesandamountsofhealthinsurancebenefits availableunderthehealthinsuranceplan(s),therequirementsforparticipatinginthehealth insuranceplan(s)andtheothertermsandconditionsofcoverageandbenefitsofthehealth 48 31 www.myFBMC.com Members of the Board District # 1 ROBIN SMITH-MARTIN MARK T. PORTER Superintendent of Schools District # 2 ANDY GRIFFITHS Chair District # 3 ED DAVIDSON New Beginnings…High Expectations District # 4 JOHN R. DICK District # 5 RONALD A. MARTIN Vice Chair New Health Insurance Marketplace Coverage Options and Your Health Coverage PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014. Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1 1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs. 241 Trumbo Road Key West, FL 33040 Tel. (305) 293-1400 Fax (305) 293-1408 www.KeysSchools.com 49 Monroe County School District Page 2 of 3 Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employeroffered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact: ___Employee Benefits & Risk Management Department_________________. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit www.HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. PART B: Information about Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. Employer name Employer Identification Number (EIN) Monroe County District School Board 59-6000750 Employer Address Employer Phone Number 241 Trumbo Road 305-293-1400, Ext. 53342 City State ZIP code Key West FLORIDA 33040 Who can we contact about employee health coverage at this job? Wanda Menendez, Employee Benefits & Risk Management Specialist Phone number (if different from above) Email address [email protected] [email protected] 50 Monroe County School District Page 3 of 3 Here is some basic information about health coverage offered by this employer: As your employer, we offer a health plan to: ____ All employees. __X__ Some employees. Eligible employees are: Employees that work at least 51% of the average time required for the position held. With respect to dependents: __X__ We do offer coverage. Eligible dependents are: 1. The Covered Employee’s spouse under a legally valid existing marriage; 2) The covered employee’s natural, newborn, adopted, foster, or step child(ren) (or a child for whom the Covered Employee has been court-appointed as legal guardian or legal custodian or a child that has been placed for adoption) who has not reached the end of the Calendar Year in which he or she reaches age 26 (or in the case of a Foster Child, is no longer eligible under the Foster Child Program), regardless of the dependent child’s student or marital status, financial dependency on the Covered Employee, whether the dependent child is eligible for or enrolled in any other group health plan.; 3) The newborn child of a covered dependent child who has not reached the end of the Calendar Year in which he or she becomes 26. Coverage for such newborn child will automatically terminate 18 months after the birth of the newborn child. Children may be covered up to the end of the calendar year in which they reach 30, subject to statutory conditions and contribution requirements. ____ We do not offer coverage This coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on the employee wages. **Even though we intend your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount. If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here’s the employer information you’ll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums 51 Benefits Directory Medical Benefits Florida Blue 1-888-387-4962 BCBSFL.com Prescription Plans Envision Rx Customer Service Help Desk 1-800-361-4542 www.envisionrx.com Dental Insurance CompBenefits (Dental Plans) Member Services Mon-Fri, 8 A.M. - 5 P.M. ET 1-800-432-3376 www.compbenefits.com Vision Insurance Humana - Vision Care Plan (Vision Plan) 1-866-537-0229 HumanaVisionCare.com Voluntary Insurance Benefits American Fidelity Assurance Company Disability Income, Cancer, Hospital Gap, Critical Illness, Accident, and Life 2000 N Classen Oklahoma City, OK 73106 800-654-8489 www.americanfidelity.com Vista 401(k) Plan Mon-Fri, 8 A.M. - 5 P.M. 1-866-325-1278 Automated Services 1-800-213-2310 www.vista401k.com Minnesota Life Underwritten by: Ochs, Inc. (Group Term Life Insurance) Customer Service Mon - Fri, 9 A.M. - 5:30 P.M. ET 1-800-392-7295 www.ochsinc.com Section 125 Services & Flexible Spending Accounts American Fidelity Assurance Company 2000 N Classen Oklahoma City, OK 73106 800-654-8489 www.americanfidelity.com Other Contact Information Monroe County School District School Board Office Mon-Fri, 8 A.M. - 5 P.M. ET (305) 293-1400 American Fidelity Assurance Company Mark A. Cisneros, Manager I 601 Cleveland St #501-10 Clearwater FL 33755 877-425-1104 [email protected] This Enrollment Benefits booklet is not a contract, is not legally binding, and does not alter any original plan documents. Rather, it is intended to be a summary of available benefits provided through your employer. Every effort has been made to ensure the accuracy of this information. However, the actual determination of your benefits is based solely on the plan documents and if statements in this description differ from the applicable plan documents, coverage documents or Summary Plan Descriptions, then the terms and conditions of those documents will prevail. Please check with your employer’s Benefit’s Office for further guidance.
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