EMPLOYEE BENEFITS PLAN ARTSPACE CHARTER SCHOOL PLAN YEAR: July 1, 2020 through June 30, 2021
ARRANGED BY:
www.piercegroupbenefits.com
EMPLOYEE BENEFITS GUIDE
TABLE OF CONTENTS Welcome to the ArtSpace Charter School comprehensive benefits program. This booklet highlights the benefits offered to all eligible employees for the plan year listed below. Benefits described in this booklet are voluntary, employee-paid benefits unless otherwise noted.
ENROLLMENT PERIOD: JUNE 2, 2020 - JUNE 3, 2020 EFFECTIVE DATES: JULY 1, 2020 - JUNE 30, 2021
State Of North Carolina Teachers’ And State Employees’ Health Plan – page Plan Comparison**
43
Medical Bridge Benefits
page
45
Benefits Plan Overview
page
2
Online Enrollment Instructions
page
5
Telemedicine
page
7
Life Insurance
page
50
Dental Benefits
page
10
Identity Theft Shield & Life Events Legal Plan
page
52
Vision Benefits
page
14
Cobra Continuation Of Coverage Rights
page
53
Group Term Life Insurance
page
15
Authorization Form
page
55
Notice Of Insurance Information Practices
page
56
Continuation Of Coverage for Benefits Form
page
57
Cancer Benefits
page
18
Critical Care Benefits
page
21
Disability Benefits
page
25
Accident Benefits
page
39
** for informational purposes only
Rev. 06/03/2020
PRE-TAX & POST-TAX BENEFITS
ARTSPACE CHARTER SCHOOL ENROLLMENT PERIOD: JUNE 2, 2020 - JUNE 3, 2020 EFFECTIVE DATES: JULY 1, 2020 - JUNE 30, 2021
PRE-TAX BENEFITS Dental Insurance
Vision Insurance*
Accident Benefits
Medical Bridge Benefits
Principal
Colonial Life
Cancer Benefits
Colonial Life
Superior
Colonial Life
POST-TAX BENEFITS Short-Term Disability Benefits
Colonial Life
Group Term Life Insurance Employer-Paid Benefit
Principal
Long-Term Disability Benefits
Critical Care Benefits Colonial Life
Principal
Life Insurance
Colonial Life • Term Life Insurance • Whole Life Insurance
Telemedicine
Call A Doctor Plus
Identity Theft Shield & Life Events Legal Plan
Legal Shield
*EMPLOYEES WILL NEED TO RE-ENROLL IN VISION BENEFITS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING JULY 1, 2020. Please note other insurance products will remain in effect unless you see a representative to change them.
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QUALIFICATIONS & IMPORTANT INFO
THINGS YOU NEED TO KNOW QUALIFICATIONS: • You must work 20 hours or more per week.
IMPORTANT FACTS: • The plan year for Colonial Insurance products, Principal Long-Term Disability, Principal Dental, Principal Group Term Life, Superior Vision, Call A Doctor Plus Telemedicine and Legal Shield Identity Theft Shield & Life Events Legal Plan lasts from July 1, 2020 through June 30, 2021. Please Note: Dental benefits are based on the Calendar Year, running from January 1st through December 31st. Dental benefits and deductibles will reset every January 1st. • Deductions for Colonial Insurance products, Principal Long-Term Disability, Principal Dental, Superior Vision, Call A Doctor Plus Telemedicine and Legal Shield Identity Theft Shield & Life Events Legal Plan will begin July 2020. • If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when meeting with the Benefits Representative. • Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as defined by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time, or vice-versa. • Once a family status change has occurred, an employee has 30 days to notify the North Carolina Service Center at 1-888-662-7500 to request a change in elections. • The Colonial Cancer plan and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until July 31, 2020. • Additionally, some policies may include a pre-existing condition clause. Please read your policy carefully for full details. • Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution.
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EMPLOYEE BENEFITS GUIDE
ARTSPACE CHARTER SCHOOL IN PERSON
ONLINE
You may enroll or make changes online to your flexible benefits plan. To enroll online, please visit https://harmonyenroll.coloniallife.com
During your open enrollment period, a Pierce Group Benefits representative will be available by appointment to answer any questions you may have and to assist you in the enrollment process.
ENROLLMENT PERIOD: JUNE 2, 2020 - JUNE 3, 2020 YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT PERIOD: • Enroll in your Vision Insurance*. • Enroll, change or cancel your Dental Insurance. • Enroll, change or cancel your Telemedicine coverage. • Enroll, change or cancel your Pre-Paid Legal.** • Enroll, change or cancel your Colonial products (see the following pages for changes that can be completed online). YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS BY SPEAKING WITH THE BENEFITS REPRESENTATIVE ASSIGNED TO YOUR LOCATION DURING THE ENROLLMENT PERIOD: • Enroll, change or cancel your Long-Term Disability Insurance. *EMPLOYEES WILL NEED TO RE-ENROLL IN VISION BENEFITS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING JULY 1, 2020. **Please see the coordinating pages of your benefit booklet/back cover for enrollment instructions and/or contact information for the Legal plan.
ACCESS YOUR BENEFITS ONLINE WHENEVER, WHEREVER. Benefits Details | Educational Videos | Download Forms | Online Chat with Service Center To view your personalized benefits website, go to:
www.piercegroupbenefits.com/artspacecharterschool or piercegroupbenefits.com and click “Find Your Benefits”.
IMPORTANT NOTE & DISCLAIMER
This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail. All information in this booklet including premiums quoted is subject to change. All policy descriptions are for information purposes only. Your actual policies may be different than those in this booklet.
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HARMONY ONLINE ENROLLMENT:
Harmony
COMPLETE THE STEPS BELOW TO BEGIN THE ONLINE ENROLLMENT PROCESS
HELPFUL TIPS:
• If you are a new employee and unable to log into the online system, please speak with the Benefits Representative assigned to your location, or contact Human Resources. • If you are an existing employee and unable to log into the online system, please contact the Harmony Help Desk at 866-875-4772 between 8:30am and 6:00pm, or speak with the Benefits Representative assigned to your location. Go to https://harmonyenroll.coloniallife.com 1. • Enter your User Name: ART6Z5N- and then Last Name and then Last 4 of Social Security Number (ART6Z5N-SMITH6789) • Enter your Password: Four digit Year of Birth and then Last 4 of Social Security Number (19766789)
2.
The screen prompts you to create a NEW password [____________________________].
3.
Choose a security question and enter answer [______________________________________].
4.
Click on ‘I Agree’ and then “Enter My Enrollment”.
5.
The screen shows ‘Me & My Family’. Verify that the information is correct and enter the additional required information (title, marital status, work phone, e-mail address). Click ‘Save & Continue’ twice.
6.
The screen allows you to add family members. It is only necessary to enter family member information if adding or including family members in your coverage. Click ‘Continue’.
7.
The screen shows updated personal information. Verify that the information is correct and make changes if necessary. Click ‘Continue’.
8.
The screen shows ‘My Benefits’. Review your current benefits and make changes/selections for the upcoming plan year. • DENTAL (Choose one of the options and click ‘Save & Continue’):
1. If you have existing coverage and would like to keep it without making changes, click ‘Keep This Benefit’; 2. If you would like to enroll in coverage, or change existing coverage, choose your plan in the Enroll section; 3. If you would like to decline coverage, click ‘Decline/Cancel Coverage’ Select family members that you wish to cover by clicking ‘Add a Family Member’.
• VISION* (Choose one of the options and click ‘Save & Continue’):
1. If you would like to enroll in coverage, choose your plan in the Enroll section; 2. If you would like to decline coverage, click ‘Decline/Cancel Coverage’ Select family members that you wish to cover by clicking ‘Add a Family Member’.
• TELEMEDICINE (Choose one of the options and click ‘Save & Continue’):
1. If you have existing coverage and would like to keep it without making changes, click ‘Keep This Benefit’; 2. If you would like to enroll in coverage, or change existing coverage, choose your plan in the Enroll section; 3. If you would like to decline coverage, click ‘Decline/Cancel Coverage’
*EMPLOYEES WILL NEED TO RE-ENROLL IN VISION BENEFITS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING JULY 1, 2020. <<< enrollment instructions continued on next page >>>
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Harmony
HARMONY ONLINE ENROLLMENT CONT.:
• CANCER ASSIST You may enroll online in Cancer Assist coverage. • DISABILITY – NCK1000 You may enroll online in NCK1000 – the North Carolina Educator Disability Plan. • ACCIDENT 1.0 You may enroll online in Accident 1.0; however persons over age 64 applying for coverage and employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative. • MEDICAL BRIDGE You may enroll online in Medical Bridge coverage. • CRITICAL CARE You may enroll online in Critical Care coverage. • TERM LIFE 5000 You may enroll online in Term Life 5000; however, employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative. • WHOLE LIFE 5000 You may enroll online in Whole Life 5000; however, employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative.
9.
Click ‘Finish’.
10.
Click ‘I Agree’ to electronically sign the authorization for your benefit elections.
11.
Click ‘Print a copy of your Elections’ to print a copy of your elections, or download and save the document. Please do not forget this important step!
12.
Click ‘Log out & close your browser window’ and click ‘Log Out’.
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Available soon to ArtSpace Charter School employees! 24/7 access to quality care... on your schedule! Visit with your Benefit Counselor during your upcoming Annual Enrollment! Complete
Teladoc Connect in under 10 minutes to US-based, board certified physicians who can answer questions, diagnose and even prescribe when necessary.
Pharmacy Discount Card Save up to 75% on your prescription medication using our pharmacy discount card. It’s easy to use and accepted at over 50,000 pharmacies nationwide!
Life Assistance Access to professional Life Counselors and specialists who can help you achieve balance in your personal, family and work life is just a call away.
Bill Saver Our Bill Saver program can help reduce the amount you owe for medical and dental bills over $400, often resulting in savings between 25-50%. . Individual Rate PMPM Family Rate PFPM
ü ü ü ü $10.50 $13.50.
We Win When You Win.
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Explanation of Benefits The Call A Doctor Plus program provides your team with fast, convenient, 24/7 access to quality care by phone, video or mobile app. Here is more information about each service offered, including how to access the benefit.
Teladoc – Talk to a doctor in minutes Teladoc provides your team with 24/7 phone or video access to doctors who can diagnose common medical conditions, provide treatment plans, and even write prescriptions when needed. Whether they’re on vacation or it’s 2 in the morning, your team can have access to the care they need, when they need it.
Key Benefits: ! ! ! ! ! !
Talk to a doctor in 10 minutes on average No co-pays, deductibles or per-call charges 92% of issues are resolved on the first call US-based, board-certified doctors Connect 24/7/365 by phone, video or app Get answers, prescriptions and treatment plans
Get Started in 3 Easy Steps! 1. Visit Teladoc.com or call (800) 835-2362 and select the option to ‘set up your account’. 2. Be prepared to provide the following information a. First Name b. Last Name c. Date of Birth d. Zip Code e. Email Address: your primary email address f. Preferred Language g. Gender h. The name of your employer 3. Follow the rest of the steps, complete your medical history and you’re all set! Note: if trying to register online and your account cannot be found, please call (800) 8352362 so that Teladoc’s Client Service team can help you locate and set up your account.
Once you are finished, you can add dependents and download the mobile app.
Contact Teladoc ! Phone: (800) 835-2362 ! Online: www.teladoc.com
Health Advocate – Help for life’s challenges Health Advocate gives your team 24/7 access to a Licensed Professional Counselor for help with personal, family, and work problems. They also have access to a work/life specialist who can help them find a wide range of support resources to help balance their work and life. All it takes is one phone call!
Key Benefits: ! ! ! ! ! !
Support for stress, depression or anxiety Help with work, marital or family issues Network attorneys to assist with legal issues Financial professionals for money matters Childcare and Eldercare services Thousands of online resources
Medical Bill Saver Your team also has access to Health Advocates Medical Bill Saver program. Medical Bill Saver can help your team reduce the cost of uncovered medical and dental bills over $400. It’s easy and can often result in 25 to 50% savings. ! We work directly with doctors and other providers on your behalf ! We have very high success rates of achieving significant savings ! Our work often results in lower out-of-pocket costs ! You become a savvier healthcare consumer through the process ! Everyone in your immediate family can use the service. ! …and much more!
Contact Health Advocate
! Phone: (877) 240-6863 ! Online: members.healthadvocate.com o Select ‘Complete Telehealth’
Pharmacy Discount Card – Save on prescription medication Our FREE pharmacy discount card allows your employees to save up to 75% on your prescription medication using the pharmacy discount card. It’s easy to use and accepted at over 50,000 pharmacies nationwide!
Key Benefits: ! ! ! ! !
Save up to 75% on prescriptions No claim forms to file No deductibles No limits or maximums No pre-existing conditions
Accessing the Discount Card
1. Register for a card at npsncard.com/teladoc a. Provide your personal information, including name, address, email and/or phone b. Click ‘submit’ and a card is sent to you by mail in 3 to 4 weeks c. If selected, your card will be immediately texted to your phone 2. Find a provider. a. Use searchrx.com to search local partners for the lowest possible price b. Search from over 50,000 pharmacies to find the best price 3. Go to your pharmacy of choice and present your card. a. You will pay the discounted rate at the time of purchase by showing your card. b. You will not have to fill out any reimbursement paperwork your savings are immediate!
Contact the Discount Card
! Online: npsncard.com/teladoc
Policyholder: ARTSPACE CHARTER SCHOOL
Voluntary Dental PPO Benefit Summary Predetermination of Benefits: Before treatment begins for inlays, onlays, single crowns, prosthetics, periodontics and oral surgery, you may file a dental treatment plan with Principal Life Insurance Company. Principal Life will provide a written response indicating benefits that may be payable for the proposed treatment. This chart provides you a brief summary of the key benefits of the dental coverage available from Principal Life Insurance Company. Following the chart, you will find additional information to answer questions you may have. For a complete list of all your dental coverage benefits and restrictions, please refer to your booklet or contact your employer. Eligibility Job Class
ALL MEMBERS
Benefits Payable Network
Unit 1 – Preventive Unit 2 – Basic Unit 3 – Major
Dental Preferred Provider Organization (PPO)
Calendar Year Deductible In-Network Non-Network
Coinsurance (Policy Pays) In-Network Non-Network
$0
$0
100%
100%
$50
$50
80%
80%
$50
$50
50%
50%
Family Deductible Maximum
3 times the per person deductible amount
Combined Deductible
In-network deductibles for basic and major procedures are combined. Non-network deductibles for basic and major procedures are combined.
Combined Maximums
Maximums for preventive, basic, and major procedures are combined. In-network Calendar year maximums are $1,000 per person. Non-network Calendar year maximums are $1,000 per person.
Maximum Accumulation
This allows for a portion of unused maximum benefit to carry over to next year's maximum benefit amount. To qualify, you must have had a dental service performed within the Calendar year and used less than the maximum threshold. The threshold is equal to the lesser of 50% of the maximum benefit or $1000. If qualification is met, 50% of the threshold is carried over to next year's maximum benefit. You can accumulate no more than four times the carry over amount.
Emergency Services
If a member requires treatment or service for an emergency dental condition, benefits for such treatment or service received from a non-preferred dental provider will be paid as if the treatment or service had been provided by a preferred dental provider. The member must provide information either with the claim or during an appeal that identifies the situation as an emergency.
Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
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$42.20 $85.32 $96.02 $144.50
07/2017
VOLUNTARY DENTAL
Participating Provider Services
If treatment or service for a listed covered charge is not available within 35 miles travel distance through a preferred dental provider without unreasonable delay* and the person receives such treatment or service from a non-preferred dental provider, that dental provider will be reimbursed at the same benefits as the preferred dental provider would have been reimbursed. The member must provide information either before the claim is submitted or with the claim or during an appeal that informs Principal Life why it was necessary for the member to utilize a non-preferred provider versus a preferred provider. *Urgent Care: General Dentists Oral Surgeons Orthodontists Other Specialists
90% within 24 hours 100% within 24 hours 100% within 24 hours 100% within 24 hours
*Routine Care: General Dentists Oral Surgeons Orthodontists Other Specialists
85% within 12 weeks 90% within 8 weeks 90% within 8 weeks 90% within 8 weeks.
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VOLUNTARY DENTAL
How Are Dental Procedures Covered? The list of common procedures shows what unit the procedure is included in and how often they are covered.
Unit 1 – Preventive Procedures
• • • • • • • • •
Unit 2 – Basic Procedures
•
• • • Unit 3 – Major Procedures
• • • • • • • • • • •
Routine exams - one per six months Routine cleaning (prophylaxis) - one per six months (Expectant mothers, diabetics and those with heart disease receive one additional routine or periodontal cleaning within a calendar year.) Second Opinion Consultation Fluoride – one treatment each calendar year (covered only for dependent children under age 16) Space maintainers - covered only for dependent children under age 16; repairs not covered Sealants – on first and second permanent molars for dependent children under age 16; one each tooth each 36 months Harmful Habit Appliance - covered only for dependent children under age 16 X-rays - Bitewing (one set every calendar year), occlusal, periapical X-rays – Full mouth survey (one every 60 months), extraoral Periodontal prophylaxis - if three months have elapsed after active surgical periodontal treatment; subject to Routine cleaning frequency limit (Expectant mothers, diabetics and those with heart disease receive one additional routine or periodontal cleaning within a calendar year.) Emergency exams – subject to Routine exam frequency limit Fillings and stainless steel crowns Simple Oral Surgery General Anesthesia (covered only for specific procedures)/IV Sedation Complex Oral Surgical Procedures Non-surgical Periodontics, including scaling and root planing - once each quadrant each 24 months (For expectant mothers, diabetics and those with heart disease, this procedure is provided with no deductible and 100% coinsurance.) Periodontal Surgical Procedures – one each quadrant each 36 months Simple Endodontics (root canal therapy for anterior teeth) Complex Endodontics (root canal therapy for molar teeth) Repairs to Partial Denture, Bridge, Crown, Relines, Rebasing, Tissue Conditioning and Adjustment to Bridge/Denture, within policy limitations Crowns – each 120 months per tooth if tooth cannot be restored by a filling. Inlays, Onlays, Cast Post and Core, Core Buildup - each 120 months per tooth Bridges - Initial placement / Replacement of bridges 120 months old. Dentures - Initial placement of complete or partial dentures / Replacement of complete or partial dentures over 60 months old
There is Coordination of Benefits, which is a procedure for limiting benefits from two or more carriers to 100% of the claimant's covered expenses.
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VOLUNTARY DENTAL
Understanding Your Dental Benefits Am I Eligible For Coverage? To be eligible for coverage, you must qualify as an eligible member and be considered actively at work.
You must be enrolled for dental coverage before it can be offered to your dependents. Eligible dependents include your spouse and children. Additional eligibility requirements may apply.
An annual enrollment applies. Members can enroll for dental coverage during the annual enrollment period and not be subject to the late entrant waiting period. Certain restrictions apply.
How Do I Find A Participating Provider?
Use the Provider Directory on www.principal.com to locate nearby dentists or see if your dentist participates in your network. 1
Visit www.principal.com/dentist.
2
Begin your search by picking the state where you would like to find a provider. Next, specify a network. Depending on the network chosen, you may be transferred to a partner site.
3
Enter the name of the provider you are looking for (if known). If you are looking for a nearby dentist, enter the city and state and/or ZIP code. Be sure to indicate how far you are willing to travel.
4
Select the desired specialty or use the No Specialty Preference default. Click Continue.
5
Select a language if your preference is other than English. Click Continue.
You may nominate your dentist for inclusion in our network. Please submit the dentist's name, address, phone and specialty by calling 1-800-832-4450, or submit through www.principal.com/refer-dental-provider.
What Are The Restrictions Of My Coverage? This Benefit Summary is a summary only. For a complete list of benefit restrictions, please refer to your booklet. Limitations & Exclusions Late Entrant Provision
Those members enrolling more than 31 days after becoming eligible will be subject to an individual benefit waiting period, subject to policy guidelines.
Missing Tooth
Benefits for the initial placement of bridges, partials and dentures are not covered if those teeth were missing prior to becoming insured under the Principal Life policy. When the policy replaces coverage under a prior plan, continuous coverage under the prior plan may be applied to the missing tooth provision requirement.
Prevailing Charge
When using non-network providers, you pay any amount over the allowable charge.
Other Limitations
There are additional limitations to your coverage. A complete list is included in your booklet.
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Vision plan benefits for ArtSpace Charter School Copays
Services/frequency
Monthly premiums
Exam
$15
Emp. only
Materials1
$15
Contact lens fitting
$25
Emp. + 1 dependent Emp. + family
$8.22
Exam
12 months
$14.06 $24.24
Frame
24 months
Contact lens fitting
12 months
Lenses
12 months
Contact lenses
12 months
(standard & specialty)
(Based on date of service)
Benefits through Superior National network Exam (ophthalmologist) Exam (optometrist) Frames Contact lens fitting (standard2) Contact lens fitting (specialty2) Lenses (standard) per pair Single vision Bifocal Trifocal Progressives lens upgrade Polycarbonate for Dependent Children Contact lenses4
In-network
Out-of-network
Covered in full Covered in full $130 retail allowance Covered in full $50 retail allowance
Up to $44 retail Up to $39 retail Up to $52 retail Not covered Not covered
Covered in full Covered in full Covered in full See description3 Covered in full $130 retail allowance
Up to $26 retail Up to $34 retail Up to $50 retail Up to $50 retail Not covered Up to $100 retail
Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1 Materials co-pay applies to lenses and frames only, not contact lenses 2 Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting applies to new contact wearers and/or a member who wear toric, gas permeable, or multi-focal lenses. 3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 4 Contact lenses are in lieu of eyeglass lenses and frames benefit
Discount features
superiorvision.com
Look for providers in the provider directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-30%) prior to service as they vary.
(800) 507-3800
Discounts on covered materials Frames: Lens options: Progressives:
20% off amount over allowance 20% off retail 20% off amount over retail lined trifocal lens, including lens options Specialty contact lens fit: 10% off retail, then apply allowance
Discounts on non-covered exam, services and materials
Maximum member out-of-pocket The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) lenses. Scratch coat Ultraviolet coat Tints, solid or gradients Anti-reflective coat Polycarbonate High index 1.6 Photochromics 5
Single vision $13 $15 $25 $50 $40 $55 $80
Bifocal & trifocal $13 $15 $25 $50 20% off retail 20% off retail 20% off retail
Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, miscellaneous options: 20% off retail Disposable contact lenses: 10% off retail Retinal imaging: $39 maximum out-of-pocket
LASIK Laser vision correction (LASIK) is a procedure that can reduce or eliminate your dependency on glasses or contact lenses. This corrective service is available to you and your eligible dependents at a special discount (20-50%) with your Superior Vision plan. Contact QualSight LASIK at (877) 201-3602 for more information.
Discounts and maximums may vary by lens type. Please check with your provider.
The Plan discount features are not insurance.
North Carolina residents: Please contact our customer service department if you are unable to secure a timely (at least 30 days) appointment with your provider or need assistance finding a provider within a reasonable distance (30 miles) of your residence. Adjustments to your benefits may be available
All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions. Superior Vision Services, Inc. P.O. Box 967 Rancho Cordova, CA 95741 (800) 507-3800 superiorvision.com The Superior Vision Plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, AKA The Guardian or Guardian Life NVIGRP 5-07 0520-BSv2/NC
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Policyholder: ARTSPACE CHARTER SCHOOL
Group Term Life Benefit Summary This chart provides you a brief summary of the key benefits of the life coverage available from Principal Life Insurance Company. Following the chart, you will find additional information to answer questions you may have. For a complete list of all your life coverage benefits and restrictions, please refer to your booklet or contact your employer. Eligibility Job Class
ALL MEMBERS
Benefits Payable Employee Life Benefits Benefit Amount Proof of Good Health
$20,000 Proof of good health is required for life insurance amounts greater than: If you are Under 70: $20,000 If you are 70 and older:
Age Reductions
The lesser of $20,000 or the amount with the prior carrier 35% benefit reduction at age 65, with an additional 15% reduction at age 70. Age reductions apply to the benefit amount after proof of good health .
Additional Employee Benefits Coverage During Disability Accelerated Death Benefit Individual Purchase Rights
If you become disabled before age 60, coverage will continue and premium may be waived.
Coverage Outside of the US
Benefits will not be paid if you are outside the United States for certain reasons for more than six months.
If you are terminally ill, you may be able to receive a portion of your life coverage benefit as a lump sum. If you terminate employment, you may be able to convert coverage to an individual policy.
Limitations & Exclusions
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GROUP TERM LIFE
Accidental Death & Dismemberment (AD&D) Coverage Benefit Amount
Your benefit is equal to your group term life benefit amount if loss is due to accident or injury. If loss is due to exposure to the elements or disappearance, your loss may be covered. You may be paid: • Full benefit when you lose: your life / both hands / both feet / sight of both eyes / one hand and sight of one eye / one foot and sight of one eye / one hand and one foot. • Half of the benefit when you lose: one hand / one foot / sight of one eye. • One-fourth of the benefit when you lose the thumb and index finger on the same hand. The loss must occur within 365 days of the accident.
Additional Benefits Seatbelt/Airbag Education Repatriation Loss of Use/Paralysis
Loss of Speech and/or Hearing
$10,000 if you are wearing a seatbelt or are protected by an airbag and die in an automobile accident $3,000 per year for up to four years for dependent(s) enrolled at an accredited post-secondary school at the time of your death Up to $2,000 for preparation and transportation of your body if you die at least 100 miles from your permanent residence For total and irrevocable loss of voluntary movement for 12 consecutive months or paralysis that is permanent, complete and irreversible, the benefit is: 100% for quadriplegia; 50% for paraplegia, hemiplegia, loss of use of both hands or both feet, or loss of use of one hand and one foot; or 25% for loss of use of one arm, one leg, one hand or one foot When loss is irrevocable and continues for 12 consecutive months, the benefit is: 100% for loss of both speech and hearing; 50% for loss of speech or hearing; 25% for loss of hearing in one ear
Limitations & Exclusions Other Limitations
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The Benefit Summary is a summary only. For a complete list of benefit restrictions, please refer to your booklet.
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GROUP TERM LIFE
Understanding Your Life Coverage Benefits Am I Eligible For Coverage? To be eligible for coverage, you must qualify as an eligible member and be considered actively at work. You will be considered actively at work if you are able and available for active performance of all of your regular duties. Short-term absence because of a regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal time off is considered active work provided you are able and available for active performance of all of your regular duties and were working the day immediately prior to the date of your absence. Spouse and child coverage is not available.
What Additional Benefits Are Included? Coverage During Disability
Accelerated Death Benefit
Individual Purchase Rights
Claim Processing
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If you become totally disabled before age 60, coverage will continue and premium will be waived. You must be totally disabled for 9 months before the waiver begins. Coverage continues without premium payment until you recover or for two years, whichever occurs first. If you are terminally ill you can receive up to 75% of your benefit amount in a lump sum, not to exceed $250,000, as long as: • Your life expectancy is 12 months or less (as diagnosed by a physician), and • Your death benefit is at least $10,000. If you use the accelerated benefit, your death benefit is reduced by the accelerated benefit payment. There are possible tax consequences to receiving an accelerated benefit payment. You should contact your tax advisor for details. Receipt of accelerated benefits could also affect eligibility for public assistance. The charge for this benefit is included in the premium. If you terminate employment, you may be able to convert coverage to individual life coverage. Upon coverage termination your employer is required to inform you of your individual purchase rights to convert to an individual policy without proof of good health. The amount you can purchase varies depending on the termination situation. Contact Principal Life for details. Principal Life makes claim administration easy and convenient for employers by offering an online life claim form. Once the form is complete, employers submit the information directly over a secure, confidential Web site, expediting the claim review process. The employer can choose to use the online form or a printable version that can be faxed or mailed. Along with the online claim form, Principal Life also provides Express Claim Processing for claims that meet certain criteria. Through the Express Claim Process, decisions are reached within five working days without the employer or beneficiary submitting paperwork.
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07/2017
Cancer Insurance Our Cancer Assist plan helps employees protect themselves and their loved ones through their diagnosis, treatment and recovery journey. This individual voluntary policy pays benefits that can be used for both medical and/or out-of-pocket, non-medical expenses traditional health insurance may not cover. Available exclusively at the workplace, Cancer Assist is an attractive addition to any competitive benefits package that won’t add costs to a company’s bottom line.
Competitive advantages Composite rates. Four distinct plan levels, each featuring the same benefits with premiums and benefit amounts designed to meet a variety of budgets and coverage needs (benefits overview on reverse). Indemnity-based benefits pay exactly what’s listed for the selected plan level. The plan’s Family Care Benefit provides a daily benefit when a covered dependent child receives inpatient or outpatient cancer treatment. Employer-optional cancer wellness/health screening benefits available: Part One covers 24 tests. If selected, the employer chooses one of four benefit amounts for employees: $25, $50, $75 or $100. This benefit is payable once per covered person per calendar year. Part Two covers an invasive diagnostic test or surgical procedure if an abnormal result from a Part One test requires additional testing. This benefit is payable once per calendar year per covered person and matches the Part One benefit.
Flexible family coverage options Individual, Individual/Spouse, One-parent and Two-parent family policies. Family coverage includes eligible dependent children (to age 26) for the same rate, regardless of the number of children covered.
Attractive features Available for businesses with 3+ eligible employees. Broad range of policy issue ages, 17-75. Each plan level features full schedule of 30+ benefits and three optional riders (benefit amounts may vary based on plan level selected). Benefits don’t coordinate with any other coverage from any other insurer. HSA compliant. Guaranteed renewable. Portable. Waiver of premium if named insured is disabled due to cancer for longer than 90 consecutive days and the date of diagnosis is after the waiting period and while the policy is in force. Form 1099s may not be issued in most states because all benefits require that a charge is incurred. Discuss details with your benefits representative, or consult your tax adviser if you have questions.
Talk to your benefits representative today to learn more about this product and how it helps provide extra financial protection to employees who may be impacted by cancer.
Optional riders (available at an additional cost/payable once per covered person) Initial Diagnosis of Cancer Rider pays a one-time benefit for the initial diagnosis of cancer. A benefit amount in $1,000 increments from $1,000-$10,000 may be chosen. The benefit for covered dependent children is two and a half times ($2,500-25,000) the chosen benefit amount. Initial Diagnosis of Cancer Progressive Payment Rider pays a $50 lump-sum payment for each month the rider has been in force, after the waiting period, once cancer is first diagnosed. The issue ages for this rider are 17-64. Specified Disease Hospital Confinement Rider pays $300 per day for confinement to a hospital for treatment of one of 34 specified diseases covered under the rider.
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INDIVIDUAL CANCER INSURANCE
Cancer Assist Benefits Overview This overview shows benefits available for all four plan levels and the range of benefit amounts payable for most common cancer treatments. Each benefit is payable for each covered person under the policy. Actual benefits vary based on the plan level selected.
Radiation/Chemotherapy
Injected chemotherapy by medical personnel: $250-$1,000 once per calendar week Radiation delivered by medical personnel: $250-$1,000 once per calendar week Self-injected chemotherapy: $150-$400 once per calendar month Topical chemotherapy: $150-$400 once per calendar month Chemotherapy by pump: $150-$400 once per calendar month Oral hormonal chemotherapy (1-24 months): $150-$400 once per calendar month Oral hormonal chemotherapy (25+ months): $75-$200 once per calendar month Oral non-hormonal chemotherapy: $150-$400 once per calendar month
Anti-nausea Medication
$25-$60 per day, up to $100-$240 per calendar month
Medical Imaging Studies
$75-$225 per study, up to $150-$450 per calendar year
Outpatient Surgical Center
$100-$400 per day, up to $300-$1,200 per calendar year
Skin Cancer Initial Diagnosis
$300-$600 payable once per lifetime
Surgical Procedures
Inpatient and Outpatient Surgeries: $40-$70 per surgical unit, up to $2,500-$6,000 per procedure
Reconstructive Surgery
$40-$60 per surgical unit, up to $2,500-$3,000 per procedure including 25% for general anesthesia
Anesthesia
General: 25% of Surgical Procedures Benefit Local: $25-$50 per procedure
Hospital Confinement Each benefit requires that charges are incurred for treatment. All benefits and riders are subject to a 30-day waiting period. Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. States without a waiting period will have a pre-existing condition limitation. Product has exclusions and limitations that may affect benefits payable. Benefits vary by state and may not be available in all states. See your Colonial Life benefits representative for complete details.
30 days or less: $100-$350 per day 31 days or more: $200-$700 per day
Family Care
Inpatient and outpatient treatment for a covered dependent child: $30-$60 per day, up to $1,500-$3,000 per calendar year
Second Medical Opinion on Surgery or Treatment $150-$300 once per lifetime
Home Health Care Services
Examples include physical therapy, speech therapy, occupational therapy, prosthesis and orthopedic appliances, durable medical equipment: $50-$150 per day, up to the greater of 30 days per calendar year or twice the number of days hospitalized per calendar year
Hospice Care
Initial: $1,000 once per lifetime Daily: $50 per day $15,000 maximum for initial and daily hospice care per lifetime
Transportation and Lodging
Transportation for treatment more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip Companion Transportation (for any companion, not just a family member) for commercial travel when treatment is more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip Lodging for the covered person or any one adult companion or family member when treatment is more than 50 miles from the covered person’s home: $50-$80 per day, up to 70 days per calendar year
ColonialLife.com © 2014 Colonial Life & Accident Insurance Company Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 1-14 | 101478
Benefits also included in each plan
Air Ambulance, Ambulance, Blood/Plasma/Platelets/Immunoglobulins, Bone Marrow or Peripheral Stem Cell Donation, Bone Marrow Donor Screening, Bone Marrow or Peripheral Stem Cell Transplant, Cancer Vaccine, Egg(s) Extraction or Harvesting/Sperm Collection and Storage (Cryopreservation), Experimental Treatment, Hair/External Breast/Voice Box Prosthesis, Private Full-time Nursing Services, Prosthetic Device/Artificial Limb, Skilled Nursing Facility, Supportive or Protective Care Drugs and Colony Stimulating Factors
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INDIVIDUAL CANCER INSURANCE
Cancer Insurance Wellness Benefits
To encourage early detection, our cancer insurance offers benefits for wellness and health screening tests.
Part One: Cancer Wellness/Health Screening Provided when one of the tests listed below is performed after the waiting period and while the policy is in force. Payable once per calendar year, per covered person.
Cancer Wellness Tests .
Health Screening Tests
Bone marrow testing
Blood test for triglycerides
Breast ultrasound
Carotid Doppler
CA 15-3 [blood test for breast cancer]
Echocardiogram [ECHO]
CA 125 [blood test for ovarian cancer]
Electrocardiogram [EKG, ECG]
CEA [blood test for colon cancer]
Fasting blood glucose test
Chest X-ray
.
Serum cholesterol test for HDL and LDL levels
.
Stress test on a bicycle or treadmill
Colonoscopy .
Flexible sigmoidoscopy Hemoccult stool analysis Mammography
.
Pap smear PSA [blood test for prostate cancer]
.
Serum protein electrophoresis [blood test for myeloma]
.
Skin biopsy Thermography ThinPrep pap test Virtual colonoscopy
For more information, talk with your benefits counselor.
©2014 Colonial Life & Accident Insurance Company Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 1-14
Part Two: Cancer Wellness — Additional Invasive Diagnostic Test or Surgical Procedure Provided when a doctor performs a diagnostic test or surgical procedure after the waiting period as the result of an abnormal result from one of the covered cancer wellness tests in Part One. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.
Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. The policy has exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable – for example: CanAssist-TX).
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CANCER ASSIST WELLNESS – 101486
Group Specified Disease Insurance Plan 3 Full
If you’re diagnosed with a covered specified disease, group specified disease insurance* from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery. *The policy name is Specified Disease Group Insurance.
Face amount: $_______________ Plan features
A lump-sum payment that can be used as you see fit Adjustable face amount to best meet your personal needs May pay multiple times for a covered specified disease Guaranteed renewable Portable
Specified disease benefit For the diagnosis of this covered specified disease condition:1
For more information, talk with your benefits counselor.
ColonialLife.com
This percentage of the face amount is payable:
Heart attack (myocardial infarction)
100%
Stroke
100%
End-stage renal (kidney) failure
100%
Major organ failure
100%
Coma
100%
Permanent paralysis due to a covered accident
100%
Blindness
100%
Occupational infectious HIV or occupational infectious hepatitis B, C or D
100%
Coronary artery bypass graft surgery/disease2
25%
Subsequent diagnosis of a different specified disease3 If you receive a benefit for a specified disease, and later you are diagnosed with a different specified disease, the original percentage of the face amount is payable for that particular specified disease. Subsequent diagnosis of the same specified disease3 If you receive a benefit for a specified disease, and later you are diagnosed with the same specified disease, 25% of the original face amount is payable. Specified disease conditions that do not qualify are: coronary artery bypass graft surgery/coronary artery disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.
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GROUP CRITICAL CARE PLAN 3 FULL - GUARANTEED RENEWABLE
1 Please refer to the certificate for complete definitions of covered conditions.
ColonialLife.com
2 Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass graft surgery when health savings account (HSA) compliant plan is selected. 3 Dates of diagnoses of a covered specified disease must be separated by at least 180 days. THIS POLICY PROVIDES LIMITED BENEFITS.
EXCLUSIONS AND LIMITATIONS FOR SPECIFIED DISEASE We will not pay the Specified Disease Benefit or Benefit Payable Upon Subsequent Diagnosis of a Specified Disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; psychiatric or psychological conditions; suicide or injuries which any covered person intentionally does to himself; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a specified disease. This is not an insurance contract and only the actual certificate provisions will control. Applicable to certificate form GCC1.0-C-GR-NC. Please see your Colonial Life benefits counselor for details.
Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC Š2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
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2-17 | NS-15526
Group Specified Disease Insurance First Diagnosis Building Benefit Rider (Specified Disease)
A specified disease can have a big impact on your finances. To help protect your way of life, you can add the first diagnosis building benefit rider to your group specified disease coverage. Available at an additional cost, the rider provides a lump-sum benefit when a covered specified disease* is first diagnosed.
First diagnosis building benefit rider Payable once per covered person per lifetime
¾ Named insured ............................................................ Accumulates $1,000 each year ¾ Covered spouse/dependent child ..................................... Accumulates $500 each year
The rider covers the same family members as your group specified disease insurance. The benefit amount accumulates each year the rider is in force before a diagnosis is made, up to a maximum of 10 years. If you are diagnosed with a covered specified disease before the end of the first rider year, the rider will pay one-half of the annual building benefit amount.
For more information, talk with your benefits counselor.
ColonialLife.com
* Conditions that do not apply to the rider include coronary artery bypass graft surgery/coronary artery disease. Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass graft surgery when health savings account (HSA) compliant plan is selected.
The certificate to which the rider is attached has exclusions and limitations. This is not an insurance contract and only the actual certificate provisions will control. Applicable to rider form R-GCC1.0-BB-NC. Please see your Colonial Life benefits counselor for details. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. GROUP CRITICAL CARE FIRST DIAGNOSIS BUILDING BENEFIT RIDER – SPECIFIED DISEASE | 1-17 | 100584-1
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Specified Disease Insurance Health Screening Benefit
The optional health screening benefit can help you reduce the risk of serious illness through early detection. Health screening benefit ................................................................ $_______________ Maximum of one screening test per covered person per calendar year.
Blood test for triglycerides
Pap smear
Bone marrow testing
PSA (blood test for prostate cancer)
Breast ultrasound
Serum cholesterol test for HDL and LDL levels
CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) Carotid Doppler CEA (blood test for colon cancer) Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG)
For more information, talk with your benefits counselor.
Fasting blood glucose test
Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy
Flexible sigmoidoscopy Hemoccult stool analysis Mammography
ColonialLife.com
For cost and complete details, see your Colonial Life benefits counselor. Applicable to form CI-1.0-NC and GCC1.0-P-NC. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2016 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. GROUP CRITICAL CARE, CRITICAL ILLNESS 1.0 – HEALTH SCREENING BENEFIT | 12-16 | 100595-2
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Educator Income Protection Insurance
How long could you afford to go without a paycheck? Monthly Expenses:
$_________________ Mortgage/rent
$_________________ Groceries
$_________________ Car
$_________________ Medical bills
$_________________ Utilities
$_________________ Other Total $_________________
Colonial Life’s Income Protection for School Personnel in North Carolina was designed especially to supplement existing state plans in North Carolina and help protect your paycheck.
My Coverage Worksheet (For use with your Colonial Life Benefits Counselor) Employee Coverage (includes both on- and off-job benefits) How much coverage do I need? On-Job Accident/On-Job Sickness $_____________ Off-Job Accident/Off-Job Sickness $_____________
= Total Disability
On-Job
Off-Job
First 3 months
$_____________/month
$_____________/month
Next 9 months
$_____________/month
$_____________/month
$____________/month
$_____________/month
= Partial Disability
Up to 3 months
When will my benefits start? After an Accident: ___________ days
After a Sickness: ___________ day
What additional features are available? l.
Normal pregnancy is covered the same as any other covered sickness.
l..
Waiver of Premium.
NCK 1000
l
You’re eligible for most benefits from the first day of your covered accident – including weekends, holidays and summer vacation – with no waiting period. Disability benefits may have an elimination period.
How much will it cost? Your cost will vary based on the level of coverage you select.
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Employee Coverage In addition to disability coverage, this plan also provides employees with benefits for medical fees related to accidents, hospital confinement, accidental death and dismemberment, as well as fractures and dislocations. Even if you’re not disabled, the following benefits are payable for covered accidental injuries: Even if you’re not disabled, the following benefits are payable for covered accidental injuries:
Medical Fees for Accidents Only Medical Fees are for doctor office visits, X-rays, and hospital emergency room expenses, including supplies used. Up to ................................................................................................................................................................................................. $350
Hospital Confinement Benefit for Accident or Sickness Pays in addition to disability benefit. l
Benefits begin on the first day of confinement in a hospital for a covered accident or covered sickness. Up to 3 months .................................................................................................................... $1,200/month ($40/day) The Hospital Confinement benefit increases to $6,200/month when the Total Disability benefit ends at age 70.
Accidental Death and Dismemberment Benefits Benefits payable for death or dismemberment occurring within 90 days from date of accident. l. l
l
l
Accidental Death .............................................................................................................................................................. $10,000 Loss of a Finger or Toe Single Dismemberment ................................................................................................................................................. $750 Double Dismemberment ............................................................................................................................................$1,500 Loss of a Hand, Foot or Sight of an Eye Single Dismemberment ..............................................................................................................................................$5,000 Double Dismemberment ......................................................................................................................................... $10,000 Common Carrier Death (includes school bus for school activities) .............................................................. $20,000
Complete Fractures Complete Fractures requiring closed reduction Hip, Thigh ....................................................................................................................................................................................$1,500 Vertebrae ....................................................................................................................................................................................... 1,350 Pelvis ............................................................................................................................................................................................... 1,200 Skull (depressed) ......................................................................................................................................................................... 1,125 Leg .......................................................................................................................................................................................................900 Foot, Ankle, Kneecap .....................................................................................................................................................................750 Forearm, Hand, Wrist .....................................................................................................................................................................750 Lower Jaw ..........................................................................................................................................................................................600 Shoulder Blade, Collarbone ........................................................................................................................................................600 Skull (simple) ....................................................................................................................................................................................525 Upper Arm, Upper Jaw .................................................................................................................................................................525 Facial Bones ......................................................................................................................................................................................450 Vertebral Processes ........................................................................................................................................................................300 Coccyx, Rib, Finger, Toe ................................................................................................................................................................120
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Complete Dislocations .Complete Dislocations requiring closed reduction with anesthesia Hip ...................................................................................................................................................................................................$1,350 Knee .....................................................................................................................................................................................................975 Shoulder .............................................................................................................................................................................................750 Collarbone ..........................................................................................................................................................................................675 Ankle, Foot .........................................................................................................................................................................................600 Hand .....................................................................................................................................................................................................525 Lower Jaw ...........................................................................................................................................................................................450 Wrist .....................................................................................................................................................................................................375 Elbow ...................................................................................................................................................................................................300 One Finger, Toe .................................................................................................................................................................................120 l
For a fracture or dislocation requiring an open operation, your benefit would be 1½ times the amount shown.
l
For a chip fracture, your benefit would be 25% of the amount shown. Chip fractures are those in which a fragment of bone is broken off near a joint at a point where a ligament is attached.
l
For multiple fractures or dislocations, you would receive each amount, up to a total of 1½ times the highest amount.
l
For your first dislocation, you would receive the amount shown; however, recurrent dislocations of the same joint are not covered.
Optional Spouse and Dependent Coverage You may cover one or all of the eligible dependent members of your family for an additional premium. Eligible dependents include your spouse and ALL dependent children who are younger than age 26.
Medical Fees for Accidents Only Medical Fees are for doctor office visits, X-rays, and hospital emergency room expenses, including supplies used. Up to ................................................................................................................................................................................................... $350
Hospital Confinement Benefit for Accident or Sickness
l
Up to 3 months........................................................................................................................ $1,200/month ($40/day)
Accidental Death and Dismemberment Benefits
l
Accidental Death.........................................................................................................................................................$1,000
l
Loss of a Finger or Toe
Single Dismemberment............................................................................................................................................$75
Double Dismemberment...................................................................................................................................... $150
l
Loss of a Hand, Foot or Sight of an Eye
Single Dismemberment......................................................................................................................................... $500
Double Dismemberment...................................................................................................................................$1,000
l
Common Carrier Death (includes school bus for school activities) ........................................................ $2,000
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Here are some
frequently asked questions about Colonial Life’s Educator Income Protection insurance:
Will my disability income payment be reduced if I have other insurance?
How do I file a claim Visit coloniallife.com or call our Policyholder Service Center at 1.800.325.4368 for additional information.
You’re paid regardless of workers’ compensation or any other insurance you may have with other insurance companies. Benefits are paid directly to you (unless you specify otherwise).
What is a pre-existing condition? A pre-existing condition means a sickness or physical condition for which any covered person was treated, received medical advice, or had taken medication within 12 months before the effective date of the policy. If you are age 65 or older when the policy is issued, pre-existing conditions include only conditions specifically excluded from coverage by the rider.
When am I considered totally disabled? Totally disabled means you are: l Unable to perform the material and substantial duties of your job; l Not, in fact, working at any job; and l Under the regular and appropriate care of a doctor.
If you become disabled due to a pre-existing condition, we will not pay for any disability period if it begins during the first 12 months the policy is in force.
What if I want to return to work part-time after I am totally disabled? You may be able to return to work part-time and still receive benefits. We call this “Partial Disability.” This means you may be eligible for coverage if: l You are unable to perform the material and substantial duties of your job for 20 hours or more per week, l You are able to work at your job or your place of employment for less than 20 hours per week, l Your employer will allow you to return to your job or place of employment for less than 20 hours per week; and l You are under the regular and appropriate care of a doctor. The total disability benefit must have been paid for at least one full month immediately prior to your being partially disabled.
When do disability benefits end? The Total Disability Benefit will end on the policy anniversary date on or next following your 70th birthday. The Hospital Confinement benefit increases when the Total Disability Benefit ends.
What if I change employers or retire?
What is a covered accident or a covered sickness? A covered accident is an accident. A covered sickness means an illness, infection, disease or any other abnormal physical condition. A covered accident or covered sickness: Occurs after the effective date of the policy; l Occurs while the policy is in force; and l Is of a type listed on the Policy Schedule; and l Is not excluded by name or specific description in the policy. l
EXCLUSIONS We will not pay benefits for losses that are caused by or are the result of: alcoholism or drug addiction; flying; hazardous avocations; felonies or illegal occupations; having a pre-existing condition as defined and limited by the policy; psychiatric or psychological condition; racing; semi-professional or professional sports; suicide or self-inflicted injury, war or armed conflict. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form NCK1000-NC. This is not an insurance contract and only the actual policy provisions will control. NCK 1000
If you change jobs or retire, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable for life as long as you pay your premiums when they are due or within the grace period.
Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com
© 2013 Colonial Life & Accident Insurance Company Colonial Life are underwritten byLife Colonial Life & Accident Colonial Life products are products underwritten by Colonial & Accident Insurance Insurance Company, for which Colonial Life is the marketing brand. Company, for which Colonial Life is the marketing brand. 71381-1 7/13 62617-4
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Policyholder: ARTSPACE CHARTER SCHOOL
Voluntary Long Term Disability (LTD) Benefit Summary
This chart provides you a brief summary of the key benefits of the long-term disability coverage available from Principal Life Insurance Company. Following the chart, you will find additional information to answer questions you may have. For a complete list of all your long-term disability coverage benefits and restrictions, please refer to your booklet or contact your employer. Eligibility Job Class
MBRS ELECTING HIGH LTD PLAN
Eligible Members
All active, full time employees (except seasonal, temporary, or contract workers) who work at least 20 hours per week
Primary Monthly Benefit
60% of your predisability earnings up to $5,000.
Benefit Amount
Primary monthly benefit less other income sources
Definition of Earnings
Contract Salary - 12 months
Elimination Period
90 days
Own Occupation Period
2 years
Maximum Benefit Payment Period
To age 65
Benefits Payable
Benefit Qualification
Additional Benefits Rehabilitation Incentive Benefit
5% increase in the monthly benefit percentage
Survivor Benefit
Three times your primary monthly benefit less other income sources to your survivor.
Pre-Existing Conditions
12 months prior/12 months insured
Other Limitations
There are additional limitations to your coverage. A complete list is included in your booklet.
Limitations & Exclusions
Principal Long Term Disability Rates Age High Option <24 $0.13 / $100 25-29 $0.22 / $100 30-34 $0.30 / $100 35-39 $0.42 / $100 40-44 $0.67 / $100 45-49 $0.82 / $100 50-54 $1.00 / $100 55-59 $1.32 / $100 60-64 $1.23 / $100 65-69 $0.51 / $100 70-74 $0.25 / $100 05091710435 - 1
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07/2017
VOLUNTARY LONG-TERM DISABILITY
Understanding Your Long-Term Disability (LTD) Benefits Am I Eligible For Coverage? To be eligible for coverage, you must qualify as an eligible member and be considered actively at work. You will be considered actively at work if you are able and available for active performance of all of your regular duties. Short term absence because of a regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal time off is considered active work provided you are able and available for active performance of all of your regular duties and were working the day immediately prior to the date of your absence.
How Do I Qualify For Benefits? 1) Meet the Definition of Disability. Disabilities must be solely and directly caused by injury or sickness (including pregnancy). During the elimination period and the own occupation period, one of these situations must apply: After completing the own occupation period, one of these situations apply:
• •
• •
You cannot perform the majority of the substantial and material duties of your own occupation. You are performing the duties of your own occupation on a modified basis or any occupation and are unable to earn more than 80% of your indexed predisability earnings.
You cannot perform the majority of the substantial and material duties of any occupation for which you are or may reasonably become qualified based on education, training, or experience. You are performing the substantial and material duties of your own occupation or any occupation on a modified basis and are unable to earn more than 60% of your indexed predisability earnings.
2) Satisfy the Elimination Period. The amount of time you must be disabled before receiving benefits is called the elimination period. Long-Term Disability benefits begin after you have been disabled for 90 days. The elimination period can be satisfied with days of total or partial disability.
If you recover and return to work during the elimination period and become disabled again, you may not have to satisfy a new elimination period. If you become disabled again, your elimination period will pick up at the point where it was left off when you recovered. You have a period twice as long as the elimination period to satisfy the required number of days of disability.
How Much Monthly Benefit Will I Receive? Your benefits will be determined based on your Contract Salary - 12 months. When you are unable to work in any capacity during the benefit payment period, your monthly benefit equals your primary monthly benefit, less income from other sources.
05091710435 - 1
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07/2017
VOLUNTARY LONG-TERM DISABILITY
Your primary monthly benefit is equal to 60% of your predisability earnings, but will not exceed $5,000. Your monthly benefit will not be less than the minimum monthly benefit of $100. Benefits if Working If you are able to work while disabled, you may still be eligible to receive a disability benefit. If you are working during the benefit payment period, your monthly benefit for the 12 month work incentive period is the lesser of: •
100% of the indexed earnings you received before becoming disabled, less income from other sources, less current earnings; or
•
Your primary monthly benefit, less income from other sources.
After the work incentive period, your monthly benefit equals your primary monthly benefit, less income from other sources and multiplied by your income loss percentage. You must work to your full medical and vocational capacity. If you choose not to, your benefits will be paid as if you are working to your full capacity. Income you receive from other sources can be deducted from your primary monthly benefit. Other sources include: All retirement or disability benefits that you and your dependents receive, or could have received, from Social Security, or other government agencies /Salary continuance, personal time off or sick pay / Workers’ Compensation benefits / Income from state disability plans / Payments from policies that provide coverage for time away from work, if paid in part by or deducted from payroll by the policyholder / Income from other group disability coverage policies / Disability or retirement benefits paid by pension plans sponsored by the policyholder / Renewal commissions received from the policyholder / Severance pay / All payments for the month that the member receives under state unemployment laws / Any income you receive for services rendered prior to your Date of Disability will not be considered Other Income Sources.
How Long Will I Receive My Benefits? The benefit payment period is the length of time you'll receive benefits for a qualifying disability after the elimination period is satisfied. Your age at the time disability occurs determines the length of time you are eligible to receive disability benefits. Age Disability Occurs
Benefits are Payable:
Under Age 62
Until the later of the date you reach age 65 or 42 months 42 months 36 months 30 months 24 months 21 months 18 months 15 months 12 months
Age 62 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and over
05091710435 - 1
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07/2017
VOLUNTARY LONG-TERM DISABILITY
Your disability benefits will end when you: Recover / Cease to be under the regular and appropriate care of a physician, unless you have reached your maximum point of recovery and are still disabled / Fail to provide any required proof of disability / Fail to submit to a required medical examination / Fail to report income from other sources, or any other required earnings information / Fail to pursue Social Security disability benefits or Workers' Compensation benefits / Die. If you recover and return to work for six months or less during the benefit payment period and then again become disabled from the same or related cause, you are not required to complete a new elimination period.
What Additional Benefits Are Included? Work Incentive Benefit
Survivor Benefit
Rehabilitation Plan
Rehabilitation Incentive Benefit Mandatory Rehabilitation
The Work Incentive Benefit is paid to you if you are disabled and you return to work on a limited or part-time basis. To receive benefits, you must be working. The Work Incentive Benefit equals the primary monthly benefit with no offset for work earnings unless the combination of work earnings, disability benefits and other income sources exceeds 100% of your predisability earnings. If this occurs, the Work Incentive Benefit will be reduced by the amount in excess of 100% of your predisability earnings. The Survivor Benefit is a lump sum payment issued to your survivors, should you die while receiving disability benefits. The benefit payment is equal to three times your primary monthly benefit less other income sources. While disabled, you may qualify to participate in a Rehabilitation Plan. Our rehabilitation staff works with you, your physician(s) and your employer to create an individual rehabilitation plan to assist you in returning to work. If you are not disabled, but have a condition that could prevent you from performing the substantial and material duties of your own occupation, preventive rehabilitation services may be offered. The Rehabilitation Incentive Benefit can increase the benefit percentage by 5% if you become totally disabled and participate in and satisfy the requirements of an individual rehabilitation plan. The Mandatory Rehabilitation provision indicates that, if appropriate, you may be required to participate in an individual rehabilitation plan. Any expenses associated with the rehabilitation plan will be paid for by Principal Life.
What Are The Restrictions Of My Coverage? This Benefit Summary is a summary only. For a complete list of benefit restrictions, please refer to your booklet. Preexisting Conditions
A preexisting condition is an injury or sickness (including pregnancy) and all related conditions and complications, in the 12 months prior to your effective date under this policy, for which you: • Received medical treatment, consultation, care or service; or • Were prescribed or took prescription medications Benefits will not be paid for disabilities resulting from preexisting conditions unless, when you become disabled, you have been actively at work for one full day after being covered under the policy for 12 consecutive months.
Treatment of Mental Health Conditions and Drug and Alcohol Abuse Conditions
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Preexisting condition exclusions also apply to benefit increases due to policy amendments and changes in earnings of 25% or greater. A disability is considered due to alcohol, drug or chemical abuse, dependency or addiction or a mental health condition if the disability is caused by one of these condition(s) and not by other disabling conditions.
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VOLUNTARY LONG-TERM DISABILITY
Treatment of Mental Health Conditions and Drug and Alcohol Abuse Conditions
Maximum benefit payment periods for: Mental health conditions – 24 months Alcohol, drug or chemical abuse conditions – 24 months The benefit payment period listed above is a lifetime maximum for all periods of disability. All disabilities from conditions with the same maximum benefit payment period contribute towards one lifetime maximum. However, if at the end of the benefit payment period, you are confined in a hospital or any other type of facility providing treatment for any of these conditions, the benefit payment period may be extended to include the time period you are confined for treatment.
WE’LL GIVE YOU AN EDGE ® Principal Life Insurance Company, Des Moines, Iowa 50392-0002, www.principal.com This is a summary of life coverage underwritten by or with administrative services provided by Principal Life Insurance Company. This benefit summary is for administrative purposes and is not a complete statement of benefits and restrictions. You’ll receive a benefit booklet with details about your coverage. If there is a discrepancy between this summary and your benefit booklet, the benefit booklet prevails. GP 55672-13 | 04/2017 | © 2017 Principal Financial Services, Inc.
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Policyholder: ARTSPACE CHARTER SCHOOL
Voluntary Long Term Disability (LTD) Benefit Summary
This chart provides you a brief summary of the key benefits of the long-term disability coverage available from Principal Life Insurance Company. Following the chart, you will find additional information to answer questions you may have. For a complete list of all your long-term disability coverage benefits and restrictions, please refer to your booklet or contact your employer. Eligibility Job Class
MBRS ELECTING LOW LTD PLAN
Eligible Members
All active, full time employees (except seasonal, temporary, or contract workers) who work at least 20 hours per week
Benefits Payable Primary Monthly Benefit
50% of your predisability earnings up to $5,000.
Benefit Amount
Primary monthly benefit less other income sources
Definition of Earnings
Contract Salary - 12 months
Benefit Qualification Elimination Period
90 days
Own Occupation Period
2 years
Maximum Benefit Payment Period
5 years
Additional Benefits Rehabilitation Incentive Benefit
5% increase in the monthly benefit percentage
Survivor Benefit
Three times your primary monthly benefit less other income sources to your survivor.
Limitations & Exclusions
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Pre-Existing Conditions
12 months prior/12 months insured
Other Limitations
There are additional limitations to your coverage. A complete list is included in your booklet.
Principal Long Term Disability Rates Age Low Option <24 $0.08 / $100 25-29 $0.14 / $100 30-34 $0.18 / $100 35-39 $0.23 / $100 40-44 $0.30 / $100 45-49 $0.38 / $100 50-54 $0.50 / $100 55-59 $0.81 / $100 60-64 $0.76 / $100 65-69 $0.31 / $100 70-74 $0.15 / $100
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VOLUNTARY LONG-TERM DISABILITY
Understanding Your Long-Term Disability (LTD) Benefits Am I Eligible For Coverage? To be eligible for coverage, you must qualify as an eligible member and be considered actively at work. You will be considered actively at work if you are able and available for active performance of all of your regular duties. Short term absence because of a regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal time off is considered active work provided you are able and available for active performance of all of your regular duties and were working the day immediately prior to the date of your absence.
How Do I Qualify For Benefits? 1) Meet the Definition of Disability. Disabilities must be solely and directly caused by injury or sickness (including pregnancy). During the elimination period and the own occupation period, one of these situations must apply: After completing the own occupation period, one of these situations apply:
• •
• •
You cannot perform the majority of the substantial and material duties of your own occupation. You are performing the duties of your own occupation on a modified basis or any occupation and are unable to earn more than 80% of your indexed predisability earnings.
You cannot perform the majority of the substantial and material duties of any occupation for which you are or may reasonably become qualified based on education, training, or experience. You are performing the substantial and material duties of your own occupation or any occupation on a modified basis and are unable to earn more than 50% of your indexed predisability earnings.
2) Satisfy the Elimination Period. The amount of time you must be disabled before receiving benefits is called the elimination period. Long-Term Disability benefits begin after you have been disabled for 90 days. The elimination period can be satisfied with days of total or partial disability.
If you recover and return to work during the elimination period and become disabled again, you may not have to satisfy a new elimination period. If you become disabled again, your elimination period will pick up at the point where it was left off when you recovered. You have a period twice as long as the elimination period to satisfy the required number of days of disability.
How Much Monthly Benefit Will I Receive? Your benefits will be determined based on your Contract Salary - 12 months. When you are unable to work in any capacity during the benefit payment period, your monthly benefit equals your primary monthly benefit, less income from other sources.
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VOLUNTARY LONG-TERM DISABILITY
Your primary monthly benefit is equal to 50% of your predisability earnings, but will not exceed $5,000. Your monthly benefit will not be less than the minimum monthly benefit of $100. Benefits if Working If you are able to work while disabled, you may still be eligible to receive a disability benefit. If you are working during the benefit payment period, your monthly benefit for the 12 month work incentive period is the lesser of: •
100% of the indexed earnings you received before becoming disabled, less income from other sources, less current earnings; or
•
Your primary monthly benefit, less income from other sources.
After the work incentive period, your monthly benefit equals your primary monthly benefit, less income from other sources and multiplied by your income loss percentage. You must work to your full medical and vocational capacity. If you choose not to, your benefits will be paid as if you are working to your full capacity. Income you receive from other sources can be deducted from your primary monthly benefit. Other sources include: All retirement or disability benefits that you and your dependents receive, or could have received, from Social Security, or other government agencies /Salary continuance, personal time off or sick pay / Workers’ Compensation benefits / Income from state disability plans / Payments from policies that provide coverage for time away from work, if paid in part by or deducted from payroll by the policyholder / Income from other group disability coverage policies / Disability or retirement benefits paid by pension plans sponsored by the policyholder / Renewal commissions received from the policyholder / Severance pay / All payments for the month that the member receives under state unemployment laws / Any income you receive for services rendered prior to your Date of Disability will not be considered Other Income Sources.
How Long Will I Receive My Benefits? The benefit payment period is the length of time you'll receive benefits for a qualifying disability after the elimination period is satisfied. Your age at the time disability occurs determines the length of time you are eligible to receive disability benefits. Age Disability Occurs
Benefits are Payable:
Under Age 62
Until the earlier of the date you reach age 65 or 5 years 42 months 36 months 30 months 24 months 21 months 18 months 15 months 12 months
Age 62 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and over
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VOLUNTARY LONG-TERM DISABILITY
Your disability benefits will end when you: Recover / Cease to be under the regular and appropriate care of a physician, unless you have reached your maximum point of recovery and are still disabled / Fail to provide any required proof of disability / Fail to submit to a required medical examination / Fail to report income from other sources, or any other required earnings information / Fail to pursue Social Security disability benefits or Workers' Compensation benefits / Die. If you recover and return to work for six months or less during the benefit payment period and then again become disabled from the same or related cause, you are not required to complete a new elimination period.
What Additional Benefits Are Included? Work Incentive Benefit
Survivor Benefit
Rehabilitation Plan
Rehabilitation Incentive Benefit Mandatory Rehabilitation
The Work Incentive Benefit is paid to you if you are disabled and you return to work on a limited or part-time basis. To receive benefits, you must be working. The Work Incentive Benefit equals the primary monthly benefit with no offset for work earnings unless the combination of work earnings, disability benefits and other income sources exceeds 100% of your predisability earnings. If this occurs, the Work Incentive Benefit will be reduced by the amount in excess of 100% of your predisability earnings. The Survivor Benefit is a lump sum payment issued to your survivors, should you die while receiving disability benefits. The benefit payment is equal to three times your primary monthly benefit less other income sources. While disabled, you may qualify to participate in a Rehabilitation Plan. Our rehabilitation staff works with you, your physician(s) and your employer to create an individual rehabilitation plan to assist you in returning to work. If you are not disabled, but have a condition that could prevent you from performing the substantial and material duties of your own occupation, preventive rehabilitation services may be offered. The Rehabilitation Incentive Benefit can increase the benefit percentage by 5% if you become totally disabled and participate in and satisfy the requirements of an individual rehabilitation plan. The Mandatory Rehabilitation provision indicates that, if appropriate, you may be required to participate in an individual rehabilitation plan. Any expenses associated with the rehabilitation plan will be paid for by Principal Life.
What Are The Restrictions Of My Coverage? This Benefit Summary is a summary only. For a complete list of benefit restrictions, please refer to your booklet. Preexisting Conditions
A preexisting condition is an injury or sickness (including pregnancy) and all related conditions and complications, in the 12 months prior to your effective date under this policy, for which you: • Received medical treatment, consultation, care or service; or • Were prescribed or took prescription medications Benefits will not be paid for disabilities resulting from preexisting conditions unless, when you become disabled, you have been actively at work for one full day after being covered under the policy for 12 consecutive months.
Treatment of Mental Health Conditions and Drug and Alcohol Abuse Conditions
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Preexisting condition exclusions also apply to benefit increases due to policy amendments and changes in earnings of 25% or greater. A disability is considered due to alcohol, drug or chemical abuse, dependency or addiction or a mental health condition if the disability is caused by one of these condition(s) and not by other disabling conditions.
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07/2017
VOLUNTARY LONG-TERM DISABILITY
Treatment of Mental Health Conditions and Drug and Alcohol Abuse Conditions
Maximum benefit payment periods for: Mental health conditions – 24 months Alcohol, drug or chemical abuse conditions – 24 months The benefit payment period listed above is a lifetime maximum for all periods of disability. All disabilities from conditions with the same maximum benefit payment period contribute towards one lifetime maximum. However, if at the end of the benefit payment period, you are confined in a hospital or any other type of facility providing treatment for any of these conditions, the benefit payment period may be extended to include the time period you are confined for treatment.
WE’LL GIVE YOU AN EDGE ® Principal Life Insurance Company, Des Moines, Iowa 50392-0002, www.principal.com This is a summary of life coverage underwritten by or with administrative services provided by Principal Life Insurance Company. This benefit summary is for administrative purposes and is not a complete statement of benefits and restrictions. You’ll receive a benefit booklet with details about your coverage. If there is a discrepancy between this summary and your benefit booklet, the benefit booklet prevails. GP 55672-13 | 04/2017 | © 2017 Principal Financial Services, Inc.
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Accident Insurance
Accidents happen in places where you and your family spend the most time – at work, in the home and on the playground – and they’re unexpected. How you care for them shouldn’t be. In your lifetime, which of these accidental injuries have happened to you or someone you know?
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Sports-related accidental injury Broken bone Burn Concussion Laceration
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Back or knee injuries
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Car accidents Falls & spills Dislocation Accidental injuries that send you to the Emergency Room, Urgent Care or doctor’s office
Accident 1.0-Preferred with Health Screening Benefit
Colonial Life’s Accident Insurance is designed to help you fill some of the gaps caused by increasing deductibles, co-payments and out-of-pocket costs related to an accidental injury. The benefit to you is that you may not need to use your savings or secure a loan to pay expenses. Plus you’ll feel better knowing you can have greater financial security.
What additional features are included? l
Worldwide coverage
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Portable
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What if I change employers? If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable as long as you pay your premiums when they are due or within the grace period.
Compliant with Healthcare Spending Account (HSA) guidelines
Can my premium change?
Will my accident claim payment be reduced if I have other insurance?
Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued.
You’re paid regardless of any other insurance you may have with other insurance companies, and the benefits are paid directly to you (unless you specify otherwise).
How do I file a claim? Visit coloniallife.com or call our Customer Service Department at 1.800.325.4368 for additional information.
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Benefits listed are for each covered person per covered accident unless otherwise specified.
Initial Care l
Accident Emergency Treatment........... $150
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Ambulance........................................$400
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X-ray Benefit....................................................$50
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Ambulance.............................. $2,000
Common Accidental Injuries Dislocations (Separated Joint) Hip Knee (except patella) Ankle – Bone or Bones of the Foot (other than Toes) Collarbone (Sternoclavicular) Lower Jaw, Shoulder, Elbow, Wrist Bone or Bones of the Hand Collarbone (Acromioclavicular and Separation) One Toe or Finger Fractures Depressed Skull Non-Depressed Skull Hip, Thigh Body of Vertebrae, Pelvis, Leg Bones of Face or Nose (except mandible or maxilla) Upper Jaw, Maxilla Upper Arm between Elbow and Shoulder Lower Jaw, Mandible, Kneecap, Ankle, Foot Shoulder Blade, Collarbone, Vertebral Process Forearm, Wrist, Hand Rib Coccyx Finger, Toe
Non-Surgical
Surgical
$6,600 $3,300 $2,640 $1,650 $990 $990 $330 $330
$13,200 $6,600 $5,280 $3,300 $1,980 $1,980 $660 $660
Non-Surgical
Surgical
$5,500 $2,200 $3,300 $1,650 $770 $770 $770 $660 $660 $660 $550 $440 $220
$11,000 $4,400 $6,600 $3,300 $1,540 $1,540 $1,540 $1,320 $1,320 $1,320 $1,100 $880 $440
Your Colonial Life policy also provides benefits for the following injuries received as a result of a covered accident. l
Burn (based on size and degree).....................................................................................$1,000 to $12,000
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Coma..............................................................................................................................................................$10,000
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Concussion........................................................................................................................................................$150
Emergency Dental Work........................................$75 Extraction, $300 Crown, Implant, or Denture l Lacerations (based on size)............................................................................................................$50 to $800 l
Requires Surgery l
Eye Injury............................................................................................................................................................$300
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Tendon/Ligament/Rotator Cuff...........................................................$500 - one, $1,000 - two or more
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Ruptured Disc...................................................................................................................................................$500
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Torn Knee Cartilage........................................................................................................................................$500
Surgical Care Surgery (cranial, open abdominal or thoracic)................................................................................. $1,500
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Surgery (hernia)...............................................................................................................................................$150
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Surgery (arthroscopic or exploratory).....................................................................................................$250
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Blood/Plasma/Platelets.................................................................................................................................$300
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Transportation/Lodging Assistance If injured, covered person must travel more than 50 miles from residence to receive special treatment and confinement in a hospital. Transportation..............................................................................$500 per round trip up to 3 round trips
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Lodging (family member or companion)................................................$125 per night up to 30 days for a hotel/motel lodging costs
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Accident Hospital Care Hospital Admission*......................................................................................................... $1,500 per accident
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Hospital ICU Admission*................................................................................................. $3,000 per accident * We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both. l
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Hospital Confinement.......................................................... $250 per day up to 365 days per accident
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Hospital ICU Confinement ....................................................$500 per day up to 15 days per accident
Accident Follow-Up Care l
Accident Follow-Up Doctor Visit........................................................... $50 (up to 3 visits per accident)
Medical Imaging Study.......................................................................................................$250 per accident (limit 1 per covered accident and 1 per calendar year)
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Occupational or Physical Therapy...................................................... $35 per treatment up to 10 days
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Appliances ........................................................................................... $125 (such as wheelchair, crutches)
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Prosthetic Devices/Artificial Limb .....................................................$500 - one, $1,000 - more than 1
Rehabilitation Unit..................................................$100 per day up to 15 days per covered accident, and 30 days per calendar year. Maximum of 30 days per calendar year
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Accidental Dismemberment l
Loss of Finger/Toe..................................................................................$750 – one, $1,500 – two or more
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Loss or Loss of Use of Hand/Foot/Sight of Eye......................$7,500 – one, $15,000 – two or more
Catastrophic Accident For severe injuries that result in the total and irrecoverable: l
Loss of one hand and one foot
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Loss of the sight of both eyes
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Loss of both hands or both feet
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Loss of the hearing of both ears
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Loss or loss of use of one arm and one leg or
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Loss of the ability to speak
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Loss or loss of use of both arms or both legs
Named Insured................. $25,000 Spouse...............$25,000 Child(ren)..........$12,500 365-day elimination period. Amounts reduced for covered persons age 65 and over. Payable once per lifetime for each covered person.
Accidental Death Accidental Death
Common Carrier
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Named Insured
$25,000
$100,000
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Spouse
$25,000
$100,000
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Child(ren)
$5,000
$20,000
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Health Screening Benefit
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$50 per covered person per calendar year
Provides a benefit if the covered person has one of the health screening tests performed. This benefit is payable once per calendar year per person and is subject to a 30-day waiting period.
Tests include: l.
Blood test for triglycerides
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Hemoccult stool analysis
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Bone marrow testing
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Mammography
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Breast ultrasound
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Pap smear
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CA 15-3 (blood test for breast cancer)
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PSA (blood test for prostate cancer)
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CA125 (blood test for ovarian cancer)
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Carotid doppler
Serum cholesterol test to determine level of HDL and LDL
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CEA (blood test for colon cancer)
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Chest x-ray
Serum protein electrophoresis (blood test for myeloma)
Colonoscopy
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Stress test on a bicycle or treadmill
Echocardiogram (ECHO)
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Skin cancer biopsy
Electrocardiogram (EKG, ECG)
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Thermography
Fasting blood glucose test
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ThinPrep pap test
Flexible sigmoidoscopy
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Virtual colonoscopy
My Coverage Worksheet (For use with your Colonial Life benefits counselor) Who will be covered? (check one) Employee Only
Spouse Only
One-Parent Family, with Employee
One Child Only
One-Parent Family, with Spouse
Employee & Spouse Two-Parent Family
On and Off -Job Benefits
Off -Job Only Benefits
EXCLUSIONS We will not pay benefits for losses that are caused by or are the result of: hazardous avocations; felonies or illegal occupations; racing; semi-professional or professional sports; sickness; suicide or self-inflicted injuries; war or armed conflict; in addition to the exclusions listed above, we also will not pay the Catastrophic Accident benefit for injuries that are caused by or are the result of: birth; intoxication. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form Accident 1.0-HS-NC. This is not an insurance contract and only the actual policy provisions will control.
Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com
©2014 Colonial Life & Accident Insurance Company | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 6-14
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71740-NC
Accident 1.0-Preferred with Health Screening Benefit
When are covered accident benefits available? (check one)
ac
a a
a
a
c
a
a
a
b
a
b
a
a
a a
. c
.
c
a
a b a .
a
a
a
2020 STATE HEALTH PLAN COMPARISON Active and Non-Medicare Subscribers
80/20 PLAN
70/30 PLAN
PLAN DESIGN FEATURES IN-NETWORK
OUT-OFNETWORK
IN-NETWORK
OUT-OFNETWORK
$1,250 Individual $3,750 Family
$2,500 Individual $7,500 Family
$1,500 Individual $4,500 Family
$3,000 Individual $9,000 Family
Coinsurance
20% of eligible expenses after deductible is met
40% of eligible expenses after deductible and the difference between the allowed amount and the charge
30% of eligible expenses after deductible is met
50% of eligible expenses after deductible and the difference between the allowed amount and the charge
Out-of-Pocket Maximum (Combined Medical and Pharmacy)
$4,890 Individual $14,670 Family
$9,780 Individual $29,340 Family
$5,900 Individual $16,300 Family
$11,800 Individual $32,600 Family
Preventive Services
$0 (covered at 100%)
N/A
$0 (covered at 100%)
N/A
$25 for PCP; $10 if you use PCP on ID card; $80 Specialist
40% after deductible is met
$45 for PCP; $30 if you use PCP on ID card; $94 for Specialist
50% after deductible is met
Annual Deductible
Office Visits
Urgent Care
$70
PCP: Primary Care Provider
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$100
a
80/20 PLAN
70/30 PLAN
PLAN DESIGN FEATURES OUT-OFNETWORK
IN-NETWORK Emergency Room (Copay waived w/admission or observation stay)
Inpatient Hospital
$300 copay, then 20% after deductible is met
$300 copay, then 20% after deductible is met
$300 copay, then 40% after deductible is met
IN-NETWORK
OUT-OFNETWORK
$337 copay, then 30% after deductible is met
$337 copay, then 30% after deductible is met
$337 copay, then 50% after deductible is met
PHARMACY BENEFITS Tier 1 (Generic)
$5 copay per 30-day supply
$16 copay per 30-day supply
$30 copay per 30-day supply
$47 copay per 30-day supply
Deductible/coinsurance
Deductible/coinsurance
Tier 4 (Low-Cost Generic Specialty)
$100 copay per 30-day supply
$200 copay per 30-day supply
Tier 5 (Preferred Specialty)
$250 copay per 30-day supply
$350 copay per 30-day supply
Tier 6 (Non-preferred Specialty)
Deductible/coinsurance
Deductible/coninsurance
Preferred Diabetic Testing Supplies**
$5 copay per 30-day supply
$10 copay per 30-day supply
Tier 2 (Preferred Brand & High-Cost Generic) Tier 3 (Non-preferred Brand)
** Preferred Brand is the OneTouch Test Strips. Non-preferred diabetic testing supplies are considered a Tier 3 member copay.
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Hospital Confinement Indemnity Insurance Plan 3 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement. ......................................................................... $_______________ Maximum of one benefit per covered person per calendar year
Observation room................................................................................... $100 per visit Maximum of two visits per covered person per calendar year
Rehabilitation unit confinement. ................................................................. $100 per day Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year
Waiver of premium
Available after 30 continuous days of a covered hospital confinement of the named insured
Diagnostic procedure Tier 1. . . . . .......................................................................................... ................. $250 Tier 2. . . . . .......................................................................................... ................. $500 Maximum of $500 per covered person per calendar year for all covered diagnostic procedures combined
Outpatient surgical procedure Tier 1. . . . . .......................................................................................... . $_______________ Tier 2. . . . . ............................................................................................ $_______________
For more information, talk with your benefits counselor.
Maximum of $___________ per covered person per calendar year for all covered outpatient surgical procedures combined
The following is a list of common diagnostic procedures that may be covered.
Tier 1 diagnostic procedures Breast – Biopsy (incisional, needle, stereotactic) Diagnostic radiology – Nuclear medicine test Digestive – Barium enema/lower GI series – Barium swallow/upper GI series – Esophagogastroduodenoscopy (EGD) Ear, nose, throat, mouth – Laryngoscopy Gynecological – Hysteroscopy – Amniocentesis – Loop electrosurgical – Cervical biopsy excisional procedure – Cone biopsy (LEEP) – Endometrial biopsy
Liver – biopsy Lymphatic – biopsy Miscellaneous – Bone marrow aspiration/biopsy Renal – biopsy Respiratory – Biopsy – Bronchoscopy – Pulmonary function test (PFT) Skin – Biopsy – Excision of lesion Thyroid – biopsy Urologic – Cystoscopy
Tier 2 diagnostic procedures Cardiac – Angiogram – Arteriogram – Thallium stress test – Transesophageal echocardiogram (TEE)
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Diagnostic radiology – Computerized tomography scan (CT scan) – Electroencephalogram (EEG) – Magnetic resonance imaging (MRI) – Myelogram – Positron emission tomography scan (PET scan) IMB7000 – PLAN 3
The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.
Tier 1 outpatient surgical procedures Breast
Gynecological
Cardiac
Liver
Digestive
Musculoskeletal system
– Axillary node dissection – Breast capsulotomy – Lumpectomy
– Dilation and curettage (D&C) – Endometrial ablation – Lysis of adhesions
– Pacemaker insertion
– Paracentesis
– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions
– Carpal/cubital repair or release – Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair) – Removal of orthopedic hardware – Removal of tendon lesion
Skin
– Laparoscopic hernia repair – Skin grafting
Ear, nose, throat, mouth – Adenoidectomy – Removal of oral lesions – Myringotomy – Tonsillectomy – Tracheostomy – Tympanotomy
Tier 2 outpatient surgical procedures Breast
Gynecological
Cardiac
Musculoskeletal system
– Breast reconstruction – Breast reduction
– Hysterectomy – Myomectomy
– Angioplasty – Cardiac catheterization
Digestive
– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy
Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty
Thyroid
– Excision of a mass
Eye
ColonialLife.com
– Arthroscopic knee surgery with meniscectomy (knee cartilage repair) – Arthroscopic shoulder surgery – Clavicle resection – Dislocations (open reduction with internal fixation) – Fracture (open reduction with internal fixation) – Removal or implantation of cartilage – Tendon/ligament repair
– Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy) – Vitrectomy
Urologic
– Lithotripsy
EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. Pre-exisiting conditions are those conditions whether diagnosed or not, for which a covered person received medical advice, diagnosis or care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the policy. If a covered person is 65 or older when the policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-NC. This is not an insurance contract and only the actual policy provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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7-15 | 101581-NC
Hospital Confinement Indemnity Insurance Health Screening Individual Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.
Health screening .............................................................................. $_____________ Maximum of one health screening test per covered person per calendar year; subject to a 30-day waiting period
Blood test for triglycerides Bone marrow testing Breast ultrasound CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) CEA (blood test for colon cancer) Carotid Doppler
Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy
Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy
For more information, talk with your benefits counselor.
Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels
ColonialLife.com
Waiting period means the first 30 days following any covered person’s policy coverage effective date, during which no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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IMB7000 – HEALTH SCREENING BENEFIT | 2-15 | 101579
Hospital Confinement Indemnity Insurance Medical Treatment Package The medical treatment package for Individual Medical BridgeSM coverage can help pay for deductibles, co-payments and other out-of-pocket expenses related to a covered accident or covered sickness.
The medical treatment package paired with Plan 3 provides the following benefits: Air ambulance ............................................................................................. $1,000 Maximum of one benefit per covered person per calendar year
Ambulance .................................................................................................... $100 Maximum of one benefit per covered person per calendar year
Appliance ...................................................................................................... $100 Maximum of one benefit per covered person per calendar year
Doctor’s office visit ................................................................................... $25 per visit Maximum of three visits per calendar year for named insured coverage or maximum of five visits per calendar year for all covered persons combined
Emergency room visit ............................................................................. $100 per visit
For more information, talk with your benefits counselor.
Maximum of two visits per covered person per calendar year
X-ray ................................................................................................ $25 per benefit Maximum of two benefits per covered person per calendar year
THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS
ColonialLife.com
We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-NC. This is not an insurance contract and only the actual policy provisions will control. Š2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. IMB7000-MEDICAL TREATMENT PACKAGE NORTH CAROLINA EDUCATORS | 1-16 | NS-15014-NC
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Hospital Confinement Indemnity Insurance Optional Riders Individual Medical BridgeSM offers two optional benefit riders – the daily hospital confinement rider and the enhanced intensive care unit confinement rider. For an additional cost, these riders can help provide extra financial protection to help with out-of-pocket medical expenses.
Daily hospital confinement rider ................................................................. $100 per day Per covered person per day of hospital confinement Maximum of 365 days per covered person per confinement
Enhanced intensive care unit confinement rider .............................................. $500 per day Per covered person per day of intensive care unit confinement Maximum of 30 days per covered person per confinement
Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.
For more information, talk with your benefits counselor.
EXCLUSIONS
ColonialLife.com
We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. Pre-exisiting conditions are those conditions whether diagnosed or not, for which a covered person received medical advice, diagnosis or care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the policy. If a covered person is 65 or older when the policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000-NC and R-EIC7000-NC. This is not an insurance contract and only the actual policy or rider provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 7-15 | 101582-NC
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Term Life Insurance Life insurance protection when you need it most Life insurance needs change as life circumstances change. You may need different coverage if you’re getting married, buying a home or having a child. Term life insurance from Colonial Life provides protection for a specified period of time, typically offering the greatest amount of coverage for the lowest initial premium. This fact makes term life insurance a good choice for supplementing cash value coverage during life stages when obligations are higher, such as while children are younger. It’s also a good option for families on a tight budget — especially since you can convert it to a permanent cash value plan later.
With this coverage: A beneficiary can receive a benefit that is typically free from income tax. The policy’s accelerated death benefit can pay a percentage of the death benefit if the covered person is diagnosed with a terminal illness. You can convert it to a Colonial Life cash value insurance plan, with no proof of good health, to age 75. Coverage is guaranteed renewable up to age 95 as long as premiums are paid when due. Portability allows you to take it with you if you change jobs or retire.
Talk with your Colonial Life benefits counselor to learn more.
ColonialLife.com
Spouse coverage options
Dependent coverage options
Two options are available for spouse coverage at an additional cost:
You may add a Children’s Term Life Rider to cover all of your eligible dependent children with up to $20,000 in coverage each for one premium.
1. Spouse Term Life Policy: Offers guaranteed premiums and level death benefits equivalent to those available to you –whether or not you buy a policy for yourself. 2. Spouse Term Life Rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).
The Children’s Term Life Rider may be added to either the primary or spouse policy, not both.
If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 7-19 | NS-16570-1
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Whole Life Insurance Life insurance that comes with guarantees — because life doesn’t You can’t predict the future, but you can rest easier knowing you have life insurance with lifelong guarantees. Whole life insurance provides guaranteed features – cash value accumulation, premium rates and a death benefit (minus any loans and loan interest) – that help ensure those benefits will be there to help protect your family’s way of life.
With this coverage: Life insurance benefits for the beneficiary are typically tax-free. You have three opportunities to purchase additional coverage with no proof of good health required if you are 50 or younger with the Guaranteed Purchase Option Rider. The policy’s built-in terminal illness accelerated death benefit provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness.1 A $3,000 immediate claim payment that can help your designated beneficiary pay for funeral costs or other expenses.
Talk with your Colonial Life benefits counselor to learn more.
ColonialLife.com
You can take the policy with you even if you change jobs or retire; with no increase in premium.
Paid-Up at Age 70 or Paid-Up at Age 100 These two plan options allow you to select what age your premium payments will end. You can choose to have your policy paid up when you reach age 70 or 100.
1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits. If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 7-19 | NS-16576-1
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What is LegalShield? It’s total access. It’s total freedom. Everyone deserves legal protection. And now, with LegalShield, everyone can access it. No matter how traumatic. No matter how trivial. Whatever your situation is, we are here to help. From real estate to divorce advice, identity theft and beyond, we have your rights covered. Welcome to total peace of mind. Welcome to LegalShield.
What your membership includes. Know your rights in any situation. LegalShield gives you the ability to talk to an attorney on any matter without worrying about high hourly costs. For the listed payroll deducted amount you can access legal advice, no matter how traumatic or trivial the issue. That’s why under the protection of LegalShield you and your family can live your life worry-free, every day, every night, now and forever. * Legal Advice – unlimited issues * Letters/calls made on your behalf * Contracts & documents
Life Events We Help With: Warranties Overcharges Defective Products Property Disputes Possible Foreclosure Traffic Tickets Credit Liability Matters
Reviewed up to 15 pages * Lawyers prepare Your Will, Living Will & Healthcare POA & Durable POA Traffic-Related Issues( no waiting period for violations) * Trial Defense Pre-Trial Representation at trial Residential Loan Document Assistance
Lease Agreements Civil Rights Child Support Divorce Guardianship IRS Audits ……and much more
Your LegalShield Plan Covers:
* Uncontested Name Change Assistance * Uncontested Adoption Representation * Uncontested Separation / Divorce Representation * IRS Audit Assistance * 25% Preferred Member Discount * 24/7 Emergency Access for covered situations
The member
The member’s spouse or significant other Never married dependent children under 23 living at home Dependent children under age 18 for whom the member is legal guardian Full-time college students up to age 26 never married, dependent children Physically or mentally challenged child living at home
------------------------------------------------------------------------------------------------------------------------------------
IDShield
Your IDShield Covers:
Everything you would expect with a great Identity Theft service by Kroll Advisory Solutions, the world’s leading risk consulting company in identity theft restoration.
The member
The member’s spouse or significant other Safeguard for minors - Up to 8 dependents under the age of 18
CONSULTATION
Special Group Rates:
Unlimited Counseling with Investigator, SSN Fraud Detection,
12 Month
Monthly ID Theft Updates, Emergency Assistance 24/7/365, Data Breach Notifications, Identity Alert System, Lost/Stolen Wallet Assistance, Reduce Pre-Approved Card Offers, Sex Offender Registry Reports, Live Support. RESTORATION * Licensed Private Investigators, Complete Restoration for Medical ID, Financial and Complete Identity, $5 Million Service Guarantee. PRIVACY MONITORING * Global Black Market Website Surveillance for Name, DOB, SSN, Emails(10), Phone(10), Driver’s License, Passport, Medical ID(10) File Sharing Network Searches, Address Change Verification. SECURITY MONITORING Global Black Market Website Surveillance for SSN, CC Numbers(10)
Legal Plan Only IDShield Individual Legal +IDShield Individual
23.95
IDSHield Family Legal +IDShield Family
18.95
8.95 32.90
38.90
Bank Account Numbers(10), Credit Inquiry Alerts, Payday Loan Monitoring, Minor Identity Protection, Court Records, Credit Monitoring and Quarterly Score Tracker. This is a general overview of your legal plan coverage for illustration purposes only. See a plan contract for complete terms, coverage, amounts, conditions and exclusions.
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General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction You are receiving this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.” Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to ArtSpace Charter School, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Jane Horning at ArtSpace Charter School. Applicable documentation will be required i.e. court order, certificate of coverage etc.
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How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov. Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan Contact Information ArtSpace Charter School 2030 US Highway 70 Swannanoa, NC 28778 COBRA Administrator for Vision Coverage Superior Vision Services 11090 White Rock Road Suite 175 Rancho Cordova, CA 95670 COBRA Administrator for Dental Coverage Principal Life P.O. Box 39710 Colorado Springs, CO 80949
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Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives. Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments. Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by those laws. This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202. You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, or Conservator. ________________________ (Printed name of individual subject to this disclosure)
_____________ (Social Security Number)
___________________ (Signature)
________________ (Date Signed)
If applicable, I signed on behalf of the proposed insured as __________________________ (indicate relationship). If legal Guardian, Power or Attorney Designee, or Conservator.
________________________________ (Printed name of legal representative)
_____________________________ (Signature of legal representative)
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___________ (Date Signed)
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I’m Leaving, Now What? State Health Insurance Under certain qualifying events, employees and dependents have the opportunity to continue coverage for 18-36 months under the COBRA Act. Please contact the State Health Plan at 1-888-234-2416. If you are retiring, you must either log in to www.myncretirement.com or call 1-888-234-2416.
Other Benefits If you wish to continue coverage of any of the following benefits, Pierce Group Benefits will be happy to serve you:
•
Dental and Vision Insurance
•
Telemedicine Supplemental/Voluntary Insurances - Cancer, Disability, Life, etc.
•
Please visit
www.piercegroupbenefits.com/individualfamily
or call 888-662-7500 for more information on these policies, as well as to enroll/continue your benefits. You may also click on the “Individual & Family” button on the Pierce Group Benefits homepage, www.piercegroupbenefits.com to access this information.
Transferring from one Employer to Another? If you are transferring from a current PGB client to another, some benefits may be eligible for transfer. Please call 888-662-7500 and a Service Specialist will be glad to help you.
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CONTACT INFORMATION: PRINCIPAL - DENTAL INSURANCE
SUPERIOR - VISION INSURANCE
• Customer Service: 1-800-247-4695
• Customer Service: 1-800-507-3800 • Website: www.superiorvision.com
LEGAL SHIELD - PRE-PAID LEGAL
PRINCIPAL - LONG-TERM DISABILITY
• Mark Spessard: 919-730-0720 • Email Address: mcs.legalshield@gmail.com
• Customer Service: 1-800-245-1522
HARMONY ONLINE ENROLLMENT NORTH CAROLINA STATE HEALTH PLAN
• See pages 5-6 for online enrollment instructions • Technical Help Desk: 1-866-875-4772
• Customer Service: 1-888-234-2416 • Website: http://shpnc.org
TO VIEW YOUR BENEFITS ONLINE
CALL A DOCTOR PLUS - TELEMEDICINE
Visit www.piercegroupbenefits.com/
See the inside of your benefit booklet for information on how to set up your account and contact Call A Doctor Plus!
For additional information concerning plans offered to employees of ArtSpace Charter School, please contact our North Carolina Service Center at 1-888-662-7500, ext. 100
artspacecharterschool
COLONIAL LIFE VISIT COLONIALLIFE.COM TO SET UP YOUR PERSONAL ACCOUNT • Website: www.coloniallife.com • Claims Fax: 1-800-880-9325
• Customer Service & Wellness Screenings: 1-800-325-4368 • TDD for hearing impaired customers call: 1-800-798-4040
If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 18 months, you need the name and date of the test performed as well as your doctor’s name and phone number. Colonial also needs to know if this is for you or another covered individual and their name and social security number. You may: • FILE BY PHONE! Call 1-800-325-4368 and provide the information requested by Colonial’s Automated Voice Response System, 24 hours per day, 7 days a week, or • SUBMIT ON THE INTERNET using the Wellness Claim Form at www.coloniallife.com, or • Write your name, address, social security number and/or policy/certificate number on your bill and indicate “Wellness Test.” Fax this to Colonial at 1-800-880-9325 or MAIL to PO Box 100195, Columbia, SC 29202 If your Wellness/Cancer Screening test was more than 18 months ago, you must fax or mail Colonial a copy of the bill or statement from your doctor indicating the type of procedure performed, the charge incurred and the date of service. Please write your full name, social security number, and current address on the bill. Please Note: If your cancer policy includes a second part to the screening benefit, bills for tests covered and a copy of the diagnostic report (reflecting the abnormal reading of your first test) must be mailed or faxed to us for benefits to be provided.
When you terminate employment, you have the opportunity to continue your Colonial coverage either through direct billing or automatic payment through your bank account. Please contact Colonial at 1-800-325-4368 to request the continuation of benefits form.