EMPLOYEE BENEFITS GUIDE 2026 PLAN YEAR:
OCTOBER 1, 2026 - SEPTEMBER 30, 2027
CHARLES CITY COUNTY PUBLIC SCHOOLS
WWW.PIERCEGROUPBENEFITS.COM
EMPLOYEE SERVICES: 800-387-5955
TABLE OF CONTENTS
EMPLOYEE BENEFITS GUIDE Welcome to Charles City County Public Schools’ comprehensive benefits program. This guide highlights the benefits offered to all eligible employees for the plan year listed below. Benefits described in this guide are voluntary, employeepaid benefits unless otherwise noted.
ENROLLMENT DATES: August 3, 2026 - August 17, 2026 PLAN YEAR & EFFECTIVE DATES: October 1, 2026 - September 30, 2027
Important Contact Information............................... 3 Eligibility Requirements......................................... 4 Overview Of Benefits............................................. 5 Important Notices................................................. 6 Mid-Year Events..................................................... 7 Enrollment Information.......................................... 9 Health Insurance................................................... 10 Dental Insurance................................................... 15 Vision Insurance.................................................... 17 Health Savings Account......................................... 21 The HSA Store....................................................... 23 Flexible Spending Account..................................... 24 The FSA Store....................................................... 28 Dependent Care Account....................................... 29 Cancer Benefits..................................................... 32 Critical Illness Benefits.......................................... 42 Disability Benefits................................................. 55 Accident Benefits.................................................. 67 Medical Bridge Benefits......................................... 77 Term Life Insurance............................................... 85 Whole Life Insurance............................................. 89 Group Critical Illness Benefits................................ 93 Colonial Life Policyholder Service Guide................. 102 Authorization For Colonial Life Insurance Form....... 103 Additional Benefits................................................ 104 Required Health Care Notices................................ 105 COBRA Continuation Of Coverage.......................... 110 Privacy Notices..................................................... 112 Continuation Of Coverage...................................... 113
Click on the video below to help you prepare for annual enrollment and learn about the benefits available to you!
IMPORTANT NOTE & DISCLAIMER This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail.
CHARLES CITY COUNTY PUBLIC SCHOOLS 2026-2027 Benefits Plan
October 1, 2026 - September 30, 2027
All information in this guide, including premiums quoted, is subject to change. All policy descriptions are for informational purposes only. Your actual policies may be different from those in this guide. Rev: 7/15/2026
IMPORTANT CONTACT INFORMATION CARRIER
PHONE/FAX
WEBSITE
The Local Choice (Health, Dental, Vision)
The Local Choice Anthem
P: 800-552-2682
-
www.thelocalchoice.virginia.gov
Health Savings Account
Ameriflex
P: 888-868-3539
service@myameriflex.com
www.myameriflex.com
Flexible Spending Accounts
Ameriflex
P: 888-868-3539
service@myameriflex.com
www.myameriflex.com
Group Critical Illness Benefits
Aflac
P: 800-433-3036
-
aflacgroupinsurance.com
Custom Benefits Website
Pierce Group Benefits
P: 1-800-387-5955 F: 984-225-2605
service@ piercegroupbenefits.com
www.PierceGroupBenefits.com/ CharlesCityCountyPublicSchools
-
www.coloniallife.com
Customer Service & Wellness Screenings
Supplemental Benefits
Colonial Life
1-800-325-4368 F:1-800-880-9325 TDD For Hearing Impaired Customers
1-800-798-4040
Under certain qualifying events, employees and dependents may have the opportunity to continue coverage for 18-36 months under the COBRA Act. 3
ELIGIBILITY REQUIREMENTS CURRENT EMPLOYEE? ANNUAL ENROLLMENT DATES:
August 3, 2026 - August 17, 2026
PLAN YEAR & EFFECTIVE DATES: October 1, 2026 - September 30, 2027
ELIGIBILITY • Employees working 30 hours or more per week are eligible for benefits. • Aflac benefits are only available for HDHP enrollees.
NEW HIRE? Congratulations on your new employment! Your employment means more than just a paycheck. Your employer also provides eligible employees with a valuable benefits package. Above you will find eligibility requirements and below you will find information about how to enroll in these benefits as a new employee. The Local Choice Benefits - Please reach out to your Benefits Department within 30 days of your date of hire. All Other Benefits - Please call PGB’s Employee Services within 30 days of your date of hire and a PGB Benefits Representative will help you enroll in benefits. The Employee Services number is located in the contact section of this guide. Be sure to also review your group’s custom benefits website, that allows for easy, year-round access to benefit information, live chat support, benefit explainer videos, plan certificates and documents, and carrier contacts and forms.
www.PierceGroupBenefits.com/CharlesCityCountyPublicSchools 4
OVERVIEW OF BENEFITS PRE – TAX BENEFITS Health Insurance The Local Choice - Anthem
POST – TAX BENEFITS Disability Benefits Colonial Life
- Anthem Health - Delta Dental - Anthem Blue View Vision
Health Savings Account Ameriflex - Individual Maximum: $4,400/year Max -Family Maximum: $8,750/year Max HSA plans can only be established in conjunction with a qualified High-Deductible Health Plan (HDHP) Employer contributes $156.76 per month to eligible employees accounts. **HSA Administrative Fee – By electing an HSA product, you also agree to the associated monthly service fee of $2.50.
Critical Illness Benefits Colonial Life
Life Insurance Colonial Life - Term Life Insurance - Whole Life Insurance
Flexible Spending Accounts Ameriflex - Medical Reimbursement: $3,400/year Max - Dependent Care Reimbursement: $7,500/year Max - Limited Medical Reimbursement: $3,400/year Max
*You will need to re-enroll in the Flexible Spending Accounts if you want them to continue next year. If you do not re-enroll, your contribution will stop effective September 30, 2026.
ADDITIONAL BENEFITS Group Critical Illness Benefits Aflac
Cancer Benefits Colonial Life
Accident Benefits Colonial Life
Medical Bridge Benefits Colonial Life
Please note your insurance products will remain in effect unless you speak with a representative to change them. 5
IMPORTANT NOTICES When do my benefits start? The plan year for Colonial Life Insurance Products, The Local Choice Benefits (Anthem Health, Delta Dental, and Anthem Blue View Vision), Ameriflex Health Savings Accounts and Ameriflex Flexible Spending Accounts runs from October 1, 2026, through September 30, 2027. When do my deductions start? Deductions for The Local Choice Benefits (Anthem Health, Delta Dental, and Anthem Blue View Vision) and Ameriflex Health Savings Accounts start September 2026 for all enrolled employees. Deductions for Colonial Life Insurance Products and Ameriflex Flexible Spending Accounts start October 2026 for all enrolled employees. Why have my Medical Bridge benefits not started yet? The Health Screening Rider on the Colonial Medical Bridge plan has a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until October 31, 2026. How do Flexible Spending Account (FSA) funds work, and do my FSA funds have to be used by a specific deadline? Flexible Spending Account expenses must be incurred during the plan year to be eligible for reimbursement. After the plan year ends, an employee has 30 days to submit claims for incurred qualified spending account expenses (or 30 days after employment termination date). If employment is terminated before the plan year ends, the spending account also ends. Failure to use all allotted funds in the FSA account will result in a “Use It or Lose It” scenario. Your plan includes a grace period which is an additional 2.5 months (running October 1, 2027, through December 15, 2027), during which you can incur eligible expenses that can be reimbursed. Therefore, you have from October 1, 2026, through December 15, 2027, to incur qualified expenses eligible for reimbursement. If you do not incur qualified expenses by December 15, 2027, and/or file by December 31, 2027, any contributions are forfeited under the “Use It or Lose It” rule. My spouse is enrolled in a Health Savings Account (HSA), am I eligible for an FSA? As a married couple, one spouse cannot be enrolled in a Medical Reimbursement FSA at the same time the other opens or contributes to an HSA. How do Dependent Care Account (DCA) funds work and when do they need to be used? Dependent Care Accounts are like FSA accounts and allow you to request reimbursement up to your current balance. However, you cannot receive more reimbursement than what has been deducted from your pay. Any remaining funds in your DCA account must be utilized before the deadline. Failure to use all allotted funds in the DCA account will result in a “Use It or Lose It” scenario. When will I get my card? If you will be receiving a new debit card, whether you are a new participant or to replace your expired card, please be aware that it may take up to 30 days following your plan effective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses. Please note that your debit card is good through the expiration date printed on the card. I want to sign my family up for benefits as well, what information will I need? If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking with the Benefits Representative. What does Pre-Tax vs. Post-Tax Change? Pre-Tax benefits take funds directly from your paycheck to cover benefits before going through State and Federal taxing process. Post-Tax collects funds for benefits after taxes have been taken out. 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. Can I change my benefit elections outside of the enrollment period? Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change, otherwise known as a qualifying life event (Mid-Year Events), as defined by the Internal Revenue Code. Examples of Mid-Year Events can be found in the chart on the next page. Once a Mid-Year Event has occurred, an employee has 30 days to notify PGB’s Employee Services at 1-800-387-5955 to request a change in elections. I have a pre-existing condition. Will I still be covered? Some policies may include a pre-existing condition clause. Please read your policy carefully for full details.
Employee Services: 800-387-5955
www.PierceGroupBenefits.com/ CharlesCityCountyPublicSchools 6
Effective Dates:
October 1, 2026 - September 30, 2027
MID-YEAR EVENTS The benefit elections you make during Annual Enrollment or as a New Hire will remain in effect for the entire plan year. You will not be able to change or revoke your elections once they have been made unless a Mid-Year Event (status change) occurs. The summary of events that allow an employee to make benefit changes and instructions for processing those life event changes can be reviewed in the chart below.
MID-YEAR EVENT
ACTION REQUIRED
RESULT IF ACTION IS NOT TAKEN
New Hire
Make elections within 30 days of hire date. Documentation is required.
You and your dependents are not eligible until the next Annual Enrollment period.
Marriage
Add your new spouse to your elections within 30 days of the marriage date. A copy of the marriage certificate must be presented.
Your spouse is not eligible until the next Annual Enrollment period.
Divorce
Remove the former spouse within 30 days of the divorce. Proof of the divorce will be required. A copy of the divorce decree must be presented.
Benefits are not available for the divorced spouse and will be recouped if paid erroneously.
Enroll the new dependent in your elections within 30 days of the birth or adoption date, even if you already have family coverage. A copy of the birth certificate, mother’s copy of birth certificate, or hospital discharge papers must be presented. Once you receive the child’s Social Security Number, don’t forget to update your child’s insurance information record.
The new dependent will not be covered until the next Annual Enrollment period.
Remove or update dependent elections within 30 days of the dependent aging out. For more information and assistance, please call PGB Employee Services at 800-387-5955.
Coverage for the dependent will end at the time of the dependent aging out and the policyholder must remove/update the dependent elections in order for the change to be reflected in the employee’s deductions.
Death of a Spouse or Dependent
Remove the dependent from your elections within 30 days from the date of death. Death certificate must be presented.
You could pay a higher premium than required and you may be overpaying for coverage required.
Change in Spouse’s Employment or Coverage
Add or drop benefits from your elections within 30 days of the event date. A letter from the employer or insurance company must be presented.
You will not be able to make changes until the next Annual Enrollment period.
Birth or Adoption of a Child
Dependent Aging Out
The examples included in this chart are not all-inclusive. Please speak to a Benefits Representative to learn more. 7
MID-YEAR EVENTS MID-YEAR EVENT
ACTION REQUIRED
RESULT IF ACTION IS NOT TAKEN
Part-Time to Full-Time or Vice Versa
Change your elections within 30 days from the employment status change to receive COBRA information or to enroll in benefits as a full-time employee. Documentation from the employer must be provided.
Benefits may not be available to you or your dependents if you wait to enroll in COBRA. Full-time employees will have to wait until the next Annual Enrollment period.
Transferring Employers
If you are transferring from one PGB client to another, some benefits may be eligible for transfer. Please call PGB Employee Services at 800-387-5955 for more information and assistance.
You may lose the opportunity to transfer benefits.
Loss of Government or Education Sponsored Health Coverage
If you, your spouse, or a dependent loses coverage under any group health coverage sponsored by a governmental or educational institution, you may be eligible to add additional coverage for eligible benefits.
You and your dependents are not eligible until the next Annual Enrollment period.
Entitlement to Medicare or Medicaid
If you, your spouse, or dependent becomes entitled to or loses coverage under Medicare or Medicaid, you may be able to change coverage under the accident or health plan.
You and your dependents are not eligible until the next Annual Enrollment period.
Non-FMLA Leave
An employee taking a leave of absence, other than under the Family & Medical Leave Act, may not be eligible to re-enter the Flexible Benefits program until next plan year. Please contact your Benefit Administrator for more information.
You and your dependents are not eligible until the next Annual Enrollment period.
Retiring
Your individual supplemental/voluntary policies through Colonial Life are portable! To move them from payroll deduction to direct billing, please complete and submit the Payment Method Change Form to Colonial Life within 30 days of retiring. You are also eligible for post-employment Dental, Vision, and Telemedicine benefits through PGB. Please visit: www.piercegroupbenefits.com/ individualcoverage or call our Employee Services at 800-387-5955 for more information and assistance.
If you do not transfer your policies from payroll deduction to direct billing, Colonial Life will terminate your policies resulting in a loss of coverage.
The examples included in this chart are not all-inclusive. Please speak to a Benefits Representative to learn more. 8
ENROLLMENT INFORMATION IN-PERSON During your annual enrollment period, a PGB Benefits Representative will be available by appointment to meet with you one-on-one to help you evaluate your benefits based on your individual and family needs, answer any questions you may have, and assist you in the enrollment process.
ANNUAL ENROLLMENT PERIOD:
AUGUST 3, 2026 - AUGUST 17, 2026 BENEFIT ELECTION OPTIONS YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS DURING THE ANNUAL ENROLLMENT PERIOD: • • • •
Enroll in, change, or cancel The Local Choice benefits (Anthem Health, Delta Dental, and Anthem Blue View Vision). Enroll in, change, or cancel Health Savings Accounts. Enroll/Re-Enroll in Flexible Spending Accounts.+ Enroll in, change, or cancel Colonial coverage.
+You will need to re-enroll in the Flexible Spending Accounts if you want them to continue each year.
ACCESS YOUR BENEFIT OPTIONS WHENEVER, WHEREVER You can view details about what benefits your employer offers, view educational videos about all of your benefits, download forms, chat with one of our knowledgeable Benefits Representatives, and more on your personalized benefits website. To view your custom benefits website, visit: www.PierceGroupBenefits.com/CharlesCityCountyPublicSchools 9
Click on the video below to learn more about Health Insurance!
HEALTH INSURANCE
Charles City County Schools October 1, 2026 - September 30, 2027 High Deductible Health Plan Plan Year Deductible (applies as indicated) One Person Family (two or more people)
In-Network
Plan Year Out-of-Pocket Expense Limit Individual Out-of-Pocket Maximum Family Out-of-Pocket Maximum
In-Network
$5,000 $10,000
Key Advantage 1000 In-Network
Out-of-Network
$1,000 $2,000
$2,000 $4,000
Out-of-Network
In-Network
Out-of-Network
$10,000 $20,000
$5,000 $10,000
$9,000 $18,000
Out-of-Network
$3,400 $6,800
Lifetime Maximum
Covered Services Doctor's Visits (Outpatient or In-Office) Primary Care Physician Visits Chiropractic, Spinal Manipulations (30 visit limit)
20% Coinsurance, after deductible
$25 Copayment
Specialist Visits Chiropractic, Spinal Manipulations (30 visit limit)
20% Coinsurance, after deductible
$40 Copayment
Shots - Allergy or Therapeutic Injections Doctor's Office, ER, or Outpatient Setting
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Diagnostic Tests, Labs, and X-Rays Specific conditions/diseases at doctor's office, ER, or Outpatient Setting
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Preventive Care Visits
Covered at 100%
Covered at 100%
Emergency Room Visits
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Ambulance Services
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Inpatient Hospital Services
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Outpatient Hospital Services
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Outpatient Diagnostic Test, Labs, and X-Rays
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Outpatient Therapy Services - Occupational, Speech, Physical, Cardiac, Chemotherapy, Radiation, Infusion, & Respiratory
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Diabetic Equipment
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Prenatal & Provider Services- PCP
20% Coinsurance, after deductible
$25 Copayment
Prenatal & Provider Services - Specialist
20% Coinsurance, after deductible
$40 Copayment
Hospital Services for Delivery
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Diagnostic Tests, Labs, and X-Rays
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Inpatient Treatment/Residential Treatment
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Partial Hospitalization (Day) Program
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Outpatient Professional Provider Services
20% Coinsurance, after deductible
$25 Copayment
Must meet annual deductible
$150/$300
Tier 1
20% Coinsurance after deductible
$10 Copayment, no deductible
Tier 2
20% Coinsurance after deductible
$30 Copayment after RX Deductible
Tier 3
20% Coinsurance after deductible
$45 Copayment after RX Deductible
Tier 4
20% Coinsurance after deductible
20% Coinsurance after RX Deductible up to $200
Home Delivery Services-Mail Order (90-day supply)
20% Coinsurance, after deductible
2x Retail Copay
Diabetic Supplies
20% Coinsurance, after deductible
20% Coinsurance, no deductible
Hospital & Other Services (Pre-certification may be required)
Maternity
Behavioral Health
Prescription Drug Benefit* Retail Pharmacy (up to a 34-day supply) Rx Deductible - Individual/Family
*You have a mandatory generic drug program. However, if there is no generic equivalent for the drug, you may get the brand and pay only the applicable benefit level. If there is a generic equivalent available, you may opt to use the brand but you'll pay the applicable brand level plus the difference between the brand and generic allowable charge. ** This plan will waive the hospital Copayment if the member enrolls in the maternity management pre-natal program within the first trimester of pregnancy, has a dental cleaning during pregnancy and satisfactorily completes the program. *** Your outpatient prescription drug benefit will no longer include coverage for glucagon-like peptide-1 (GLP-1) medications used for weight loss ^ Anthem Employee Assistance Program (EAP) Expansion: Anthem EAP is now available to all employees, even those not enrolled in health insurance. Employees and their household members are eligible for up to four free online or in-person counseling sessions per issue each year. In addition, other well-being resources can be accessed on the EAP website.
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Anthem Health & Wellness Programs Anthem can help you make the most of your benefits so you can be your healthiest. Take advantage of these wellness programs and services included in your health plan.
Sydney Health mobile app The SydneySM Health mobile app gives you a quick connection to benefit information, tools, and helpful resources. Download the app today and log in using your anthem.com username and password to: View your ID card and claims. Easily chat with customer service. • Connect quickly to virtual care. • Find wellness programs. •
Simplify your healthcare by downloading Sydney Health today
•
Anthem Health Guide Anthem Health Guides are specially trained to answer your health plan questions and steer you to the right programs and support for your unique needs. Your guide will also remind you of any screenings or routine exams that are due, help you save money on your prescription drugs, compare costs for care, and find in-network doctors in your area. Call 800-552-2682, Monday to Friday 8:00 a.m. to 6:00 p.m.
Employee Assistance Program (EAP) Life can be challenging, and Anthem EAP is here to help. Your EAP includes up to 4 free, confidential counseling sessions per issue per plan year for you, your covered dependents, and members of your household. It’s also a valuable source for information about emotional well-being, childcare and elder care resources, financial and legal issues, and smoking cessation. Go to anthemeap.com, and log in using Commonwealth of Virginia as your company, and then select The Local Choice, or call 855-223-9277. 12
LiveHealth Online Using the Sydney Health app, you can have a private, secure, video visit wherever you are with a doctor. Urgent care virtual visits are available on demand 24/7. Virtual appointments can also be scheduled to meet with a dermatologist, therapist, psychologist, psychiatrist, physical therapist or a sleep specialist. No cost for Key Advantage Plans. Twenty percent coinsurance, after deductible for HDHP plans.
24/7 NurseLine 24/7 NurseLine has registered nurses ready and willing to help you at any time of the day. Call 24/7 NurseLine (800-337-4770) to speak with a nurse about health questions, symptoms, or the best place to seek treatment. Your call is always free and completely confidential.
Lark Diabetes Prevention Program A personalized digital health coaching program that leverages smart connected devices to lower risk for type 2 diabetes. Eligible members will be invited to participate in the program.
Building Healthy Families Available in the Sydney Health app, families can get personalized, on-demand health support during pregnancy, postpartum, or while raising young children. Key Advantage Expanded and Key Advantage 250 members can have their hospital copayment waived when they complete the following: 1. Register for Building Healthy Families and complete the profile 2. Take the pregnancy screener 3. Complete one of six mini assessments within the app
ConditionCare Extra support for members with: Asthma Diabetes • Coronary artery disease • Heart failure • Chronic obstructive pulmonary disease (COPD) • Hypertension • •
ConditionCare provides Nurse Care Managers who work with you or a covered family member to help you better understand and manage a condition and meet personalized health goals. Call 844-507-8472 to enroll or we may call you to see if you would like to participate.
Sydney Health is offered through an arrangement with Carelon Digital Platforms, a separate company offering mobile application services on behalf of your health plan. ©2020-2022 Commonwealth of Virginia complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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A10739 (2/2024)
Discover a powerful and more personalized health app View all your benefits and access wellness tools to improve your overall health with the Sydney HealthSM app
The Sydney Health mobile app works with you by guiding you to better overall health — and for you by bringing your benefits and health information together in one convenient place. Sydney Health has everything you need to know about your benefits, so you can make the most of them while taking care of your health.
Working with you
Working for you
} Reminding you about important
} Giving you instant access to your
preventive care needs*
medical, dental and vision benefits and claims*
} Planning and tracking your health
goals, fitness, and rewards
} Storing your member ID card so
} Guiding you with insights based on
your history and changing health needs
you can show, email, or fax it right from your phone } Providing answers quickly through
} Empowering you with personalized
tools to find doctors, hospitals, labs, and other health care providers in your plan and compare costs.* } Helping you manage prescriptions and
save money by comparing pharmacy costs and locating coupons
real-time live chat with an Anthem representative } Connecting you to virtual care
options for primary, urgent or specialty care
Simplify your healthcare by downloading Sydney Health today
* Based on your plan enrollment. Sydney Health is offered through an arrangement with Carelon Digital Platforms, a separate company offering mobile application services on behalf of your health plan ©2020-2022. Commonwealth of Virginia complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. A10723 11/23
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Click on the video below to learn more about Dental Insurance!
DENTAL INSURANCE
You Have Two Choices for Dental Benefits Comprehensive Dental Option Comprehensive Dental
You Pay
Dental Plan Year Deductible
$25/one person $50/two people $75/family
Plan Year Maximum (except Orthodontics)
OR Preventive Dental Option This covers only preventive services, and is available for a lower premium. Preventive Dental
Preventive Dental Care $0 (No dental (routine oral exam and deductible or plan cleaning twice per plan year, year maximum) x-rays, sealants and fluoride for children)
$1,500
Preventive Dental Care (routine oral exam and cleaning twice per plan year, x-rays, sealants and fluoride for children)
$0
Primary Dental Care (fillings, root canal, simple extractions, periodontic services, etc.)
20% coinsurance after dental deductible
Major Dental Care (crowns, inlays, onlays, dentures and fixed bridges)
50% coinsurance after dental deductible
Orthodontic Services (for children and adults)
50% coinsurance, no dental deductible, with $1,500 lifetime maximum
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. ©2013 Anthem Blue Cross and Blue Shield.
A10284 (7/2017)
You Pay
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To change your current dental option, you must complete an enrollment form at open enrollment or with a qualifying event.
Click on the video below to learn more about Vision Insurance!
VISION INSURANCE
Routine Vision – Blue View Vision Network You have an allowance for eyeglass lenses or contact lenses every plan year. You pay the remaining cost for frames and lenses after Your Health Plan’s Reimbursement. Covered Services
Blue View Vision Network (once per plan year)
Non-Blue View
Routine eye exam
You pay $15 copayment
Plan pays up to to $50
Standard eyeglass lenses
You pay $20 copayment
Plan pays up to: $50 single lenses; $75 bifocal; $100 trifocal
Plan pays up to $100* retail allowance
Plan pays up to $80
Elective Conventional2
Plan pays up to $100 allowance then 15% discount off remaining balance
Plan pays up to $80
Elective Disposable2
Plan pays up to $100 allowance (no additional discount)
Plan pays up to $80
Covered in full
Plan pays up to $210
(in lieu of contact lenses) Polycarbonate lenses included at no additional cost for children under 19 years old
Eyeglass frames Contact lenses1 (in lieu of eyeglass lenses)
Non-Elective2
Retinal Imaging
Not more than $39
At member’s option can be performed at time of eye exam
Lens options UV coating, tints, standard scratch-resistant
You pay $15
Not available
Standard polycarbonate (Adult)
You pay $40
Not available
Standard progressive (in addition to bifocal copayment)
You pay $65
Not available
Standard anti-reflective
You pay $45
Not available
Other add-ons (i.e. high index lenses, anti-fog coating)
You pay 20% off retail
Not available
*You may select a frame greater than the covered allowance and receive a 20% discount for any additional cost over the allowance. 1
Declining Balance. Your plan has a declining balance allowance. This means if you do not use your allowance all at once, the remainder will be available for you to use at a later time. However, any remaining balance will not carry over to the next benefit year. All services or supplies using the declining balance for a benefit period must be received In-Network based on where the first paid claim is incurred..
2
Elective contact lenses are typically elected in lieu of eyeglass lenses. Non-Elective contact lenses are medically necessary contacts when glasses are not an option for vision.
Your High Deductible Health Plan is HSA Compatible Enrollment in a HDHP allows you to set up a personal Health Savings Account (HSA) through a bank or other financial institution to help you manage healthcare expenses or save for retirement. HSAs were created as part of Medicare reform legislation in 2003. An HSA is a tax-favored account that allows those covered by a HDHP to pay for certain qualified medical expenses. It can help you save on the cost of your health insurance and healthcare expenses, and also help pay for covered services before you satisfy the health plan deductible. If you decide to set up an HSA to work with your HDHP, confer with your tax advisor, bank or other financial institution. The following web sites are a good place to start learning more about HSAs.
• www.treasury.gov – Provides an overview of HSAs, answers to frequently asked questions and important IRS forms and applications. Search using keyword HSA.
• www.irs.gov – Provides information about how HSAs impact your Federal taxes and qualified medical expenses (Publications 969 and 502). Search using keyword HSA.
• www.hhs.gov – Provides general information about HSAs and other tax-favored health plans. Search using keyword HSA. Note: If you have an HSA, you cannot also have a Flexible Spending Account unless it is limited in scope. More information is available from tax consultants or financial institutions.
6 18
Key Advantage 1000 Benefits At-A-Glance (continued) Routine Vision – Blue View Vision Network You have an allowance for eyeglass lenses or contact lenses every plan year. You pay the remaining cost for frames and lenses after Your Health Plan’s Reimbursement. Covered Services
Blue View Vision Network (once per plan year)
Non-Blue View
Routine eye exam
You pay $40 copayment
Plan pays up to to $50
Standard eyeglass lenses
You pay $20 copayment
Plan pays up to: $50 single lenses; $75 bifocal; $100 trifocal
Plan pays up to $100* retail allowance
Plan pays up to $80
Elective Conventional2
Plan pays up to $100 allowance then 15% discount off remaining balance
Plan pays up to $80
Elective Disposable2
Plan pays up to $100 allowance (no additional discount)
Plan pays up to $80
Non-Elective2
Plan pays up to $250 allowance
Plan pays up to $210
(in lieu of contact lenses)
Polycarbonate lenses included at no additional cost for children under 19 years old
Eyeglass frames Contact lenses
1
(in lieu of eyeglass lenses)
Retinal Imaging
Not more than $39
At member’s option can be performed at time of eye exam
Lens options UV coating, tints, standard scratch-resistant
You pay $15
Not available
Standard polycarbonate (Adult)
You pay $40
Not available
Standard progressive (in addition to bifocal copayment)
You pay $65
Not available
Standard anti-reflective
You pay $45
Not available
Other add-ons (i.e. high index lenses, anti-fog coating)
You pay 20% off retail
Not available
*You may select a frame greater than the covered allowance and receive a 20% discount for any additional cost over the allowance. 1
Declining Balance. Your plan has a declining balance allowance. This means if you do not use your allowance all at once, the remainder will be available for you to use at a later time. However, any remaining balance will not carry over to the next benefit year. All services or supplies using the declining balance for a benefit period must be received In-Network based on where the first paid claim is incurred..
2
Elective contact lenses are typically elected in lieu of eyeglass lenses. Non-Elective contact lenses are medically necessary contacts when glasses are not an option for vision.
6 19
Charles City County Schools October 1, 2026 - September 30, 2027 Contribution Schedule High Deductible Health Plan with Comprehensive Dental and Vision (HDHP)
Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution Employee 24 Deduction Contribution
Employee Only
Employee + Spouse
Employee + Child
Employee + Children
Employee + Family
$973.00
$1,799.00
$1,799.00
$2,627.00
$2,627.00
$973.00
$1,408.62
$1,799.00
$2,335.68
$1,832.16
$0.00
$390.38
$0.00
$291.32
$794.84
$0.00
$195.19
$0.00
$145.66
$397.42
Charles City County Schools contributes $156.76 monthly ($78.37/pay) to all employee Health Savings Accounts. Employees who enroll in a High Deductible Health Plan will also be automatically enrolled in Aflac Group Critical Illness sponsored by Charles City County Schools
Key Advantage 1000 with Comprehensive Dental and Vision (PPO)
Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution Employee 24 Deduction Contribution
Employee Only
Employee + Spouse
Employee + Child
Employee + Children
Employee + Family
$1,179.00
$2,181.00
$2,181.00
$3,183.00
$3,183.00
$1,098.50
$1,345.40
$1,821.55
$2,315.18
$1,592.20
$80.50
$835.60
$359.45
$867.82
$1,590.80
$40.25
$417.80
$179.73
$433.91
$795.40
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Click on the video below to learn more about Health Savings Accounts!
HEALTH SAVINGS ACCOUNT
Health Savings Account A personal tax-free savings account for healthcare expenses and investing Use the below information to determine if a Health Savings Account (HSA) is right for you and how to best take advantage of an HSA account.
How It Works You can enroll in a Health Savings Account (HSA) to experience tax savings on qualified healthcare expenses such as copays, deductibles, prescriptions, over-the-counter drugs and medications, and prescriptions. There is no use-or-lose rule, meaning you can save and invest when you can or spend on eligible healthcare expenses as needed. To enroll in a HSA, you must already be enrolled in an HSA-qualifying high deductible health plan (HDHP). As a married couple, one spouse cannot be enrolled in an FSA at the same time the other is contributing to an HSA.
The Value & Perks • Triple Tax Savings: Every dollar you contribute to an HSA lowers your taxable income, funds grow tax-free, and withdrawals for qualified expenses are tax-free.
• Employee-Owned: It’s a personal savings account owned by you. Which means you can keep it even if
you switch health plans, change jobs, or retire. You’ll receive an Ameriflex Debit Mastercard linked to your HSA that can be used for eligible purchases everywhere Mastercard is accepted.
• Investing & Saving: You can save and invest your funds with over 30 investment options. HSA funds roll over year to year, allowing long-term growth if there are no immediate spending needs.
• Catch-Up Contributions: Individuals ages 55 and older who are not enrolled in Medicare can make an additional $1,000 catch-up contribution to their HSA. Eligible HSA Expenses The IRS determines what expenses are eligible under an HSA. Below are some examples of common eligible expenses:
Deductibles & copays
Prescriptions
Dental work & orthodontia
Glasses, contacts & LASIK
Band-aids
Sunscreen
For a full list of eligible expenses, go to myameriflex.com/eligibleexpenses.
Learn more at myameriflex.com | 844.423.4636 | info@myameriflex.com 22
THE HSA STORE Resources Available Through The HSA Store
• The largest selection of guaranteed HSAeligible products • Phone and live chat support available 24 hours a day / 7 days a week
Eligibility List
HSA Calculator
Search comprehensive list of eligible products and services.
Estimate how much you can save with an HSA.
Learning Center
Savings Center
• Fast and free shipping on orders over $50 • Use your HSA card or any other major credit card for purchases
Easy tips and resources for living with an HSA.
Your funds go further with the HSA Store rewards program.
Your Health, Your Funds, Your Choice Take control of your health and wellness with guaranteed HSA-eligible essentials. Pierce Group Benefits partners with the HSA store to provide one convenient location for Health Savings Account holders.
Click or Scan to Shop Now
Click on the video below to learn more about Flexible Spending Accounts!
FLEXIBLE SPENDING ACCOUNT
Flexible Spending Account An account for setting aside tax-free money for healthcare expenses Use the below information to determine if a Flexible Spending Account (FSA) is right for you and how to best take advantage of an FSA account.
How It Works When you enroll in a Flexible Spending Account (FSA) you get to experience tax savings on qualified expenses such as copays, deductibles, prescriptions, over-the-counter drugs and medications, and thousands of other everyday items. Can I have an FSA and an HSA? You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses. As per IRS Publication 969, an employee covered by an HDHP and a health FSA or an HRA that pays or reimburses qualified medical expenses generally can’t make contributions to an HSA. An employee is also not HSA-eligible during an FSA Grace Period. An employee enrolled in a Limited Purpose FSA is HSA-eligible. As a married couple, one spouse cannot be enrolled in an FSA at the same time the other is contributing to an HSA. FSA coverage extends tax benefits to family members allowing the FSA holder to be reimbursed for medical expenses for themselves, their spouse, and their dependents.
The Value & Perks • Election Accessibility: You will have access to your entire election on the first day of the plan year. • Save On Eligible Expenses: You can save up to 40% on thousands of eligible everyday expenses such as prescriptions, doctor’s visits, dental services, glasses, over-the-counter medicines, and copays.
• Keep More Money: The funds are taken out of your paycheck "pre-tax" (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. Let’s say you earn $40,000 a year and contribute $1,500 to an FSA; so, only $38,500 of your income gets taxed. That means you are increasing your take-home pay simply by participating!
• Easy Spending and Account Management: You will receive an Ameriflex Debit Mastercard linked to your FSA. You can use your card for eligible purchases everywhere Mastercard is accepted. Account information can be securely accessed 24/7 online and through the mobile app.
Learn more at myameriflex.com | 844.423.4636 | info@myameriflex.com 25
Eligible FSA Expenses The IRS determines what expenses are eligible under an FSA. Below are some examples of common eligible expenses.
Copays, deductibles, and other payments you are responsible for under your health plan.
Routine exams, dental care, prescription drugs, eye care, hearing aids, etc.
Prescription glasses and sunglasses, contact lenses and solution, LASIK, and eye exams.
Certain OTC expenses such as Band-aids, medicine, First Aid supplies, etc. (prescription required).
Diabetic equipment and supplies, durable medical equipment, and qualified medical products or services.
For a full list of eligible expenses, go to myameriflex.com/eligibleexpenses.
The “Use-or-Lose” Rule If you contribute dollars to a reimbursement account and do not use all the money you deposit, you will lose any remaining balance in the account at the end of the eligible claims period. This rule, established by the IRS as a component of tax-advantaged plans, is referred to as the “use-or-lose” rule. To avoid losing any of the funds you contribute to your FSA, it’s important to plan ahead as much as possible to estimate what your expenditures will be in a given plan year.
Learn more at myameriflex.com | 844.423.4636 | info@myameriflex.com 26
Limited Purpose FSA Set aside tax-free money for dental and vision expenses Use the below information to determine if a Limited Purpose Flexible Spending Account (LPFSA) is right for you and how to best take advantage of an LPFSA account.
How It Works A Limited Purpose Flexible Spending Account (LPFSA) is a special type of FSA that allows you to set aside tax-free money to pay for eligible dental and vision expenses. What makes an LPFSA unique is that it can be used in conjunction with a Health Savings Account (HSA), allowing you to grow your HSA funds while using the LPFSA to pay for immediate dental and vision needs. Other than the restriction of eligible expenses to vision, dental, and orthodontia, the rules governing the LPFSA are the same as those that apply to an FSA.
The Value & Perks • Save On Eligible Expenses: You can save up to 40% on qualifying expenses such as vision
appointments, LASIK, contact lenses and solution, glasses, teeth cleaning, dentures, and dental and vision copays. You can contribute to an LPFSA and HSA in the same plan year, allowing you to save and grow your HSA balance, while using the LPFSA to pay for everyday expenses.
• Keep More Money: The funds are taken out of your paycheck "pre-tax" (meaning they are subtracted
from your gross earnings before taxes) throughout the course of the year. Let’s say you earn $40,000 a year and contribute $1,500 to an LPFSA; so, only $38,500 of your income gets taxed. That means you are increasing your take-home pay simply by participating!
• Easy Spending and Account Management: You will receive an Ameriflex Debit Mastercard linked to your LPFSA. You can use your card for eligible purchases everywhere Mastercard is accepted. Account information can be securely accessed 24/7 online and through the mobile app.
Eligible LPFSA Expenses You can use your LPFSA to pay for expenses related to dental and vision. Below are some examples of common eligible expenses:
Vision exams, co-payments, and deductibles
LASIK, eyeglasses, contact lenses, and lens solution
Dental cleanings, dentures, and orthodontia work
Dental x-ray, co-payments, and deductibles
For a full list of eligible expenses, go to myameriflex.com/eligibleexpenses.
Learn more at myameriflex.com | 844.423.4636 | info@myameriflex.com 27
THE FSA STORE Resources Available Through The FSA Store
• The largest selection of guaranteed FSAeligible products • Phone and live chat support available 24 hours a day / 7 days a week
Eligibility List
FSA Calculator
Search comprehensive list of eligible products and services.
Estimate how much you can save with an FSA.
Learning Center
Savings Center
• Fast and free shipping on orders over $50 • Use your FSA card or any other major credit card for purchases
Easy tips and resources for living with an FSA.
Your funds go further with the FSA Store rewards program.
Your Health, Your Funds, Your Choice Take control of your health and wellness with guaranteed FSA-eligible essentials. Pierce Group Benefits partners with the FSA store to provide one convenient location for Flexible Spending Account holders.
Click or Scan to Shop Now 28
Click on the video below to learn more about Dependent Care Accounts!
DEPENDENT CARE ACCOUNT
Dependent Care Account Set aside tax-free money for daycare and dependent care services Use the below information to determine if a Dependent Care Account (DCA) is right for you and how to best take advantage of an DCA account.
How It Works When you enroll in a Dependent Care Account (DCA) you get to experience tax savings on expenses like daycare, elderly care, summer day camp, preschool, and other services that allow you to work full time.
The Value & Perks • Save On Eligible Expenses: You can use a DCA to pay for qualifying expenses such as daycare, summer day care, elder care, before and after school programs, and pre-school.
• Keep More Money: The funds are taken out of your paycheck "pre-tax" (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. Let’s say you earn $40,000 a year and contribute $1,500 to an DCA; so, only $38,500 of your income gets taxed. That means you are increasing your take-home pay simply by participating!
• Easy Spending and Account Management: You will receive an Ameriflex Debit Mastercard linked to your DCA. You can use your card for eligible purchases everywhere Mastercard is accepted. Account information can be securely accessed 24/7 online and through the mobile app.
Eligible DCA Expenses The IRS determines what expenses are eligible under a DCA. Below are some examples of common eligible expenses:
Private sitter
Daycare and elder care
Before- and after-school care
Summer day camp
Nanny service
Nursery school & Pre-school
For a full list of eligible expenses, go to myameriflex.com/eligibleexpenses.
Learn more at myameriflex.com | 844.423.4636 | info@myameriflex.com 30
www.myameriflex.com
Online Account Instructions How to Access Your Ameriflex Account: Go to MyAmeriflex.com and click “Login” from the upper right hand corner. When prompted, select “Participant.”
How to Register Online For Your Ameriflex Spending Account: Click the register button atop the right corner of the home screen. 1. As the primary account holder, enter your personal information. • Choose a unique User ID and create a password (if you are told that your username is invalid or already taken, you must select another). • Enter your first and last name. • Enter your email address. • Enter your Employee ID, which in most cases, will be the account holder’s Social Security Number(no dashes or spaces needed). 2. Check the box if you accept the terms of use. 3. Click 'register'. This process may take a few seconds. Do not click your browser’s back button or refresh the page. 4. Last, you must complete your Secure Authentication setup. Implemented to protect your privacy and help us prevent fraudulent activity, setup is quick and easy. After the registration form is successfully completed, you will be prompted to complete the secure authentication setup process: Step 1: Select a Security Question option, and type in a corresponding answer. Step 2: Repeat for the following three Security Questions, then click next. Step 3: Verify your email address, and then click next. Step 4: Verify and submit setup information, 5. The registration process is complete! Should you receive an information error message that does not easily guide you through the information correction process, please feel free to contact our dedicated Member Services Team at 888.868.FLEX (3539).
31
Want to Manage Your Account on the go? Download the MyAmeriflex mobile app, available through the App Store or Google Play. Your credentials for the MyAmeriflex Portal and the MyAmeriflex Mobile App are the same; there is no need for separate login information!
Click on the video below to learn more about Cancer Benefits!
CANCER BENEFITS
Cancer Insurance How would cancer impact your way of life? Hopefully, you and your family will never face cancer. If you do, a financial safety net can help you and your loved ones focus on what matters most — recovery. If you were diagnosed with cancer, you could have expenses that medical insurance doesn’t cover. In addition to your regular, ongoing bills, you could have indirect treatment and recovery costs, such as child care and home health care services.
Help when you need it most Cancer coverage from Colonial Life & Accident Insurance Company can help protect the lifestyle you’ve worked so hard to build. It provides benefits you can use to help cover: ■ Loss of income ■ Out-of-network treatment ■ Lodging and meals ■ Deductibles and co-pays
33
CANCER ASSIST
One family’s journey
Paul and Kim were preparing for their second child when they learned Paul had cancer. They quickly realized their medical insurance wouldn’t cover everything. Thankfully, Kim’s job enabled her to have a cancer insurance policy on Paul to help them with expenses.
SECOND OPINION
SURGERY
Travel expenses
Out-of-pocket costs
When the couple traveled several hundred miles from their home to a top cancer hospital, they used the policy’s lodging and transportation benefits to help with expenses.
The policy’s benefits helped with deductibles and co-pays related to Paul’s surgery and hospital stay.
For illustrative purposes only
With cancer insurance: ■ Coverage options are available for you
and your eligible dependents. ■ Benefits are paid directly to you, unless
you specify otherwise. ■ You’re paid regardless of any insurance
you may have with other companies. ■ You can take coverage with you, even if you
change jobs or retire.
ONLY of ALL
CANCERS are
hereditary.
American Cancer Society, Cancer Facts & Figures, 2013
34
Cancer insurance provides benefits to help with cancer expenses — from diagnosis to recovery.
TREATMENT
RECOVERY
Experimental care
Follow-up evaluations
Paul used his plan’s benefits to help pay for experimental treatments not covered by his medical insurance.
Paul has been cancer-free for more than four years. His cancer policy provides a benefit for periodic scans to help ensure the cancer stays in check.
Our cancer insurance offers more than 30 benefits that can help you with costs that may not be covered by your medical insurance. Treatment benefits
(inpatient or outpatient)
Surgery benefits ■ Surgical procedures
■ Radiation/chemotherapy
■ Anesthesia
■ Anti-nausea medication
■ Reconstructive surgery
■ Medical imaging studies
■ Outpatient surgical center
■ Supportive or protective care drugs
■ Prosthetic device/artificial limb
and colony stimulating factors ■ Second medical opinion
Travel benefits
■ Blood/plasma/platelets/
■ Transportation
immunoglobulins ■ Bone marrow or peripheral stem
■ Companion transportation ■ Lodging
LIFETIME RISK OF DEVELOPING CANCER
MEN 1 in 2
cell donation ■ Bone marrow or peripheral stem
cell transplant ■ Egg(s) extraction or harvesting/
sperm collection and storage ■ Experimental treatment ■ Hair/external breast/voice
box prosthesis ■ Home health care services ■ Hospice (initial or daily care)
Inpatient benefits ■ Hospital confinement ■ Private full-time nursing services ■ Skilled nursing care facility ■ Ambulance ■ Air ambulance
Additional benefits WOMEN
■ Family care
1 in 3
■ Cancer vaccine ■ Bone marrow donor screening ■ Skin cancer initial diagnosis ■ Waiver of premium
35
American Cancer Society, Cancer Facts & Figures, 2013
Optional riders For an additional cost, you may have the option of purchasing additional riders for even more financial protection against cancer. Talk with your benefits counselor to find out which of these riders are available for you to purchase. ■ Diagnosis of cancer rider — Pays a one-time, lump-sum benefit for the
ColonialLife.com
initial diagnosis of cancer. You may choose a benefit amount in $1,000 increments between $1,000 and $10,000. If your dependent child is diagnosed with cancer, we will pay two and a half times ($2,500 - $25,000) the chosen benefit amount. ■ Diagnosis of cancer progressive payment rider — Provides a lump-sum
payment of $50 for each month the rider has been in force and before cancer is first diagnosed. ■ Specified disease hospital confinement rider — Pays $300 per day if
you or a covered family member is confined to a hospital for treatment for one of the 34 specified diseases covered under the rider.
If cancer impacts your life, you should be able to focus on getting better — not on how you’ll pay your bills. Talk with your Colonial Life benefits counselor about how cancer insurance can help provide financial security for you and your family.
PRE-EXISTING CONDITION LIMITATION We will not pay benefits for the diagnosis of internal cancer or skin cancer that is a pre-existing condition, nor will we pay benefits for the treatment of internal cancer or skin cancer that is a pre-existing condition unless the covered person has satisfied the six-month pre-existing condition limitation period shown on the Policy Schedule. Pre-existing condition means a condition for which a covered person was diagnosed prior to the effective date of this policy, and for which medical advice or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of this policy. EXCLUSIONS We will not pay benefits for cancer or skin cancer: ■ If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or ■ For other conditions or diseases, except losses due directly from cancer. The policy and its riders may have additional 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-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA. ©2016 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.
36
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Cancer Insurance Level 4 Benefits BENEFIT DESCRIPTION
Cancer insurance helps provide financial protection through a variety of benefits. These benefits are not only for you but also for your covered family members.
BENEFIT AMOUNT
Air ambulance . . . .............................................................................. $2,000 per trip
Transportation to or from a hospital or medical facility [max. of two trips per confinement]
Ambulance . . . . . . ............................................................................... $250 per trip Transportation to or from a hospital or medical facility [max. of two trips per confinement]
Anesthesia
Administered during a surgical procedure for cancer treatment ■ General anesthesia ......................................................................... 25% of surgical procedures benefit ■ Local anesthesia............................................................................ $50 per procedure
Anti-nausea medication ..................................................................... $60 per day administered or Doctor-prescribed medication for radiation or chemotherapy [$240 monthly max.]
per prescription filled
Blood/plasma/platelets/immunoglobulins .............................................. $250 per day A transfusion required during cancer treatment [$10,000 calendar year max.]
Bone marrow donor screening ............................................................. $50 Testing in connection with being a potential donor [once per lifetime]
Bone marrow or peripheral stem cell donation ......................................... $1,000 Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]
Bone marrow or peripheral stem cell transplant ....................................... $10,000 per transplant
Transplant you receive in connection with cancer treatment [max. of two bone marrow transplant benefits per lifetime]
Cancer vaccine. . . .............................................................................. $50 An FDA-approved vaccine for the prevention of cancer [once per lifetime]
Companion transportation ................................................................. $0.50 per mile
Companion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,500 per round trip]
Egg(s) extraction or harvesting/sperm collection and storage
Extracted/harvested or collected before chemotherapy or radiation [once per lifetime] ■ Egg(s) extraction or harvesting/sperm collection ......................................... $1,500 ■ Egg(s) or sperm storage (cryopreservation) ............................................... $500
Experimental treatment ..................................................................... $300 per day Hospital, medical or surgical care for cancer [$15,000 lifetime max.]
For more information, talk with your benefits counselor.
Family care . . . . . . ............................................................................... $60 per day Inpatient or outpatient treatment for a covered dependent child [$3,000 calendar year max.]
Hair/external breast/voice box prosthesis ............................................... $500 per calendar year Prosthesis needed as a direct result of cancer
Home health care services .................................................................. $175 per day Examples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 100 days per covered person per lifetime]
Hospice (initial or daily care)
An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both] ■ Initial hospice care [once per lifetime] ..................................................... $1,000 ■ Daily hospice care .......................................................................... $50 per day
37
CANCER ASSIST – LEVEL 4
BENEFIT DESCRIPTION
BENEFIT AMOUNT
Hospital confinement
Hospital stay (including intensive care) required for cancer treatment ■ 30 days or less . . ........................................................................................ $350 per day ■ 31 days or more ........................................................................................ $700 per day
Lodging . . . . . . . . . . . . ......................................................................................... $80 per day Hotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]
Medical imaging studies ................................................................................. $225 per study
Specific studies for cancer treatment [$450 calendar year max.]
Outpatient surgical center .............................................................................. $400 per day Surgery at an outpatient center for cancer treatment [$1,200 calendar year max.]
Private full-time nursing services ...................................................................... $150 per day Services while hospital confined other than those regularly furnished by the hospital
Prosthetic device/artificial limb ........................................................................ $3,000 per device or limb A surgical implant needed because of cancer surgery [payable one per site, $6,000 lifetime max.]
Radiation/chemotherapy
[per day with a max. of one per calendar week] ■ Injected chemotherapy by medical personnel ........................................................ $1,000 ■ Radiation delivered by medical personnel ............................................................ $1,000 [per day with a max. of one per calendar month] ■ Self-injected . . . ......................................................................................... $400 ■ Pump . . . . . . . . . . ......................................................................................... $400 ■ Topical . . . . . . . . . . ........................................................................................ $400 ■ Oral hormonal [1-24 months] .......................................................................... $400 ■ Oral hormonal [25+ months] ........................................................................... $350 ■ Oral non-hormonal ..................................................................................... $400
Reconstructive surgery .................................................................................. $60 per surgical unit
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A surgery to reconstruct anatomic defects that result from cancer treatment [min. $350 per procedure, up to $3,000, including 25% for general anesthesia]
Second medical opinion ................................................................................. $300
A second physician’s opinion on cancer surgery or treatment [once per lifetime]
Skilled nursing care facility ............................................................................. $175 per day Confinement to a covered facility after hospital release [up to 100 days per covered person per lifetime]
Skin cancer diagnosis .................................................................................... $600 A skin cancer diagnosis while the policy is in force [once per lifetime]
Supportive or protective care drugs and colony stimulating factors ........................... $200 per day Doctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,600 calendar year max.]
Surgical procedures ...................................................................................... $70 per surgical unit Inpatient or outpatient surgery for cancer treatment [min. $350 per procedure, up to $6,000]
Transportation . . . . ........................................................................................ $0.50 per mile
Travel expenses when being treated for cancer more than 50 miles from home [up to $1,500 per round trip]
Waiver of premium ....................................................................................... Is available No premiums due if the named insured is disabled longer than 90 consecutive days
The policy has limitations and exclusions that may affect benefits payable. Most benefits require that a charge be incurred. Coverage may vary by state and may not be available in all states. For cost and complete details, see your benefits counselor. This chart highlights the benefits of policy forms CanAssist-NJ and CanAssist-VA. This chart is not complete without form 101505-NJ or 101481-VA.
©2016 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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1-16 | 101485-NJ-VA
Individual Cancer Insurance Description of Benefits THE POLICY PROVIDES LIMITED BENEFITS. 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. Coverage is dependent on answers to health questions. Applicable to policy forms CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA. Cancer Insurance Benefits Level 1 Level 2 Level 3 Level 4 Air Ambulance, per trip $2,000 $2,000 $2,000 $2,000 Maximum trips per confinement 2 2 2 2 Ambulance, per trip $250 $250 $250 $250 Maximum trips per confinement 2 2 2 2 Anesthesia, General 25% of Surgical Procedures Benefit Anesthesia, Local, per procedure $25 $30 $40 $50 Anti-Nausea Medication, per day $25 $40 $50 $60 Maximum per month $100 $160 $200 $240 Blood/Plasma/Platelets/Immunoglobulins, per day $150 $150 $175 $250 Maximum per year $10,000 $10,000 $10,000 $10,000 Bone Marrow or Peripheral Stem Cell Donation, per lifetime $500 $500 $750 $1,000 Bone Marrow or Peripheral Stem Cell Transplant, per transplant $3,500 $4,000 $7,000 $10,000 Maximum transplants per lifetime 2 2 2 2 Companion Transportation, per mile $0.50 $0.50 $0.50 $0.50 Maximum per round trip $1,000 $1,000 $1,200 $1,500 Egg(s) Extraction or Harvesting or Sperm Collection, per lifetime $500 $700 $1,000 $1,500 Egg(s) or Sperm Storage, per lifetime $175 $200 $350 $500 Experimental Treatment, per day $200 $250 $300 $300 Maximum per lifetime $10,000 $12,500 $15,000 $15,000 Family Care, per day $30 $40 $50 $60 Maximum per year $1,500 $2,000 $2,500 $3,000 Hair/External Breast/Voice Box Prosthesis, per year $200 $200 $350 $500 Home Health Care Services, per day $50 $75 $125 $175 Benefit payable for at least and not more than 100 days per covered person per lifetime Hospice, Initial, per lifetime $1,000 $1,000 $1,000 $1,000 Hospice, Daily $50 $50 $50 $50 Maximum combined Initial and Daily per lifetime $15,000 $15,000 $15,000 $15,000 Hospital Confinement, 30 days or less, per day $100 $150 $250 $350 Hospital Confinement, 31 days or more, per day $200 $300 $500 $700 Benefit payable for up to 365 days per covered person per calendar year. Lodging, per day $50 $50 $75 $80 Maximum days per year 70 70 70 70 Medical Imaging Studies, per study $75 $125 $175 $225 Maximum per year $150 $250 $350 $450 Outpatient Surgical Center, per day $100 $200 $300 $400 Maximum per year $300 $600 $900 $1,200 Private Full-time Nursing Services, per day $50 $75 $125 $150 Prosthetic Device/Artificial Limb, per device or limb $1,000 $1,500 $2,000 $3,000 Maximum per lifetime $2,000 $3,000 $4,000 $6,000
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Cancer Insurance Benefits Level 1 Level 2 Level 3 Level 4 Radiation/Chemotherapy Benefit payable period can exceed but will not be less than 365 days per covered person per lifetime Injected chemotherapy by medical personnel, per day with a $250 $500 $750 $1,000 maximum of one per calendar week Radiation delivered by medical personnel, per day with a $250 $500 $750 $1,000 maximum of one per calendar week Self-Injected Chemotherapy, per day with a maximum of one per $150 $200 $300 $400 calendar month Pump Chemotherapy, per day with a maximum of one per $150 $200 $300 $400 calendar month Topical Chemotherapy, per day with a maximum of one per $150 $200 $300 $400 calendar month Oral Hormonal Chemotherapy (1-24 months), per day with a $150 $200 $300 $400 maximum of one per calendar month Oral Hormonal Chemotherapy (25+ months), per day with a $100 $150 $250 $350 maximum of one per calendar month Oral Non-Hormonal Chemotherapy, per day with a maximum of $150 $200 $300 $400 one per calendar month Reconstructive Surgery, per surgical unit $40 $40 $60 $60 Minimum per procedure $100 $150 $250 $350 Maximum per procedure, including 25% for general anesthesia $2,500 $2,500 $3,000 $3,000 Second Medical Opinion, per lifetime $150 $200 $300 $300 Skilled Nursing Care Facility, per day, up to days confined $50 $75 $125 $175 Benefit payable for at least and not more than 100 days per covered person per lifetime Skin Cancer Initial Diagnosis $300 $300 $400 $600 Supportive/Protective Care Drugs/Colony Stimulating Factors, per day $50 $100 $150 $200 Maximum per year $400 $800 $1,200 $1,600 Surgical Procedures $40 $50 $60 $70 Minimum per procedure $100 $150 $250 $350 Maximum per procedure $2,500 $3,000 $5,000 $6,000 Transportation $0.50 $0.50 $0.50 $0.50 Maximum per round trip $1,000 $1,000 $1,200 $1,500 Waiver of Premium Yes Yes Yes Yes Additional Riders may be available at an additional cost What is not covered by the policy Pre-Existing Condition Limitation We will not pay benefits for the diagnosis of internal cancer or skin cancer that is a pre-existing condition nor will we pay benefits for the treatment of internal cancer or skin cancer that is a preexisting condition, unless the covered person has satisfied the six-month pre-existing condition limitation period. Pre-existing condition means a condition for which a covered person was diagnosed prior to the effective date of the policy and for which medical advice or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of the policy. We will not pay benefits for cancer or skin cancer: ■ If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or ■ For other conditions or diseases, except losses due directly from cancer.
Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. ADR1962-2018
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CANCER BENEFIT PREMIUMS LEVEL 1 - Composite Rates
24-Pay Premium
Employee
Employee/Spouse
One-Parent Family
Two-Parent Family
$5.73
$9.13
$5.80
$9.20
LEVEL 2 - Composite Rates
24-Pay Premium
Employee
Employee/Spouse
One-Parent Family
Two-Parent Family
$7.50
$11.75
$7.65
$11.90
LEVEL 3 - Composite Rates
24-Pay Premium
Employee
Employee/Spouse
One-Parent Family
Two-Parent Family
$10.00
$17.03
$10.23
$17.25
LEVEL 4 - Composite Rates
24-Pay Premium
Employee
Employee/Spouse
One-Parent Family
Two-Parent Family
$14.48
$24.53
$14.78
$24.83
One-Parent Family
Two-Parent Family
$0.88
$0.63
$0.88
$1.25
$0.80
$1.30
$3.90
$8.53
OPTIONAL RIDERS Employee
Employee/Spouse
Specified Disease Hospital Confinement Rider 24-Pay Premium
$0.63
Initial Diagnosis of Cancer Rider (per $1,000) 24-Pay Premium
$0.75
Initial Diagnosis of Cancer Progressive Payment Rider 24-Pay Premium
$3.90
$8.53
Sample rates only. Multiple choices and options available and rates may vary.
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Click on the video below to learn more about Critical Illness Benefits!
CRITICAL ILLNESS BENEFITS
Critical Illness Insurance*
When life takes an unexpected turn due to a critical illness diagnosis, your focus should be on recovery — not finances. Our critical illness insurance helps provide financial support with a lump-sum benefit that you can use where you need it the most. Coverage amount: ____________________________
COVERED CRITICAL ILLNESS CONDITIONS
1
BENEFITS STORY
Sudden health crisis Chris was mowing the lawn when he suffered a stroke. His recovery will be challenging, and he’s worried since his family relies on his income.
How Chris’ coverage helped
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Coma
100%
End stage renal (kidney) failure
100%
Heart attack (myocardial infarction)
100%
Major organ failure requiring transplant
100%
Occupational human immunodeficiency virus (HIV) or hepatitis
100%
Permanent paralysis
100%
Stroke2
100%
Sudden cardiac arrest
100%
Coronary artery disease (major)
50%
Coronary artery disease (minor)
10%
Transient ischemic attack (TIA)
25%
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The lump-sum payment from his critical illness insurance helped pay for: Co-payments and hospital bills not covered by his medical insurance Physical therapy to get back to doing what he loves Household expenses while he was unable to work For illustrative purposes only.
ICI6000 - CRITICAL ILLNESS
Reoccurrence of the same covered critical illness condition Key benefits
If you receive a benefit for the diagnosis of a critical illness and are later diagnosed with the same condition,3 25% of the coverage amount may be payable for that reoccurrence. Dates of diagnoses must be separated by more than 180 days.
• Available coverage for spouse and eligible dependents at 50% of your coverage amount 4
• Receive coverage regardless of medical history, within specified limits
Diagnosis of a different covered critical illness condition
• Works alongside your health savings account (HSA)
If you receive a benefit for the diagnosis of a critical illness and are later diagnosed with a different condition, 100% of the coverage amount may be payable for the subsequent condition. Dates of diagnoses must be separated by more than 180 days.
• Benefits payable regardless of other insurance
For more information about critical illness coverage, talk with your benefits counselor.
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Covered conditions for dependent children 1
COVERED CONDITIONS
Behavioral health therapy benefit When recovering from a critical illness diagnosis, mental wellbeing can be as important as physical wellbeing. A benefit may be payable each day you receive behavioral health therapy for a covered loss.
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Cerebral palsy
100%
Cleft lip or palate
100%
Congenital heart disease
100%
Cystic fibrosis
100%
Down syndrome
100%
Sickle cell anemia
100%
Spina bifida
100%
Type 1 diabetes
100%
• $50 payable up to a maximum of 15 days per insured per covered loss (up to two times per insured per calendar year). • Therapy must begin within 90 days after the covered loss, and all sessions must be received within 365 days of the covered loss.
An insured has a pre-existing condition if, within the 12 months just prior to the insured’s coverage effective date, they have an injury or sickness, whether diagnosed or not, for which:
* Critical Illness Insurance (ICI6000) is the marketing name of the insurance policy filed as “Individual Critical Illness Insurance Policy.” 1 Please refer to the policy for complete definitions of covered conditions.
• medical treatment, consultation, care or services, or diagnostic measures were received or recommended to be received during that period; or
2 In NH, the covered condition is called Severe Stroke. 3 Covered conditions that do not qualify include permanent paralysis, occupational human immunodeficiency virus (HIV) or hepatitis.
• drugs or medications were taken, or prescribed to be taken during that period; or
4 In LA and VA, includes domestic partner.
• symptoms existed. Pre-existing condition requirements are not applicable to children who are born or adopted while you are covered under this policy, and who are continuously covered from the date of birth or adoption.
THIS POLICY PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.
The pre-existing condition provision applies to any insured’s initial coverage and any increases in coverage. Coverage effective date refers to the date initial coverage becomes effective.
EXCLUSIONS AND LIMITATIONS
This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form ICI6000 (including state abbreviations where used, for example: ICI6000-AL). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.
We will not pay benefits for any covered loss that is caused by, contributed to by, or occurs as a result of felonies; intoxicants and narcotics; or war or combat. PRE-EXISTING CONDITION LIMITATION We will not pay benefits for a claim when the covered condition occurs in the first 12 months following an insured’s coverage effective date if the covered condition is caused by, contributed to by, or occurs as a result of any of the following: • a pre-existing condition; or • complications arising from treatment or surgery for, or medications taken for, a pre-existing condition.
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Critical Illness and Cancer Insurance*
When life takes an unexpected turn due to a critical illness or cancer diagnosis, your focus should be on recovery — not finances. Our critical illness and cancer insurance helps provide financial support with a lump-sum benefit that you can use where you need it the most.
BENEFITS STORY
Support for care
Coma
100%
Rebecca was born with Down syndrome. Her parents’ critical illness and cancer coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs.
End stage renal (kidney) failure
100%
How their coverage helped
Heart attack (myocardial infarction)
100%
Major organ failure requiring transplant
100%
Occupational human immunodeficiency virus (HIV) or hepatitis
100%
Permanent paralysis
100%
Stroke
100%
Coverage amount: ____________________________ COVERED CRITICAL ILLNESS CONDITIONS
2
1
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Sudden cardiac arrest
100%
Coronary artery disease (major)
50%
Coronary artery disease (minor)
10%
Transient ischemic attack (TIA)
25%
COVERED CANCER CONDITIONS
1
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Invasive cancer (including all breast cancer)
100%
Non-invasive cancer
25%
A hospital stay and treatment for corrective heart surgery Physical therapy to build muscle strength Daycare program
For illustrative purposes only.
Skin cancer initial diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 per lifetime
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ICI6000 - CRITICAL ILLNESS AND CANCER
Reoccurrence of the same covered critical illness condition If you receive a benefit for the diagnosis of a critical illness and are later diagnosed with the same condition,3 25% of the coverage amount may be payable for that reoccurrence. Dates of diagnoses must be separated by more than 180 days.
Key benefits • Available coverage for spouse5 and eligible dependents at 50% of your coverage amount • Receive coverage regardless of medical history, within specified limits • Works alongside your health savings account (HSA) • Benefits payable regardless of other insurance
Diagnosis of a different covered condition If you receive a benefit for the diagnosis of a covered condition and are later diagnosed with a different condition, 100% of the coverage amount may be payable for the subsequent condition. Dates of diagnoses must be separated by more than 180 days.4
Reoccurrence of invasive cancer (including all breast cancer) If you receive a benefit for the diagnosis of an invasive cancer, an additional benefit of 25% may be payable upon reoccurrence if: • the new date of diagnosis is more than 180 days after the first diagnosis, and • there is no evidence of disease or treatment for at least 180 days immediately prior to the subsequent diagnosis.
Reoccurrence of non-invasive cancer If you receive a benefit for the diagnosis of a non-invasive cancer, an additional benefit of 25% may be payable upon reoccurrence if: • the new date of diagnosis is more than 180 days after the first diagnosis, and • there is no evidence of disease or treatment for at least 180 days immediately prior to the subsequent diagnosis.
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Covered conditions for dependent children COVERED CONDITIONS 1
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Cerebral palsy
100%
Cleft lip or palate
100%
Congenital heart disease
100%
Cystic fibrosis
100%
Down syndrome
100%
Sickle cell anemia
100%
Spina bifida
100%
Type 1 diabetes
100%
For more information, talk with your benefits counselor.
Behavioral health therapy benefit When recovering from a critical illness or cancer diagnosis, mental wellbeing can be as important as physical wellbeing. A benefit may be payable each day you receive behavioral health therapy for a covered loss. • $50 payable up to a maximum of 15 days per insured per covered loss (up to two times per insured per calendar year). • Therapy must begin within 90 days after the covered loss, and all sessions must be received within 365 days of the covered loss.
PRE-EXISTING CONDITION LIMITATION
*Critical Illness Insurance (ICI6000) is the marketing name of the insurance policy filed as “Individual Critical Illness Insurance Policy.”
We will not pay benefits for a claim when the covered condition occurs in the first 12 months following an insured’s coverage effective date if the covered condition is caused by, contributed to by, or occurs as a result of any of the following:
1 Please refer to the policy for complete definitions of covered conditions. 2 In NH, the covered condition is called Severe Stroke.
• a pre-existing condition; or
3 Covered conditions that do not qualify include permanent paralysis, occupational human immunodeficiency virus (HIV) or hepatitis. In addition, in GA, end stage renal (kidney) failure does not qualify.
• complications arising from treatment or surgery for, or medications taken for, a pre-existing condition. An insured has a pre-existing condition if, within the 12 months just prior to the insured’s coverage effective date, they have an injury or sickness, whether diagnosed or not, for which:
4 There is no required separation period between the date of diagnosis of invasive cancer (including all breast cancer), non-invasive cancer or skin cancer and any of the critical illnesses.
• medical treatment, consultation, care or services, or diagnostic measures were received or recommended to be received during that period; or
5 In LA and VA, includes domestic partner. THIS POLICY PROVIDES LIMITED BENEFITS.
• drugs or medications were taken, or prescribed to be taken during that period; or
This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.
• symptoms existed. Pre-existing condition requirements are not applicable to children who are born or adopted while you are covered under this policy, and who are continuously covered from the date of birth or adoption.
EXCLUSIONS AND LIMITATIONS We will not pay benefits for any covered loss that is caused by, contributed to by, or occurs as a result of felonies; intoxicants and narcotics; or war or combat.
The pre-existing condition provision applies to any insured’s initial coverage and any increases in coverage. Coverage effective date refers to the date initial coverage becomes effective.
GEOGRAPHICAL LIMITATION FOR CANCER
This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form ICI6000 (including state abbreviations where used, for example: ICI6000-AL). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.
We will not pay the invasive cancer (including all breast cancer) benefit, non-invasive cancer benefit, or skin cancer benefit if the cancer is diagnosed or treated outside of the territorial limits of the United States, its possessions, or the countries of Canada and Mexico.
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Critical Illness Insurance* Infectious Diseases Rider
The sudden onset of an infectious or contagious disease can create unexpected circumstances for you or your family. The infectious diseases rider provides a lump sum that can be used toward health care expenses or meeting day-to-day needs. Payable for each covered infectious disease, once per covered person per lifetime, if hospital confined for seven or more consecutive days for treatment of the infectious disease. These benefits are for you as well as your covered family members. PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
COVERED INFECTIOUS DISEASES** Antibiotic-resistant bacteria (including MRSA)
50%
Cerebrospinal meningitis (bacterial)
50%
Diphtheria
50%
Encephalitis
50%
Legionnaires’ disease
50%
Lyme disease
50%
Malaria
50%
Necrotizing fasciitis
50%
Osteomyelitis
50%
Poliomyelitis
50%
Rabies
50%
Sepsis
50%
Tetanus
50%
Tuberculosis
50%
Coronavirus disease 2019 (COVID-19)
50%
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ICI6000 – INFECTIOUS DISEASES RIDER
Critical Illness Insurance* Progressive Diseases Rider
The debilitating effects of a progressive disease not only impact you physically, but financially as well. Changes in lifestyle may require home modification, additional medical treatment and other expenses. Payable for each covered progressive disease if the covered person is unable to perform two or more activities of daily living1 or totally disabled2 for 90 or more continuous days. This benefit is for you as well as your covered family members. COVERED PROGRESSIVE DISEASES3
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Amyotrophic lateral sclerosis (ALS)
50%
Addison’s disease
50%
Dementia (including Alzheimer’s disease)
50%
Functional loss4
50%
Huntington’s disease
50%
Lupus
50%
Multiple sclerosis (MS)
50%
Muscular dystrophy
50%
Myasthenia gravis (MG)
50%
Parkinson’s disease
50%
Systemic sclerosis (scleroderma)
50%
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ICI6000 - PROGRESSIVE DISEASES RIDER
Critical Illness Insurance* Supplemental Conditions Rider
A critical illness can have life-altering effects that not only impact you physically, but financially as well. This rider provides a lump-sum benefit if you are diagnosed with a covered supplemental condition, so you can focus on your treatment, care and recovery. We will pay a benefit for each condition only once per covered person per lifetime. This benefit is for you as well as your covered family members. PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
COVERED SUPPLEMENTAL CONDITIONS** Aggressive Crohn’s disease or severe ulcerative colitis
25%
Benign brain tumor
100%
Loss of hearing
100%
Loss of sight
100%
Loss of speech
100%
Pulmonary embolism
25%
Severe endometriosis
25%
For more information, talk with your Colonial Life benefits counselor.
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ICI6000 - SUPPLEMENTAL CONDITIONS RIDER
Critical Illness Insurance* Wellbeing Assistance Benefit
This benefit can help reduce the risk of serious illness through early detection of disease or other risk factors, giving you more protection from the unexpected. The wellbeing assistance benefit is available to you with critical illness coverage, as well as all your covered family members. Wellbeing assistance benefit . . . . . . . . . . . . . . . . . . . .$ ____________________ Payable once per covered person per calendar year • Blood test for triglycerides
• Flexible sigmoidoscopy
• Bone marrow testing
• Hemoccult stool analysis
• BRCA1 or BRCA2 testing
• Mammography
• Breast ultrasound
• Pap smear
• CA 15-3 (blood test for breast cancer)
• PSA (blood test for prostate cancer)
• CA 125 (blood test for ovarian cancer)
• Serum cholesterol test for HDL and LDL levels
• Carotid Doppler
• Serum protein electrophoresis (blood test for myeloma)
• CEA (blood test for colon cancer)
• Skin cancer biopsy
• Chest X-ray
• Stress test on a bicycle or treadmill
• Colonoscopy
• Thermography
• Echocardiogram (ECHO)
• ThinPrep pap test
• Electrocardiogram (EKG, ECG)
• Virtual colonoscopy
To learn more, talk with your Colonial Life benefits counselor.
• Fasting blood glucose test
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ICI6000 – WELLBEING ASSISTANCE BENEFIT
CRITICAL ILLNESS BENEFIT PREMIUMS Plan 1- Critical Illness Benefits Rates illustrated per unit. Named Insured unit value = $1000
Issue Age
Deduction
Named Insured
Employee & Spouse
One-Parent Family
Two Parent Family
Non-Tobacco 17-24
24-Pay Premium
$0.11
$0.17
$0.11
$0.17
25-29
24-Pay Premium
$0.14
$0.22
$0.15
$0.23
30-34
24-Pay Premium
$0.19
$0.28
$0.20
$0.30
35-39
24-Pay Premium
$0.30
$0.45
$0.31
$0.47
40-44
24-Pay Premium
$0.40
$0.60
$0.42
$0.63
45-49
24-Pay Premium
$0.55
$0.83
$0.58
$0.88
50-54
24-Pay Premium
$0.71
$1.06
$0.75
$1.12
55-59
24-Pay Premium
$0.91
$1.40
$0.95
$1.47
60-64
24-Pay Premium
$1.16
$1.80
$1.22
$1.89
65-69
24-Pay Premium
$1.23
$2.02
$1.29
$2.12
70-74
24-Pay Premium
$1.33
$2.15
One-Parent Family $3.79
Two Parent Family $5.81
Welbeing Amount $100
$1.27 $2.05 Wellbeing Assistance Benefit Rates by wellbeing amount = 1 unit Named Employee & Insured Spouse $2.37 $3.63 24-Pay Premium
Sample rates only. Multiple choices and options available and rates may vary.
53
CRITICAL ILLNESS BENEFIT PREMIUMS Plan 2- Critical Illness & Cancer Benefits Rates illustrated per unit. Named Insured unit value = $1000
Issue Age
Deduction
Named Insured
Employee & Spouse
One-Parent Family
Two Parent Family
Non-Tobacco 17-24
24-Pay Premium
$0.13
$0.20
$0.14
$0.22
25-29
24-Pay Premium
$0.19
$0.29
$0.20
$0.30
30-34
24-Pay Premium
$0.30
$0.47
$0.32
$0.49
35-39
24-Pay Premium
$0.51
$0.78
$0.54
$0.82
40-44
24-Pay Premium
$0.70
$1.07
$0.73
$1.12
45-49
24-Pay Premium
$0.88
$1.34
$0.92
$1.41
50-54
24-Pay Premium
$1.07
$1.62
$1.13
$1.70
55-59
24-Pay Premium
$1.30
$2.00
$1.37
$2.10
60-64
24-Pay Premium
$1.82
$2.81
$1.93
$2.95
65-69
24-Pay Premium
$1.94
$3.11
$2.05
$3.26
70-74
24-Pay Premium
$2.09
$3.30
One-Parent Family $3.79
Two Parent Family $5.81
Welbeing Amount $100
$1.98 $3.14 Wellbeing Assistance Benefit Rates by wellbeing amount = 1 unit Named Employee & Insured Spouse $2.37 $3.63 24-Pay Premium
Sample rates only. Multiple choices and options available and rates may vary.
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Click on the video below to learn more about Disability Benefits!
DISABILITY BENEFITS
Educator Disability Income Insurance
How long could you afford to go without a paycheck? Help protect your paycheck with Colonial Life’s short-term disability insurance. You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you couldn’t go to work due to an accident or sickness? Monthly Expenses:
$_________________
$_________________
$_________________
$_________________
$_________________
$_________________ Total $_________________
My Coverage Worksheet (For use with your Colonial Life Benefits Counselor) Who’s being covered?
You only You and your spouse You and your dependent children You, your spouse and your dependent children
How much coverage do I need? On-Job Accident/On-Job Sickness $______________ Off-Job Accident/Off-Job Sickness $______________ Select One Benefit Period Option:
On-Job
Off-Job
First 3 months
$_____________/month
$_____________/month
Next 9 months
$_____________/month
$_____________/month
First 6 months
$_____________/month
$_____________/month
Next 6 months
$_____________/month
$_____________/month
$_____________/month
$_____________/month
= Total Disability
Educator Disability 1.0-VA
Option A Option B = Partial Disability Up to 3 months
When will my benefits start? After an Accident: ___________ days
After a Sickness: ___________ days
How much will it cost? Your cost will vary based on the level of coverage you select. 56
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:
Medical Fees for Accidents Only Doctor’s Office or Urgent Care Facility Visit (Once per covered accident) ..................................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident) .............................................................................$75 Emergency Room Visit (Once per covered accident) ...................................................................................................... $150
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 sickness. Up to 3 months .................................................................................................................... $1,200/month ($40/day) The Hospital Confinement benefit increases to $6,000/month ($200/day) when the Total Disability benefit ends at age 70
Accidental Death and Dismemberment Benefits Benefits payable for death or dismemberment. l l
l
l
Accidental Death .............................................................................................................................................................. $25,000 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 ..............................................................................................................................................$7,500 Double Dismemberment ......................................................................................................................................... $15,000 Accidental Death Common Carrier ........................................................................................................................... $50,000
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 57
Complete Dislocations Complete Dislocations requiring closed reduction with anesthesia Hip ..................................................................................................................................................................................................$1,350 Knee .....................................................................................................................................................................................................975 Collarbone - sternoclavicular ......................................................................................................................................................750 Shoulder ............................................................................................................................................................................................750 Collarbone - acromioclavicular separation ............................................................................................................................675 Ankle, Foot ........................................................................................................................................................................................600 Hand ....................................................................................................................................................................................................525 Lower Jaw ..........................................................................................................................................................................................450 Wrist ....................................................................................................................................................................................................375 Elbow ..................................................................................................................................................................................................300 One Finger, Toe ................................................................................................................................................................................120 For a fracture or dislocation requiring an open reduction, your benefit would be 11/2 times the amount shown.
Additional Features l
Waiver of Premium
l
Worldwide Coverage
Optional Spouse and Dependent Coverage You may cover one or all of the eligible dependent members of your family for an additional premium.
Medical Fees for Accidents Only Doctor’s Office or Urgent Care Facility Visit (Once per covered accident) ..........................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident) .....................................................................$75 Emergency Room Visit (Once per covered accident) .............................................................................................. $150
Hospital Confinement Benefit for Accident or Sickness l
Up to 3 months ....................................................................................................................... $1,200/month ($40/day)
Accidental Death and Dismemberment Benefits l
l
Accidental Death .................................................................................................................................... Spouse $10,000 Child(ren) $5,000 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 ........................................................................................................................................ $750 Double Dismemberment ..................................................................................................................................$1,500
l
Accidental Death Common Carrier .................................................................................................Spouse $20,000 Child(ren) $10,000
58
Here are some
Colonial Life’s frequently asked questions about disability insurance: Will my disability income payment be reduced if I have other insurance?
What if I change employers?
You’re paid regardless of any other insurance you may have with other insurance companies. Benefits are paid directly to you (unless you specify otherwise).
If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable for life as long as you continue to pay your premiums when they are due.
When am I considered totally disabled?
Can my premium change?
Totally disabled means you are: l
l
l
Unable to perform the material and substantial duties of your job; Not, in fact, engaged in any employment or occupation for wage or profit for which you are qualified by reason of education, training or experience; and Under the regular and appropriate care of a doctor.
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 more than 20 hours per week, l You are able to work at your job or your place of employment for 20 hours or less per week, l Your employer will allow you to return to your job or place of employment for 20 hours or less 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 after your 70th birthday. The Hospital Confinement benefit increases when the Total Disability Benefit ends. A pre-existing condition is when you have a sickness or physical condition for which you were treated, had medical testing, received medical advice, or had taken medication within 12 months testing, or before the effective date of your policy.
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, not caused by an injury. A covered accident or covered sickness: l Occurs after the effective date of the policy; l Occurs while the policy is in force; l Is of a type listed on the Policy Schedule; and l Is not excluded by name or specific description in the policy. EXCLUSIONS We will not pay benefits for injuries received in accidents or sicknesses which are caused by or are the result of: alcoholism or drug addiction; flying; giving birth within the first nine months after the effective date of the policy; felonies or illegal occupations; having a pre-existing condition as described and limited by the policy; psychiatric or psychological condition; committing or trying to commit suicide or injuring yourself intentionally; being exposed to war or any act of war or serving in the armed forces of any country or authority. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ED DIS 1.0-VA. 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.
If you become disabled because of a pre-existing condition, Colonial Life will not pay for any disability period if it begins during the first 12 months the policy is in force. Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 6/11
©2011 Colonial Life & Accident Insurance Company. Colonial Life products are underwritten by Colonial Life & Accident Insurance Life products underwritten Colonial Life & Accident Company, for Colonial which Colonial Life are is the marketingbybrand. Insurance Company, for which Colonial Life is the marketing brand.
Colonial Life and Making benefits count are registered service marks of Colonial Life &71381-1 Accident Insurance Company. 100252 59
Educator Disability 1.0-VA
What is a pre-existing condition?
You may choose the amount of coverage to meet your needs (subject to your income). You can elect more or less coverage which will change your premium. 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.
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SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 1: On- & Off-Job Coverage
Teacher, Principal, T.A., Clerical, Café Manager Monthly premium Premiums are for base plan and disability benefits
Benefit Amount
Elimination Period
First 3 months
Next 9 Months
Units
0/7
0/14
14/14
0/30
30/30
400
200
4
$18.40
$16.00
$15.00
$14.80
$12.80
600
300
6
$24.30
$20.70
$19.20
$18.90
$15.90
800
400
8
$30.20
$25.40
$23.40
$23.00
$19.00
1000
500
10
$36.10
$30.10
$27.60
$27.10
$22.10
1200
600
12
$42.00
$34.80
$31.80
$31.20
$25.20
1400
700
14
$47.90
$39.50
$36.00
$35.30
$28.30
1600
800
16
$53.80
$44.20
$40.20
$39.40
$31.40
1800
900
18
$59.70
$48.90
$44.40
$43.50
$34.50
2000
1000
20
$65.60
$53.60
$48.60
$47.60
$37.60
2200
1100
22
$71.50
$58.30
$52.80
$51.70
$40.70
2400
1200
24
$77.40
$63.00
$57.00
$55.80
$43.80
2600
1300
26
$83.30
$67.70
$61.20
$59.90
$46.90
2800
1400
28
$89.20
$72.40
$65.40
$64.00
$50.00
3000
1500
30
$95.10
$77.10
$69.60
$68.10
$53.10
3200
1600
32
$101.00
$81.80
$73.80
$72.20
$56.20
3400
1700
34
$106.90
$86.50
$78.00
$76.30
$59.30
3600
1800
36
$112.80
$91.20
$82.20
$80.40
$62.40
3800
1900
38
$118.70
$95.90
$86.40
$84.50
$65.50
4000
2000
40
$124.60
$100.60
$90.60
$88.60
$68.60
4200
2100
42
$130.50
$105.30
$94.80
$92.70
$71.70
4400
2200
44
$136.40
$110.00
$99.00
$96.80
$74.80
4600
2300
46
$142.30
$114.70
$103.20
$100.90
$77.90
4800
2400
48
$148.20
$119.40
$107.40
$105.00
$81.00
5000
2500
50
$154.10
$124.10
$111.60
$109.10
$84.10
Spouse and Dependent Premiums Rider
Monthly Premium
Spouse Accident & Sickness Benefit Coverage
$5.50
Child(ren) Accident & Sickness Benefit Coverage
$7.50
Sample rates only. Multiple choices and options available and rates may vary.
61
SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 1: On- & Off-Job Coverage
Café Staff, Custodian Super, Custodian Staff, Maintaince Super, Maintenance Staff Monthly premium Premiums are for base plan and disability benefits
Benefit Amount
Elimination Period
First 3 months
Next 9 Months
Units
0/7
0/14
14/14
0/30
30/30
400
200
4
$23.60
$21.40
$19.40
$18.80
$16.00
600
300
6
$32.10
$28.80
$25.80
$24.90
$20.70
800
400
8
$40.60
$36.20
$32.20
$31.00
$25.40
1000
500
10
$49.10
$43.60
$38.60
$37.10
$30.10
1200
600
12
$57.60
$51.00
$45.00
$43.20
$34.80
1400
700
14
$66.10
$58.40
$51.40
$49.30
$39.50
1600
800
16
$74.60
$65.80
$57.80
$55.40
$44.20
1800
900
18
$83.10
$73.20
$64.20
$61.50
$48.90
2000
1000
20
$91.60
$80.60
$70.60
$67.60
$53.60
2200
1100
22
$100.10
$88.00
$77.00
$73.70
$58.30
2400
1200
24
$108.60
$95.40
$83.40
$79.80
$63.00
2600
1300
26
$117.10
$102.80
$89.80
$85.90
$67.70
2800
1400
28
$125.60
$110.20
$96.20
$92.00
$72.40
3000
1500
30
$134.10
$117.60
$102.60
$98.10
$77.10
3200
1600
32
$142.60
$125.00
$109.00
$104.20
$81.80
3400
1700
34
$151.10
$132.40
$115.40
$110.30
$86.50
3600
1800
36
$159.60
$139.80
$121.80
$116.40
$91.20
3800
1900
38
$168.10
$147.20
$128.20
$122.50
$95.90
4000
2000
40
$176.60
$154.60
$134.60
$128.60
$100.60
4200
2100
42
$185.10
$162.00
$141.00
$134.70
$105.30
4400
2200
44
$193.60
$169.40
$147.40
$140.80
$110.00
4600
2300
46
$202.10
$176.80
$153.80
$146.90
$114.70
4800
2400
48
$210.60
$184.20
$160.20
$153.00
$119.40
5000
2500
50
$219.10
$191.60
$166.60
$159.10
$124.10
Spouse and Dependent Premiums Rider
Monthly Premium
Spouse Accident & Sickness Benefit Coverage
$5.50
Child(ren) Accident & Sickness Benefit Coverage
$7.50
Sample rates only. Multiple choices and options available and rates may vary.
62
SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 1: On- & Off-Job Coverage
Bus Driver, Mechanic Monthly premium Premiums are for base plan and disability benefits
Benefit Amount
Elimination Period
First 3 months
Next 9 Months
Units
0/7
0/14
14/14
0/30
30/30
400
200
4
$27.00
$23.60
$21.80
$21.60
$17.80
600
300
6
$37.20
$32.10
$29.40
$29.10
$23.40
800
400
8
$47.40
$40.60
$37.00
$36.60
$29.00
1000
500
10
$57.60
$49.10
$44.60
$44.10
$34.60
1200
600
12
$67.80
$57.60
$52.20
$51.60
$40.20
1400
700
14
$78.00
$66.10
$59.80
$59.10
$45.80
1600
800
16
$88.20
$74.60
$67.40
$66.60
$51.40
1800
900
18
$98.40
$83.10
$75.00
$74.10
$57.00
2000
1000
20
$108.60
$91.60
$82.60
$81.60
$62.60
2200
1100
22
$118.80
$100.10
$90.20
$89.10
$68.20
2400
1200
24
$129.00
$108.60
$97.80
$96.60
$73.80
2600
1300
26
$139.20
$117.10
$105.40
$104.10
$79.40
2800
1400
28
$149.40
$125.60
$113.00
$111.60
$85.00
3000
1500
30
$159.60
$134.10
$120.60
$119.10
$90.60
3200
1600
32
$169.80
$142.60
$128.20
$126.60
$96.20
3400
1700
34
$180.00
$151.10
$135.80
$134.10
$101.80
3600
1800
36
$190.20
$159.60
$143.40
$141.60
$107.40
3800
1900
38
$200.40
$168.10
$151.00
$149.10
$113.00
4000
2000
40
$210.60
$176.60
$158.60
$156.60
$118.60
4200
2100
42
$220.80
$185.10
$166.20
$164.10
$124.20
4400
2200
44
$231.00
$193.60
$173.80
$171.60
$129.80
4600
2300
46
$241.20
$202.10
$181.40
$179.10
$135.40
4800
2400
48
$251.40
$210.60
$189.00
$186.60
$141.00
5000
2500
50
$261.60
$219.10
$196.60
$194.10
$146.60
Spouse and Dependent Premiums Rider
Monthly Premium
Spouse Accident & Sickness Benefit Coverage
$5.50
Child(ren) Accident & Sickness Benefit Coverage
$7.50
Sample rates only. Multiple choices and options available and rates may vary.
63
SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 2: Off-Job Coverage
Teacher, Principal, T.A., Clerical, Café Manager Monthly premium Premiums are for base plan and disability benefits Benefit Amount
Elimination Period
First 3 months
Next 9 Months
Units
0/7
0/14
14/14
0/30
30/30
400
200
4
$14.45
$12.05
$10.85
$10.05
$9.25
600
300
6
$19.35
$15.75
$13.95
$12.75
$11.55
800
400
8
$24.25
$19.45
$17.05
$15.45
$13.85
1000
500
10
$29.15
$23.15
$20.15
$18.15
$16.15
1200
600
12
$34.05
$26.85
$23.25
$20.85
$18.45
1400
700
14
$38.95
$30.55
$26.35
$23.55
$20.75
1600
800
16
$43.85
$34.25
$29.45
$26.25
$23.05
1800
900
18
$48.75
$37.95
$32.55
$28.95
$25.35
2000
1000
20
$53.65
$41.65
$35.65
$31.65
$27.65
2200
1100
22
$58.55
$45.35
$38.75
$34.35
$29.95
2400
1200
24
$63.45
$49.05
$41.85
$37.05
$32.25
2600
1300
26
$68.35
$52.75
$44.95
$39.75
$34.55
2800
1400
28
$73.25
$56.45
$48.05
$42.45
$36.85
3000
1500
30
$78.15
$60.15
$51.15
$45.15
$39.15
3200
1600
32
$83.05
$63.85
$54.25
$47.85
$41.45
3400
1700
34
$87.95
$67.55
$57.35
$50.55
$43.75
3600
1800
36
$92.85
$71.25
$60.45
$53.25
$46.05
3800
1900
38
$97.75
$74.95
$63.55
$55.95
$48.35
4000
2000
40
$102.65
$78.65
$66.65
$58.65
$50.65
4200
2100
42
$107.55
$82.35
$69.75
$61.35
$52.95
4400
2200
44
$112.45
$86.05
$72.85
$64.05
$55.25
4600
2300
46
$117.35
$89.75
$75.95
$66.75
$57.55
4800
2400
48
$122.25
$93.45
$79.05
$69.45
$59.85
5000
2500
50
$127.15
$97.15
$82.15
$72.15
$62.15
Spouse and Dependent Premiums Rider
Monthly Premium
Spouse Accident & Sickness Benefit Coverage
$5.50
Child(ren) Accident & Sickness Benefit Coverage
$7.50
Sample rates only. Multiple choices and options available and rates may vary.
64
SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 2: Off-Job Coverage
Café Staff, Custodian Super, Custodian Staff, Maintaince Super, Maintenance Staff Monthly premium Premiums are for base plan and disability benefits Benefit Amount
Elimination Period
First 3 months
Next 9 Months
Units
0/7
0/14
14/14
0/30
30/30
400
200
4
$19.65
$16.05
$14.45
$12.85
$11.65
600
300
6
$27.15
$21.75
$19.35
$16.95
$15.15
800
400
8
$34.65
$27.45
$24.25
$21.05
$18.65
1000
500
10
$42.15
$33.15
$29.15
$25.15
$22.15
1200
600
12
$49.65
$38.85
$34.05
$29.25
$25.65
1400
700
14
$57.15
$44.55
$38.95
$33.35
$29.15
1600
800
16
$64.65
$50.25
$43.85
$37.45
$32.65
1800
900
18
$72.15
$55.95
$48.75
$41.55
$36.15
2000
1000
20
$79.65
$61.65
$53.65
$45.65
$39.65
2200
1100
22
$87.15
$67.35
$58.55
$49.75
$43.15
2400
1200
24
$94.65
$73.05
$63.45
$53.85
$46.65
2600
1300
26
$102.15
$78.75
$68.35
$57.95
$50.15
2800
1400
28
$109.65
$84.45
$73.25
$62.05
$53.65
3000
1500
30
$117.15
$90.15
$78.15
$66.15
$57.15
3200
1600
32
$124.65
$95.85
$83.05
$70.25
$60.65
3400
1700
34
$132.15
$101.55
$87.95
$74.35
$64.15
3600
1800
36
$139.65
$107.25
$92.85
$78.45
$67.65
3800
1900
38
$147.15
$112.95
$97.75
$82.55
$71.15
4000
2000
40
$154.65
$118.65
$102.65
$86.65
$74.65
4200
2100
42
$162.15
$124.35
$107.55
$90.75
$78.15
4400
2200
44
$169.65
$130.05
$112.45
$94.85
$81.65
4600
2300
46
$177.15
$135.75
$117.35
$98.95
$85.15
4800
2400
48
$184.65
$141.45
$122.25
$103.05
$88.65
5000
2500
50
$192.15
$147.15
$127.15
$107.15
$92.15
Spouse and Dependent Premiums Rider
Monthly Premium
Spouse Accident & Sickness Benefit Coverage
$5.50
Child(ren) Accident & Sickness Benefit Coverage
$7.50
Sample rates only. Multiple choices and options available and rates may vary.
65
SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 2: Off-Job Coverage
Bus Driver, Mechanic Monthly premium Premiums are for base plan and disability benefits Benefit Amount
Elimination Period
First 3 months
Next 9 Months
Units
0/7
0/14
14/14
0/30
30/30
400
200
4
$22.25
$17.45
$16.05
$14.25
$12.65
600
300
6
$31.05
$23.85
$21.75
$19.05
$16.65
800
400
8
$39.85
$30.25
$27.45
$23.85
$20.65
1000
500
10
$48.65
$36.65
$33.15
$28.65
$24.65
1200
600
12
$57.45
$43.05
$38.85
$33.45
$28.65
1400
700
14
$66.25
$49.45
$44.55
$38.25
$32.65
1600
800
16
$75.05
$55.85
$50.25
$43.05
$36.65
1800
900
18
$83.85
$62.25
$55.95
$47.85
$40.65
2000
1000
20
$92.65
$68.65
$61.65
$52.65
$44.65
2200
1100
22
$101.45
$75.05
$67.35
$57.45
$48.65
2400
1200
24
$110.25
$81.45
$73.05
$62.25
$52.65
2600
1300
26
$119.05
$87.85
$78.75
$67.05
$56.65
2800
1400
28
$127.85
$94.25
$84.45
$71.85
$60.65
3000
1500
30
$136.65
$100.65
$90.15
$76.65
$64.65
3200
1600
32
$145.45
$107.05
$95.85
$81.45
$68.65
3400
1700
34
$154.25
$113.45
$101.55
$86.25
$72.65
3600
1800
36
$163.05
$119.85
$107.25
$91.05
$76.65
3800
1900
38
$171.85
$126.25
$112.95
$95.85
$80.65
4000
2000
40
$180.65
$132.65
$118.65
$100.65
$84.65
4200
2100
42
$189.45
$139.05
$124.35
$105.45
$88.65
4400
2200
44
$198.25
$145.45
$130.05
$110.25
$92.65
4600
2300
46
$207.05
$151.85
$135.75
$115.05
$96.65
4800
2400
48
$215.85
$158.25
$141.45
$119.85
$100.65
5000
2500
50
$224.65
$164.65
$147.15
$124.65
$104.65
Spouse and Dependent Premiums Rider
Monthly Premium
Spouse Accident & Sickness Benefit Coverage
$5.50
Child(ren) Accident & Sickness Benefit Coverage
$7.50
Sample rates only. Multiple choices and options available and rates may vary.
66
Click on the video below to learn more about Accident Benefits!
ACCIDENT BENEFITS
Accident Insurance Preferred Plan
Our coverage includes:
If you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life Accident Insurance can pay benefits directly to you to use however you like — from medical costs to everyday expenses — offering financial support when you need it.
• Benefits payable directly to you • No medical questions to qualify for coverage • Coverage for simple and complex injuries • Benefits payable regardless of other insurance • Worldwide coverage • Works alongside your Health Savings Account (HSA)
BENEFITS STORY
Jacob was running on the playground when he tripped and injured his hand. With Colonial Life accident benefits, Jacob’s parents were able to pay the annual deductible and co-payments.
JACOB’S ACCIDENT BENEFITS Jacob went to an urgent care facility and received immediate care.
Accident emergency treatment
$125
The doctor ordered an X-ray and discovered Jacob had fractured his hand.
• X-ray • Fracture (hand)
$40 $475
The doctor also found that Jacob had a cut on his hand.
Laceration (no stitches)
$30
Jacob was discharged with a splint.
Medical equipment (splint)
$40
Over the next several weeks, Jacob had three follow-up appointments with his doctor.
Accident follow-up treatment (3 visits)
$165
Total
$875
For illustrative purposes only for covered accidents. Benefit amounts may vary and may not cover all expenses.
68
IAC4000 – PREFERRED PLAN
BENEFITS STORY
Olivia was driving to the store when she got into a car accident. Olivia’s accident benefits helped cover her annual deductible and co-payments. OLIVIA’S ACCIDENT BENEFITS Olivia arrived by ambulance at the nearest emergency room and received immediate care.
• Ambulance • Accident emergency treatment • Injury due to auto accident
$250 $125 $250
The doctor ordered an X-ray and discovered Olivia had fractured her thigh (femur). He also ordered a CT scan of her head to check for a brain injury.
• X-ray • Medical imaging (CT) • Thigh fracture — femur (surgical)
$40 $250 $5,600
Olivia was admitted to the hospital for surgery on her leg. She was confined for three days.
• Hospital admission • Surgery (exploratory/arthroscopic) • Hospital confinement (3 days)
$1,250 $350 $900
Olivia had eight sessions of physical therapy to help regain the strength in her leg.
• Physical therapy (8 days) • Medical equipment (crutches)
$360 $125
Over the next several weeks, she had six follow-up appointments with her doctor.
Accident follow-up treatment (6 visits)
$330
Total
For illustrative purposes only for covered accidents. Benefit amounts may vary and may not cover all expenses.
$9,830
Summary of Benefits Benefits are per covered person per covered accident unless stated otherwise.
Initial care
Dislocation — separated joint • Non-surgical — repair . . . . . . . . . . . . . . . . . . . . . . . $125–$2,750 Examples: elbow: $600 | ankle: $1,250 | hip: $2,750
Accident emergency treatment. . . . . . . . . . . . . . . . . . . . . . . . . $125 Hospital emergency room, urgent care facility or physician’s office
• Incomplete dislocation — or dislocation without anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25% (payable as a % of the applicable dislocation benefit)
Accidental injury due to an automobile accident1 . . . . . . . . $250 Air ambulance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $2,400 Ambulance — ground or water . . . . . . . . . . . . . . . . . . . . . . . . . $250
• Surgical — repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250–$5,500 Examples: elbow: $1,200 | ankle: $2,500 | hip: $5,500
Observation room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$175 per day (up to two days per calendar year)
Emergency dental work . . . . . . . . . . . . . . . . . . . . . . . . . . $125–$350 Dental extraction or dental crown, denture or implant
X-ray. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40
Common accidental injuries
Eye injury — with surgical repair or removal of a foreign object . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350
Burn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,000–$15,000 (based on size and degree)
Fracture — complete
Burn — skin graft . . . . . . . . . . . . . .50% of applicable burn benefit
• Non-surgical — repair . . . . . . . . . . . . . . . . . . . . . . . $300–$3,750 Examples: hand/foot: $475 | collarbone: $775 | leg: $1,250
Coma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15,000 (lasting for seven or more consecutive days)
• Chip fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25% (payable as a % of the applicable fracture benefit )
Concussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200
• Surgical — repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . $600–$7,500 Examples: hand/foot: $950 | collarbone: $1,550 | leg: $2,500
69
Follow-up care Accident follow-up treatment, including transportation/telemedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . .$55 (up to six benefits per covered person per covered accident and up to 12 benefits per covered person per calendar year) Medical equipment • Tier 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40 Arm sling, cane, medical ring cushion, neck brace or wrist/ankle splint • Tier 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $125 Bedside commode, cold therapy system (cryotherapy), crutches, leg brace, shower chair, walker or walking boot • Tier 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250 Back brace, body jacket, continuous passive movement (CPM), halo, electric scooter, hospital bed (including rental), knee scooter, stair lift chair or wheelchair Medical imaging study — CT, CAT scan, EEG, EMG, MR or MRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250 (one per calendar year) Pain management for epidural anesthesia — non-surgical . . $125 Post-traumatic stress disorder (PTSD) . . . . . . . . . . . . . . . . . $250 Prosthetic device/artificial limb Hearing-loss injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$140
• One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $950
Knee cartilage — torn — with surgical repair . . . . . . . . . . . . . $800
• More than one . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,900
Laceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30–$750 (based on repair and length)
• Repair/replacement3 . . . . . . . . . . . . . . . . . . . . . . . . . . $475/$950
2
Rehabilitation unit confinement . . . . . . . . . . . . . . . . .$175 per day (up to 15 days, not to exceed 30 days per calendar year)
Ruptured disc — with surgical repair . . . . . . . . . . . . . . . . . . . $950 Tendon/ligament/rotator cuff — with surgical repair
Therapy — occupational, physical or speech . . . . . . $45 per day (up to 10 days)
• One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $800 • Two or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,600
Accidental dismemberment
Hospital care
Accidental dismemberment . . . . . . . . . . . . . . . . . $1,050–$40,000 • Loss, loss of use or paralysis – hand, arm, foot, leg, sight of eye • Loss, loss of use – finger, toe, partial dismemberment of finger or toe
Hospital admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,250 Hospital confinement . . . . . . . . . . . . . . . . . . . . . . . . . $300 per day (up to 365 days) Hospital sub-acute intensive care unit confinement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $400 per day (up to 30 days)
Accidental death
Intensive care unit admission . . . . . . . . . . . . . . . . . . . . . . . .$2,500
• Named insured, spouse . . . . . . . . . . . . . . . . . . . . . . . . . . $40,000
Accidental death • Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$10,000
Intensive care unit confinement . . . . . . . . . . . . . . . . $550 per day (up to 15 days)
Surgical care
Accidental death common carrier Examples of common carriers are mass transit trains, buses and planes
Blood/plasma/platelets — transfusion . . . . . . . . . . . . . . . . . $400
• Named insured, spouse . . . . . . . . . . . . . . . . . . . . . . . . . .$160,000 • Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30,000
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250–$1,900 (based on type of repair and surgery)
Transportation and lodging Transportation for hospital confinement . . $700 per round trip (up to three round trips, 50+ miles from home) Lodging–companion . . . . . . . . . . . . . . . . . . . . . . . . . . $150 per day (up to 30 days)
70
For more information, contact your Colonial Life benefits counselor.
1 Requires transportation by a licensed professional air ambulance or ambulance (ground or water). 2 One benefit for each injured ear per covered person per lifetime. 3 One repair or replacement per prosthetic device/artificial limb per covered person per lifetime. HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs. THIS POLICY PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage. EXCLUSIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered personʼs felonies or illegal occupations, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IAC4000-VA. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. ColonialLife.com
71
FOR EMPLOYEES
7-24 | 101954-1-VA
Accident Insurance Active Lifestyles Benefit
This benefit increases the amount you receive by 20% for your covered eligible benefits, giving you more financial protection for the unexpected. The active lifestyles benefit is available to you with accident coverage, as well as all your covered family members.
Example of a benefits calculation
Eligible benefits1
$2,500
Eligible benefits
$2,500
Eligible benefit amount
x 20%
Active lifestyles benefit
$500
Active lifestyles benefit calculation
$2,500
Eligible benefit amount
+ $500
Active lifestyles benefit
• Concussion • Dislocation • Emergency dental work • Eye injuries • Fractures • Knee cartilage (torn) • Laceration • Medical imaging study • Ruptured disc with surgical repair • Surgery ‐ cranial, open abdominal, thoracic/hernia
$3,000
‐ exploratory and arthroscopic
Total
• Tendon/ligament/rotator cuff with surgical repair • X-ray
For illustrative purposes only
To learn more, talk with your Colonial Life benefits counselor.
72
IAC4000 – ACTIVE LIFESTYLES BENEFIT
1 Active lifestyles benefit applies to any combination of these injuries or services due to a covered accident. HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs. THIS POLICY PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage. ADDITIONAL DISCLOSURES FOR KENTUCKY Eligibility for benefits: We will pay benefits for a covered accident if any covered person sustains an injury as a result of a covered accident if: • the covered accident occurs while the policy is in force; • the covered accident occurs on or after the policy coverage effective date; • the covered accident is an accident type listed on the policy schedule; and • the covered accident is not excluded by name or specific description in the policy. Noncancellable: This policy is noncancellable. We have no right to change the premiums we charge on this policy. Any riders attached to this policy may be subject to a change in premium. The premium can be changed following the approval of the Commissioner of Insurance only if we change it on all riders of the same kind in force in the state where the policy was issued. What is not covered by this policy: We will not pay benefits for losses that are caused by, contributed to by or occur as a result of the covered person’s felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we also will not pay the Accidental Dismemberment due to Catastrophic Accident benefit for injuries that are caused by or are the result of birth or intoxicants, narcotics and hallucinogencis. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IAC4000 (including state abbreviations where used, for example: IAC4000-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. An insurance producer may contact you. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. ColonialLife.com
73
FOR EMPLOYEES
3-24 | 101778-3
Accident Insurance Sickness Hospital Confinement Rider
These benefits can help with medical costs related to a hospital stay for a covered sickness, including costs that your health insurance may not cover, such as co-pays and deductibles. The sickness hospital confinement rider is optional coverage available to you and all your covered family members. Daily sickness hospital confinement . . . . . . . . . . . . . . . . . . . . . . . $100 per day
To learn more, talk with your Colonial Life benefits counselor.
Up to 30 days per covered person per confinement for a covered sickness Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.
74
IAC4000 – SICKNESS HOSPITAL CONFINEMENT RIDER
HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs. THIS POLICY PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage. EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of accidental injuries, alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, psychiatric or psychological conditions, intoxicants and narcotics, psychiatric or psychological conditions, suicide or injuries which you intentionally do to yourself, war or armed conflict and well baby care. PRE-EXISTING CONDITION LIMITATION Pre-existing condition means a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice, or had taken medication within 12 months before the rider coverage effective date shown on the rider schedule. After this rider has been in force for 12 months from the rider coverage effective date shown on the rider schedule, we will pay benefits as stated in the rider for any loss as the result of a pre-existing condition not excluded by name or specific description if the covered loss began at least 12 months after the rider coverage effective date. STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONS AK: Replace “alcoholism or drug addiction” with “intoxicants or narcotics.” DE: Replace “alcoholism or drug addiction” with “substance abuse.” FL: Replace “psychiatric or psychological conditions” with “mental or nervous disorders.” IL: Pre-existing Condition Limitation definition also includes “produced symptoms.” LA: Replace “alcoholism or drug addiction” with “intoxicants and narcotics.” ME: Pre-existing Condition Limitation definition does not include “had taken medication.” MO: Replace “alcoholism or drug addiction” with “substance abuse.” MT: Pre-existing Condition Limitation definition does not include “whether diagnosed or not” or “had medical testing.” NC: Pre-existing Conditions Limitation definition also includes “If a covered person is 65 or older when this policy is issued, pre-existing conditions for that covered person will include only conditions specifically eliminated by rider.” OK: Replace “psychiatric or psychological conditions” with “mental or emotional conditions.” SC: Replace “psychiatric or psychological conditions” with “mental or emotional disorders.” SD: Not applicable to “alcoholism or drug addiction.” UT: Replace “psychiatric or psychological conditions” with “mental or nervous disorders.” VT: Not applicable to “alcoholism or drug abuse, psychiatric or psychological conditions, well baby care,” or the limitation for giving birth within the first nine months after the rider coverage effective date. ADDITIONAL DISCLOSURES FOR THE STATE OF KENTUCKY Eligibility for Benefits: We will pay the benefits for a covered accident if any covered person sustains an injury as a result of a covered accident if: • The covered accident occurs while the policy is in force; • The covered accident occurs on or after the policy coverage effective date; • The covered accident is on an accident type listed on the policy schedule; and • The covered accident is not excluded by name or specific description in the policy. What is not covered by this policy: We will not pay benefits for losses that are caused by, contributed to by or occurs as a result of the covered person’s felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we also will not pay the Accidental Dismemberment due to Catastrophic Accident benefit for injuries that are caused by or are the result of birth or intoxicants, narcotics, and hallucinogenics. Termination of this Rider: This rider will terminate on the earliest of: the date the policy to which this rider is attached terminates; the date premium for this rider is not paid by the end of the grace period; or the date we receive your written request to terminate this rider. Noncancellable: This policy is noncancellable. We have no right to change the premiums we charge on this policy. Any riders attached to this policy may be subject to a change in premium. The premium can be changed following the approval of the Commissioner of Insurance only if we change it on all riders of the same kind in force in the state where the policy was issued. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy form IAC4000 and rider form R-SHC4000 (including state abbreviations where used, for example: IAC4000-AL). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.
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© 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 3-24 | 101785-5
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ACCIDENT BENEFIT PREMIUMS Preferred with Active Lifestyles On/Off-Job Accident Coverage
24-Pay Premium Named Insured
$9.14
Employee & Spouse
$15.41
One Parent Family Employee
$20.12
Two Parent Family
$26.38
Sample rates only. Multiple choices and options available and rates may vary.
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Click on the video below to learn more about Medical Bridge Benefits!
MEDICAL BRIDGE BENEFITS
Hospital Confinement Indemnity Insurance Plan 1 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
Health savings account (HSA) compatible
For more information, talk with your benefits counselor.
ColonialLife.com
This plan is compatible with HSA guidelines. This plan may also be offered to employees who do not have HSAs. Colonial Life & Accident Insurance Company’s Individual Medical Bridge offers an HSA compatible plan in most states.
THIS POLICY PROVIDES LIMITED BENEFITS. 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, war, or giving birth within the first nine months after the effective date of the policy. 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. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy. 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. ©2016 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 – PLAN 1 | 5-16 | 101576-1
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
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– 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, war, or giving birth within the first nine months after the effective date of the policy. 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. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy. 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. ©2016 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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1-16 | 101581-1
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
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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. ©2016 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 | 5-16 | 101579-1
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 cannot be paired with Plan 1. 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.
ColonialLife.com
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. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-VA. This is not an insurance contract and only the actual policy provisions will control.
©2016 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 – MEDICAL TREATMENT PACKAGE | 9-16 | 101596-VA
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, war, or giving birth within the first nine months after the effective date of the rider. 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. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000 and R-EIC7000 (including state abbreviations where used, for example: R-DHC7000-TX and R-EIC7000-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 or rider provisions will control. ©2016 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 | 6-16 | 101582-1
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MEDICAL BRIDGE BENEFIT PREMIUMS INDIVIDUAL MEDICAL BRIDGE Plan 1 Named Insured
Hospital Confinement $100 Health Screening
Ages 17-49 Ages 50-59 Ages 60-64 Ages 65-75
24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium
$1,000.00
$1,500.00
$9.10 $11.60 $14.63 $18.43
$11.83 $15.38 $19.80 $25.33
INDIVIDUAL MEDICAL BRIDGE Plan 3 Named Insured Hospital Confinement Medical Treatment Pkg $100 Health Screening
$1,000.00
$1,500.00
Outpatient Surgical Procedure
Option 1 Tier 1 $500 Tier 2 $1,000 CY Max $1,500
Option 1 Tier 1 $500 Tier 2 $1,000 CY Max $1,500
$18.90 $23.75 $29.10 $35.80
$21.63 $27.53 $34.28 $42.70
Ages 17-49 Ages 50-59 Ages 60-64 Ages 65-75
24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium
Sample rates only. Multiple choices and options available and rates may vary.
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Click on the video below to learn more about Term Life Insurance!
TERM LIFE INSURANCE
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: n A beneficiary can receive a benefit that is typically free from income tax. n The policy’s accelerated death benefit can pay a percentage of the death benefit if the covered person is diagnosed with a terminal illness. n You can convert it to a Colonial Life cash value insurance plan, with no proof of good health, to age 75. n Coverage is guaranteed renewable up to age 95 as long as premiums are paid when due. n 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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How much coverage do you need? £ YOU $ ___________________ Select the term period: £ 10-year £ 15-year £ 20-year £ 30-year £ SPOUSE $ ___________________ Select the term period: £ 10-year £ 15-year £ 20-year £ 30-year
Select any optional riders: £ Spouse term life rider $ _____________ face amount for ________-year term period £ Children’s term life rider $ _____________ face amount £ Accidental death benefit rider £ Chronic care accelerated death benefit rider
Optional riders At an additional cost, you can purchase the following riders for even more financial protection.
Spouse term life rider Your spouse may receive a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.
Children’s term life rider You can purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.
Accidental death benefit rider The beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.
Chronic care accelerated death benefit rider If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.1 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living.2 Premiums are waived during the benefit period.
Critical illness accelerated death benefit rider
£ Critical illness accelerated death benefit rider
If you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.1 A subsequent diagnosis benefit is included.
£ Waiver of premium benefit rider
Waiver of premium benefit rider Premiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period.3
To learn more, talk with your Colonial Life benefits counselor.
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. 2 Activities of daily living are bathing, continence, dressing, eating, toileting and transferring. 3 You must resume premium payments once you are no longer disabled.
EXCLUSIONS AND LIMITATIONS 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, minus any loans and loan interest to you.
ColonialLife.com
This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC18-ITL5000/ITL5000 and rider forms ICC18-R-ITL5000-STR/RITL5000- STR, ICC18-R-ITL5000-CTR/R-ITL5000-CTR, ICC18-R-ITL5000-WP/R-ITL5000-WP, ICC18-R-ITL5000-ACCD/RITL5000- ACCD, ICC18-R-ITL5000-CI/R-ITL5000-CI, ICC18-R-ITL5000-CC/R-ITL5000-CC. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 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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9-21 | 101895-2
TERM LIFE INSURANCE PREMIUMS 10-Year Term Base Plan Monthly Non-Tobacco Rates Issue Age 25 30 35 40 45 50 55 60
Pay Premium
$10,000.00
$25,000.00
$50,000.00
$100,000.00
24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium
$3.32 $3.53 $3.79 $3.99 $4.59 $5.86 $8.09 $11.68
$5.30 $5.83 $6.47 $6.98 $8.46 $11.65 $17.22 $26.20
$5.11 $5.11 $5.63 $7.02 $9.31 $12.79 $18.19 $26.98
$8.21 $8.21 $9.25 $12.04 $16.63 $23.58 $34.38 $51.96
20-Year Term Base Plan Monthly Non-Tobacco Rates Issue Age 25 30 35 40 45 50 55 60
Pay Premium
$10,000.00
$25,000.00
$50,000.00
$100,000.00
24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium
$3.36 $3.56 $3.85 $4.12 $4.84 $6.34 $9.03 $13.42
$5.39 $5.91 $6.62 $7.29 $9.11 $12.85 $19.57 $30.55
$5.27 $5.27 $5.79 $7.71 $10.90 $15.79 $23.17 $36.00
$8.54 $8.54 $9.59 $13.42 $19.79 $29.58 $44.33 $70.00
Sample rates only. Multiple choices and options available and rates may vary.
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Click on the video below to learn more about Whole Life Insurance!
WHOLE LIFE INSURANCE
Whole Life Plus Insurance*
You can’t predict your family’s future, but you can prepare for it.
Advantages of Whole Life Plus insurance
Help give your family more peace of mind and coverage for final expenses with Colonial Life Individual Whole Life Plus insurance.
• Permanent life insurance coverage that stays the same through the life of the policy
Benefits and features Choose the age when your premium payments end — Paid-Up at Age 70 or Paid-Up at Age 100 Stand-alone spouse policy available even without buying a policy for yourself
• Premiums will not increase due to changes in health or age.
Ability to keep the policy if you change jobs or retire
• Accumulates cash value based on a nonforfeiture interest rate of 3.75%2
Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness1
• Policy loans available, which can be used for emergencies
Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses
• Benefit for the beneficiary that is typically tax-free
Provides cash surrender value at age 100 (when the policy endows)
Additional coverage options Spouse term rider Cover your spouse with a death benefit up to $50,000, for 10 or 20 years.
Juvenile Whole Life Plus policy Purchase a policy (Paid-Up at Age 70) while children are young and premiums are low — whether or not you buy a policy for yourself. You may also increase the coverage when the child is 18, 21 and 24 without proof of good health.
Children’s term rider
Your cost will vary based on the amount of coverage you select.
You may purchase up to $20,000 in term life insurance coverage for all of your eligible dependent children and pay one premium. The children’s term rider may be added to either your policy or your spouse’s policy — not both. 90
WHOLE LIFE PLUS (IWL5000)
Benefits worksheet
Additional coverage options (Continued)
For use with your benefits counselor
Accelerated death benefit for long term care services rider3
How much coverage do you need?
Talk with your benefits counselor for more details.
YOU $_______________________
Accidental death benefit rider
Select the option:
Paid-Up at Age 70 Paid-Up at Age 100 SPOUSE $ __________________ Select the option:
Paid-Up at Age 70 Paid-Up at Age 100 DEPENDENT STUDENT
$ ____________________________ Select the option:
Paid-Up at Age 70 Paid-Up at Age 100 Select any optional riders:
Spouse term rider
$ _____________face amount for _________-year term period
Children’s term rider
$ ______________ face amount
Accelerated death benefit for long term care services rider
Accidental death benefit rider Chronic care accelerated death benefit rider
Critical illness accelerated death benefit rider
Guaranteed purchase option rider
Waiver of premium benefit rider
To learn more, talk with your benefits counselor.
An additional benefit may be payable if the covered person dies as a result of an accident before age 70, and doubles if the injury occurs while riding as a fare-paying passenger using public transportation. An additional 25% is payable if the injury occurs while driving or riding in a private passenger vehicle and wearing a seatbelt.
Chronic care accelerated death benefit rider If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.1 Talk with your benefits counselor for more details.
Critical illness accelerated death benefit rider If you suffer a heart attack, stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.1 A subsequent diagnosis benefit is included.
Guaranteed purchase option rider This rider allows you to purchase additional whole life coverage — without having to answer health questions — at three different points in the future. The rider may only be added if you are age 50 or younger when you purchase the policy. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.
Waiver of premium benefit rider Policy and rider premiums are waived if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premiums will resume.
* Whole Life Plus is a marketing name of the insurance policy filed as “Whole Life Insurance” in most states. 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. 2 Accessing the accumulated cash value reduces the death benefit by the amount accessed, unless the loan is repaid. Cash value will be reduced by any outstanding loans against the policy. 3 The rider is not available in all states. This life insurance does not specifically cover funeral goods or services and may not cover the entire cost of your funeral at the time of your death. The beneficiary of this life insurance may use the proceeds for any purpose, unless otherwise directed. EXCLUSIONS AND LIMITATIONS: 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, minus any loans and loan interest to you. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC19-IWL5000-70/ IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC23IWL5000-LTC/IWL5000-LTC, ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/RIWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000GPO/R-IWL5000-GPO (including state abbreviations where applicable). For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
ColonialLife.com
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FOR EMPLOYEES
8-23 | 642298-2
WHOLE LIFE INSURANCE PREMIUMS Adult Base Plan Paid-up to Age 70 Non-Tobacco Rates Issue Age 25 30 35 40 45 50
Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium
$10,000.00 $4.67 $5.50 $6.76 $8.48 $11.21 $15.59
$25,000.00 $11.68 $13.76 $16.90 $21.19 $28.01 $38.98
$50,000.00 $23.36 $27.52 $33.79 $42.38 $56.02 $77.96
$100,000.00 $46.71 $55.04 $67.59 $84.75 $112.04 $155.92
$150,000.00 $70.07 $82.57 $101.38 $127.13 $168.07 $233.88
$100,000.00 $43.00 $49.50 $58.59 $70.75 $89.13 $114.75 $153.67 $205.92
$150,000.00 $64.50 $74.25 $87.88 $106.13 $133.69 $172.13 $230.50 $308.88
Adult Base Plan Paid-up to Age 100 Non-Tobacco Rates Issue Age 25 30 35 40 45 50 55 60
Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium
$10,000.00 $4.30 $4.95 $5.86 $7.08 $8.92 $11.48 $15.37 $20.59
$25,000.00 $10.75 $12.38 $14.65 $17.69 $22.28 $28.69 $38.42 $51.48
$50,000.00 $21.50 $24.75 $29.29 $35.38 $44.57 $57.38 $76.84 $102.96
Sample rates only. Multiple choices and options available and rates may vary.
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Aflac Group Critical Illness INSURANCE – PLAN INCLUDES BENEFITS FOR CANCER AND HEALTH SCREENING
We help take care of your expenses while you take ke care of yourself.
Continental American Insurance Company, a wholly-owned subsidiary of Aflac Incorporated, is the insuring company.
AG210751VA R2
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IV (3/19)
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AFLAC GROUP CRITICAL ILLNESS Aflac can help ease the financial stress of surviving a critical illness. Chances are you may know someone who’s been diagnosed with a critical illness. You can’t help notice the difference in the person’s life—both physically and emotionally. What’s not so obvious is the impact a critical illness may have on someone’s personal finances. That’s because while a major medical plan may pay for a good portion of the costs associated with a critical illness, there are a lot of expenses that may not be covered. And, during recovery, having to worry about out-of-pocket expenses is the last thing anyone needs.
That’s the benefit of an Aflac Group Critical Illness plan. It can help with the treatment costs of covered critical illnesses, such as a heart attack or stroke. More importantly, the plan helps you focus on recuperation instead of the distraction of out-of-pocket costs. With the Critical Illness plan, you receive cash benefits directly (unless otherwise assigned)—giving you the flexibility to help pay bills related to treatment or to help with everyday living expenses.
What you need, when you need it. Group critical illness insurance pays cash benefits that you can use any way you see fit.
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Here’s why the Aflac Group Critical Illness plan may be right for you.
For more than 60 years, Aflac has been dedicated to helping provide individuals and families peace of mind and financial security when they’ve needed it most. The Aflac Group Critical Illness plan is just another innovative way to help make sure you’re well protected.
But it doesn’t stop there. Having group critical illness insurance from Aflac means that you may have added financial resources to help with medical costs or ongoing living expenses. The Aflac Group Critical Illness plan benefits include: • Critical Illness Benefit payable for: – Cancer – Heart Attack (Myocardial Infarction) – Stroke – Kidney Failure (End-Stage Renal Failure) – Major Organ Transplant – Bone Marrow Transplant (Stem Cell Transplant) – Sudden Cardiac Arrest – Coronary Artery Bypass Surgery – Non-Invasive Cancer – Skin Cancer • Health Screening Benefit
Features: • Benefits are paid directly to you, unless otherwise assigned. • Coverage is available for you, your spouse, and dependent children. • Coverage may be continued (with certain stipulations). That means you can take it with you if you change jobs or retire.
How it works
Aflac Group Critical Illness coverage is selected.
You experience chest pains and numbness in the left arm.
You visit the emergency room.
A physician determines that you have suffered a heart attack.
Aflac Group Critical Illness pays an Initial Diagnosis Benefit of
$10,000
Amount payable based on $10,000 Initial Diagnosis Benefit.
For more information, ask your insurance agent/producer, 95 call 1.800.433.3036, or visit aflacgroupinsurance.com.
Benefits Overview COVERED CRITICAL ILLNESSES:
CANCER (Internal or Invasive)
100%
HEART ATTACK (Myocardial Infarction)
100%
STROKE (Ischemic or Hemorrhagic)
100%
KIDNEY FAILURE (End-Stage Renal Failure)
100%
BONE MARROW TRANSPLANT (Stem Cell Transplant)
100%
SUDDEN CARDIAC ARREST
100%
MAJOR ORGAN TRANSPLANT (25% of this benefit is payable for insureds placed on a transplant list for a major organ transplant)
100%
NON-INVASIVE CANCER
25%
CORONARY ARTERY BYPASS SURGERY
25%
INITIAL DIAGNOSIS We will pay a lump sum benefit upon initial diagnosis of a covered critical illness when such diagnoses is caused by or solely attributed to an underlying disease. Cancer diagnoses are subject to the cancer diagnosis limitation. Benefits will be based on the face amount in effect on the critical illness date of diagnosis. ADDITIONAL DIAGNOSIS We will pay benefits for each different critical illness after the first when the two dates of diagnoses are separated by at least 6 consecutive months. Cancer diagnoses are subject to the cancer diagnosis limitation. REOCCURRENCE We will pay benefits for the same critical illness after the first when the two dates of diagnoses are separated by at least 6 consecutive months. Cancer diagnoses are subject to the cancer diagnosis limitation. CHILD COVERAGE AT NO ADDITIONAL COST Each dependent child is covered at 50 percent of the primary insured’s benefit amount at no additional charge. Children-only coverage is not available.
The plan has limitations and exclusions that may affect benefits payable. This brochure is for illustrative purposes only. Refer to your certificate 96 for complete details, definitions, limitations, and exclusions.
SKIN CANCER BENEFIT We will pay $250 for the diagnosis of skin cancer. We will pay this benefit once per calendar year. WAIVER OF PREMIUM If you become totally disabled due to a covered critical illness prior to age 65, after 90 continuous days of total disability, we will waive premiums for you and any of your covered dependents. As long as you remain totally disabled, premiums will be waived up to 24 months, subject to the terms of the plan. SUCCESSOR INSURED BENEFIT If spouse coverage is in force at the time of the primary insured’s death, the surviving spouse may elect to continue coverage. Coverage would continue at the existing spouse face amount and would also include any dependent child coverage in force at the time. HEALTH SCREENING BENEFIT (Employee and Spouse only) We will pay $50 for health screening tests performed while an insured’s coverage is in force. We will pay this benefit once per calendar year. This benefit is only payable for health screening tests performed as the result of preventive care, including tests and diagnostic procedures ordered in connection with routine examinations. This benefit is payable for the covered employee and spouse. This benefit is not paid for dependent children.
The plan has limitations and exclusions that may affect benefits payable. This brochure is for illustrative purposes only. Refer to your certificate 97 for complete details, definitions, limitations, and exclusions.
LIMITATIONS AND EXCLUSIONS All limitations and exclusions that apply to the critical illness plan also apply to all riders, if applicable, unless amended by the riders. Cancer Diagnosis Limitation Benefits are payable for cancer and/or noninvasive cancer as long as the insured: • Is treatment-free from cancer for at least 12 months before the diagnosis date; and • Is in complete remission prior to the date of a subsequent diagnosis, as evidenced by the absence of all clinical, radiological, biological, and biochemical proof of the presence of the cancer. EXCLUSIONS We will not pay for loss due to: • Self-Inflicted Injuries – injuring or attempting to injure oneself intentionally or taking action that causes oneself to become injured; • Suicide – committing or attempting to commit suicide, while sane or insane; • Illegal Acts – participating or attempting to participate in an illegal activity, or working at an illegal job: • Participation in Aggressive Conflict: − War (declared or undeclared) or military conflicts; − Insurrection or riot − Civil commotion or civil state of belligerence • Illegal Substance Abuse: − Abuse of legally-obtained prescription medication − Illegal use of non-prescription drugs Diagnosis, treatment, testing, and confinement must be in the United States or its territories. All benefits under the plan, including benefits for diagnoses, treatment, confinement and covered tests, are payable only while coverage is in force. TERMS YOU NEED TO KNOW The Bone Marrow Transplant (Stem Cell Transplant) benefit is not payable if the transplant results from a covered critical illness for which a benefit has been paid under this plan. The following are not considered internal or invasive cancers: • Pre-malignant tumors or polyps • Carcinomas in Situ • Any superficial, non-invasive skin cancers including basal cell and squamous cell carcinoma of the skin • Melanoma in Situ • Melanoma that is diagnosed as − Clark’s Level I or II, − Breslow depth less than 0.77mm, or − Stage 1A melanomas under TNM Staging Skin cancers are not payable under the Cancer (internal or invasive) Benefit or the Non-Invasive Cancer Benefit. The following are considered skin cancers:
• Basal cell carcinoma • Squamous cell carcinoma of the skin • Melanoma in Situ • Melanoma that is diagnosed as − Clark’s Level I or II, − Breslow depth less than 0.77mm, or − Stage 1A melanomas under TNM Staging Critical Illness is a disease or a sickness as defined in the plan that first manifests while your coverage is in force. Date of Diagnosis is defined as follows: • Cancer: The day tissue specimens, blood samples, or titer(s) are taken (diagnosis of cancer and/or carcinoma in situ is based on such specimens). • Non-Invasive Cancer: The day tissue specimens, blood samples, or titer(s) are taken (diagnosis of cancer and/or carcinoma in situ is based on such specimens). • Skin Cancer: The date the skin biopsy samples are taken for microscopic examination. • Bone Marrow Transplant (Stem Cell Transplant): The date the surgery occurs. • Coronary Artery Bypass Surgery: The date the surgery occurs. • Heart Attack (Myocardial Infarction): The date the infarction (death) of a portion of the heart muscle occurs. This is based on the criteria listed under the heart attack (myocardial Infarction) definition. • Kidney Failure (End-Stage Renal Failure): The date a doctor recommends that an insured begin renal dialysis. • Major Organ Transplant: The date the surgery occurs. • Stroke: The date the stroke occurs (based on documented neurological deficits and neuroimaging studies). • Sudden Cardiac Arrest: The date the pumping action of the heart fails (based on the sudden cardiac arrest definition). Dependent means your spouse or your dependent child. Spouse is your legal wife, husband, or partner in a legally recognized union. Dependent children are your or your spouse’s natural children, step-children, foster children, children subject to legal guardianship, legally adopted children, or children placed for adoption, who are younger than age 26. Newborn children are automatically covered from the moment of birth. Refer to your certificate for details. A doctor does not include you or any of your family members. For the purposes of this definition, family member includes your spouse as well as the following members of your immediate family: • Son • Daughter • Mother • Father • Sister • Brother This includes step-family members and family-members-in-law. 98
Employee is a person who meets eligibility requirements and who is covered under the plan. The employee is the primary insured under the plan.
YOU MAY CONTINUE YOUR COVERAGE Your coverage may be continued with certain stipulations. See certificate for details.
Diagnosis of a Heart Attack (Myocardial Infarction) must include the following:
TERMINATION OF COVERAGE Your insurance may terminate when the plan is terminated; the 31st day after the premium due date if the premium has not been paid; or the date you no longer belong to an eligible class. If your coverage terminates, we will provide benefits for valid claims that arose while your coverage was in force. See certificate for details.
• New and serial electrocardiographic (ECG) findings consistent with heart attack (myocardial infarction), and • Elevation of cardiac enzymes above generally accepted laboratory levels of normal. (In the case of creatine physphokinase (CPK) a CPKMB measurement must be used.)
NOTICES If this coverage will replace any existing individual policy, please be aware that it may be in your best interest to maintain your individual guaranteedrenewable policy.
Confirmatory imaging studies, such as thallium scans, MUGA scans, or stress echocardiograms may also be used. Kidney Failure (End-Stage Renal Failure) is covered only under the following conditions:
Notice to Consumer: The coverages provided by Continental American Insurance Company (CAIC) represent supplemental benefits only. They do not constitute comprehensive health insurance coverage and do not satisfy the requirement of minimum essential coverage under the Affordable Care Act. CAIC coverage is not intended to replace or be issued in lieu of major medical coverage. It is designed to supplement a major medical program.
• A doctor advises that regular renal dialysis, hemo-dialysis, or peritoneal dialysis (at least weekly) is necessary to treat the kidney failure (endstage renal failure); or • The kidney failure (end-stage renal failure) results in kidney transplantation. Maintenance Drug Therapy is meant to decrease the risk of cancer recurrence; it is not meant to treat a cancer that is still present. A Major Organ Transplant benefit is not payable if the major organ transplant results from a covered critical illness for which a benefit has been paid. Stroke does not include: • Transient Ischemic Attacks (TIAs) • Head injury • Chronic cerebrovascular insufficiency • Reversible ischemic neurological deficits unless brain tissue damage is confirmed by neurological imaging Sudden Cardiac Arrest is not a heart attack (myocardial infarction). A sudden cardiac arrest benefit is not payable if the sudden cardiac arrest is caused by or contributed to by a heart attack (myocardial infarction). Treatment does not include maintenance drug therapy or routine follow-up visits to verify whether cancer or carcinoma in situ has returned.
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GROUP CRITICAL ILLNESS ADVANTAGE INSURANCE ADDITIONAL CRITICAL ILLNESSES SUMMARY PAGE
WHAT WE WILL PAY COVERED CRITICAL ILLNESSES Illnesses Covered Under Plan
Severe Burn* Coma** Paralysis** Loss of Sight** Loss of Hearing** Loss of Speech**
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These benefits will be paid based on the face amount in effect on the critical illness date of diagnosis.
Percentage of Maximum Benefit
100% 100% 100% 100% 100% 100%
We will pay the critical illness benefit if the insured is diagnosed with one of the critical illnesses shown if the date of diagnosis occurs while the plan is in force and the critical illness is not excluded by name or specific description in the plan. Initial Diagnosis An insured may receive up to 100% of his face amount upon the diagnosis of a covered critical illness.
*This benefit is only payable for burns due to, caused by, and attributed to, a covered accident.
Additional Diagnosis Once benefits have been paid for a covered critical illness, we will pay benefits for each different critical illness when the date of diagnosis is separated by at least 6 consecutive months. **These benefits are payable for loss due to a covered underlying disease or a covered accident.
Reoccurrence Once benefits have been paid for a covered critical illness, benefits are payable for that same critical illness when the date of diagnosis is separated by at least 6 consecutive months. WHAT IS NOT COVERED, LIMITATIONS AND EXCLUSIONS, AND TERMS YOU NEED TO KNOW All limitations and exclusions that apply to the critical illness plan also apply to these benefits. No benefits will be paid for loss which occurred prior to the effective date of the plan. Date of Diagnosis is defined as follows: •
•
Coma: The first day of the period for which a doctor confirms a coma that is due to one of the underlying diseases and that has lasted for at least seven consecutive days.
•
Loss of Sight, Speech, or Hearing: The date the loss due to one of the underlying diseases is objectively determined by a doctor to be total and irreversible.
•
Paralysis: The date a doctor diagnoses an insured with paralysis due to one of the underlying diseases as specified in this plan, where such diagnosis is based on clinical and/or laboratory findings as supported by the insured’s medical records. Severe Burn: The date the burn takes place.
Critical Illness is one of the illnesses defined below: Severe Burn or Severely Burned means a burn resulting from fire, heat, caustics, electricity, or radiation. The burn must: •
Be a full-thickness or third-degree burn, as determined by a doctor. A Full-Thickness Burn or Third-Degree Burn is the destruction of the skin through the entire thickness or depth of the dermis (or possibly into underlying tissues). This results in loss of fluid and sometimes shock.
•
•
Cause cosmetic disfigurement to the body’s surface area of at least 35 square inches.
Be caused solely by or be solely attributed to a covered accident.
Underwritten by Continental American Insurance Company A proud member of the Aflac family of insurers
AG210841 R2
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IV (1/16)
Coma means a state of continuous, profound unconsciousness, lasting at least seven consecutive days, and characterized by the absence of: •
Spontaneous eye movements,
•
Response to painful stimuli, and
•
Vocalization.
Coma does not include a medically-induced coma. To be payable as an Accident benefit, the coma must be caused solely by or be solely attributed to a covered accident. To be considered a critical illness, the coma must be caused solely by or be solely attributed to one of the following diseases: •
Brain Aneurysm
•
Hyperglycemia
•
Diabetes
•
Hypoglycemia
•
Encephalitis
•
Meningitis
Epilepsy Paralysis or Paralyzed means the permanent, total, and irreversible loss of muscle function to the whole of at least two limbs. To be payable as an Accident benefit, the paralysis must be caused solely by or be solely attributed to a covered accident. To be considered a critical illness, paralysis must be caused solely by or be solely attributed to one or more of the following diseases: •
•
Amyotrophic lateral sclerosis
•
Parkinson’s disease,
•
Cerebral palsy
•
Poliomyelitis
The diagnosis of paralysis must be supported by neurological evidence. Loss of Sight means the total and irreversible loss of all sight in both eyes. To be payable as an Accident benefit, loss of sight must be caused solely by or be solely attributed to a covered accident. To be considered a critical illness, loss of sight must be caused solely by or be solely attributed to one of the following diseases: •
Retinal disease
•
Optic nerve disease
•
Hypoxia
Loss of Speech means the total and permanent loss of the ability to speak. To be payable as an Accident benefit, loss of speech must be caused solely by or be solely attributed to a covered accident. To be considered a critical illness, loss of speech must be caused solely by or be solely attributable to one of the following diseases: •
Alzheimer’s disease
•
Arteriovenous malformation
Loss of Hearing means the total and irreversible loss of hearing in both ears. Loss of hearing does not include hearing loss that can be corrected by the use of a hearing aid or device. To be payable as an Accident benefit, loss of hearing must be caused solely by or be solely attributed to a covered accident. To be considered a critical illness, loss of hearing must be caused solely by or be solely attributed to one of the following diseases: •
Alport syndrome
•
Goldenhar syndrome
•
Autoimmune inner ear disease
•
Meniere’s disease
•
Chicken pox
•
Meningitis
•
Diabetes
•
Mumps
If the coverage outlined in this summary will replace any existing coverage, please be aware that it may be in your best interest to maintain your individual guaranteed-renewable policy.
aflacgroupinsurance.com | 1.800.433.3036 | 1.866.849.2970 fax Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. Continental American Insurance Company • Columbia, South Carolina
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Colonial Life for Policyholders Portal A faster, simpler way to manage your benefits
THE PORTAL OFFERS YOU: Faster service than calling/emailing Confirmation when a claim has been submitted
Colonial Life for Policyholders is an online portal created with you in mind. It’s the most convenient and efficient way to file a claim and manage your benefits.
Here’s what you can do on Colonial Life for Policyholders:
Simplified bill payment and management Answers to frequently asked questions and live chat assistance if you don’t see what you are looking for.
LEARN MORE Find out how simple your claims and benefits experience can be by learning more about the Colonial Life for Policyholders portal. Just visit ColonialLife.com to see what this online account administration platform can do for you.
File claims with a simple, guided form
Set up direct deposit for approved payments
View claim status or policy details anytime
Opt for instant alerts by email or text
Update your personal info & preferences
BECOME A MEMBER TODAY: 1
Go to ColonialLife .com/access to register.
2
Click “create an account”, fill out the required information and click Submit.
3
Enjoy faster service and improved benefits awareness.
NEED TO FILE A CLAIM? Filing online means never waiting for mail or dealing with fax machines and complex paper forms . Our guided question wizard walks you through the process and checks for missing information that could cause delays. Opting for direct deposit can also get approved payments to you up to a week faster than paper check.
AFTER YOU FILE: Check your claim status by logging into your account at ColonialLife .com/access. You can also sign up for text or email alerts so you know instantly if status changes or more information is needed. For your convenience, you can login anytime with a mobile device to photograph and upload documents with your camera.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2022 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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43233-41
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 re- disclose the information unless permitted or required by those laws. Re-disclosed information may no longer be protected by federal privacy 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 (Social Security (Signature) (Date Signed) subject to this disclosure) Number) If applicable, I signed on behalf of the proposed insured as ____________________(indicate relationship). If legal Guardian, Power of Attorney Designee, or Conservator. ______________________________ (Printed name of legal representative)
____________________________ (Signature of legal representative)
UW Authorization
____________ (Date Signed) 62891-1
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ADDITIONAL BENEFITS VIRGINIA RETIREMENT SYSTEM (VRS) LIFE INSURANCE The Virginia Retirement System (VRS) Optional Group Life Insurance program gives you the opportunity to purchase additional insurance at favorable group rates on yourself and family. Optional group life is term insurance. Term insurance generally provides the largest immediate death protection for your premium dollar. The program is administered by the Virginia Retirement System, and is provided under a group policy issued by the Minnesota Life Insurance Company. Questions about your employer paid and optional life insurance coverage can be submitted one of three ways:
By mail: Securian Financial PO Box 1193, Richmond, VA 23218-1193
By calling: 1-800-441-2258
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Or by visiting their website: www.varetire.org/myvrs
REQUIRED HEALTH CARE NOTICES Newborn and Mothers’ Health Protection Act Group health plans and health insurance issuers generally may not, under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Women’s Health and Cancer Rights Act In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully. As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits: 1. All stages of reconstruction of the breast on which the mastectomy has been performed: 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prostheses and treatment of physical complications of the mastectomy , including lymphedemas. Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan.
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Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
REQUIRED HEALTH CARE NOTICES GEORGIA - MEDICAID
ALABAMA - MEDICAID Website: myalhipp.com Phone: 1-855-692-5447
Website: medicaid.georgia.gov/health-insurance premium-payment-program-hipp Phone: 678-564-1162, ext. 2131
ALASKA - MEDICAID
INDIANA - MEDICAID
The AK Health Insurance Premium Payment Program Website: myakhipp.com Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: dhss.alaska.gov/dpa/Pages/ medicaid/default.aspx
Healthy Indiana Plan for Low-Income Adults 19-64 Website: www.in.gov/fssa/hip Phone: 1-877-438-4479 All other Medicaid Website: www.in.gov/medicaid Phone: 1-800-457-4584
ARKANSAS - MEDICAID
IOWA - MEDICAID AND CHIP (HAWKI)
Website: myarhipp.com Phone: 1-855-MyARHIPP (855-692-7447)
Medicaid Website: dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563
CALIFORNIA - MEDICAID
KANSAS - MEDICAID
Website: www.dhcs.ca.gov/services/Pages/ TPLRD_CAU_cont.aspx Phone: 916-440-5676
Website: www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884
COLORADO - HEALTH FIRST COLORADO (MEDICAID) & CHILD HEALTH PLAN PLUS (CHP+)
KENTUCKY - MEDICAID
Health First Colorado Website: www.healthfirstcolorado.com Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711 CHP+: www.colorado.gov/pacific/hcpf/childhealth-plan-plus CHP+ Customer Service: 1-800-359-1991/State Relay 711 Health Insurance Buy-In Program (HIBI): www.colorado.gov/pacific/hcpf/health-insurancebuy-program HIBI Customer Service: 1-855-692-6442
Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: chfs.ky.gov
FLORIDA - MEDICAID
Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)
LOUISIANA - MEDICAID
Website: www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html Phone: 1-877-357-3268 106
REQUIRED HEALTH CARE NOTICES MAINE - MEDICAID
NEVADA - MEDICAID
Website: www.maine.gov/dhhs/ofi/public assistance/index.html Phone: 1-800-442-6003 TTY: Maine Relay 711
Medicaid Website: dhcfp.nv.gov Medicaid Phone: 1-800-992-0900
NEW HAMPSHIRE - MEDICAID
MASSACHUSETTS - MEDICAID AND CHIP
Website: www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext. 5218
Website: www.mass.gov/eohhs/gov/departments/ masshealth Phone: 1-800-862-4840
NEW JERSEY - MEDICAID AND CHIP
MINNESOTA - MEDICAID
Medicaid Website: www.state.nj.us/humanservices/dmahs/clients/medicaid Medicaid Phone: 609-631-2392 CHIP Website: www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710
Website: mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/medical-assistance.jsp [Under ELIGIBILITY tab, see “What if I have other health insurance?”] Phone: 1-800-657-3739
NEW YORK - MEDICAID
KANSAS - MEDICAID
Website: www.health.ny.gov/health_care/ medicaid Phone: 1-800-541-2831
Website: www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884
NORTH CAROLINA - MEDICAID
MISSOURI - MEDICAID
Website: medicaid.ncdhhs.gov Phone: 919-855-4100
Website: www.dss.mo.gov/mhd/participants/ pages/hipp.htm Phone: 573-751-2005
NORTH DAKOTA - MEDICAID Website: www.nd.gov/dhs/services/medicalserv/medicaid Phone: 1-844-854-4825
MONTANA - MEDICAID Website: dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084
OKLAHOMA - MEDICAID & CHIP Website: www.insureoklahoma.org Phone: 1-888-365-3742
NEBRASKA - MEDICAID Website: www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178
OREGON - MEDICAID & CHIP Website: healthcare.oregon.gov/Pages/index.aspx Phone: 1-800-699-9075
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REQUIRED HEALTH CARE NOTICES PENNSYLVANIA - MEDICAID
VERMONT - MEDICAID
Website: www.dhs.pa.gov/providers/Providers/ Pages/Medical/HIPP-Program.aspx Phone: 1-800-692-7462
Website: www.greenmountaincare.org Phone: 1-800-250-8427
VIRGINIA - MEDICAID AND CHIP
RHODE ISLAND - MEDICAID AND CHIP
Website: www.coverva.org/hipp Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282
Website: www.eohhs.ri.gov Phone: 1-855-697-4347 or 401-462-0311 (Direct RIte Share Line)
WASHINGTON - MEDICAID
SOUTH CAROLINA - MEDICAID
Website: www.hca.wa.gov Phone: 1-800-562-3022
Website: www.scdhhs.gov Phone: 1-888-549-0820
WEST VIRGINIA - MEDICAID
SOUTH DAKOTA - MEDICAID
Website: mywvhipp.com Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
Website: dss.sd.gov Phone: 1-888-828-0059
TEXAS - MEDICAID
WISCONSIN - MEDICAID AND CHIP
Website: gethipptexas.com Phone: 1-800-440-0493
Website: www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002
UTAH - MEDICAID
WYOMING - MEDICAID
Medicaid Website: medicaid.utah.gov CHIP Website: health.utah.gov/chip Phone: 1-877-543-7669
Website: wyequalitycare.acs-inc.com Phone: 307-777-7531
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REQUIRED HEALTH CARE NOTICES To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
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COBRA CONTINUATION OF COVERAGE INTRODUCTION: You’re getting this notice because you recently gained coverage under a group 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.
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.”
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.
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 Charles City County Public Schools 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.
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 [choose and enter appropriate information: must pay or aren’t required to pay] for COBRA continuation coverage.
When is COBRA continuation coverage available?
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
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; • 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: Charles City County Public Schools. Applicable documentation will be required i.e. court order, certificate of coverage etc. 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,
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COBRA CONTINUATION OF COVERAGE or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.
the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.
There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.
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, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), 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. Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?: In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period to sign up for Medicare Part A or B, beginning on the earlier of • The month after your employment ends; or • The month after group health plan coverage based on current employment ends. If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of
For more information visit https://www.medicare.gov/medicare-and-you. 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 knowabout 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 Charles City County Public Schools ATTN: Dr. Toni Childress, Human Resources Rebecca Lopez, Payroll, Benefits, VRS Specialist 10035 Courthouse Road Charles City, VA 23030 Phone:804-652-4612 COBRA Administrator for Medical Reimbursement: 2508 Highlander Way, Suite 200 Carrolton, TX 75006 Phone: 888-868-3539 COBRA Administrator for The Local Choice Benefits: Inspira Financial 888-678-7835 / TTY:711 Monday-Friday, 7am – 7pm CST
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PRIVACY NOTICES Non Public Information (NPI) We collect Non Public Information (NPI) about our customers to provide them with insurance products and services. This may include telephone number, address, date of birth, occupation, income and health history. We may receive NPI from your applications and forms. medical providers, other insurers, employers, insurance support organizations, and service providers. We share the types of NPI described above primarily with people who perform insurance, business, and professional services for us, such as helping us pay claims and detect fraud. We may share NPI with medical providers for insurance and treatment purposes. We may share NPI with an insurance support organization. The organization may retain the NPI and disclose it to others for whom it performs services. In certain cases, we may share NPI with group policy holders for reporting and auditing purposes. We may share NPI with parties to a proposed or final sale of insurance business or for study purposes. We may also share NPI when otherwise required or permitted by law, such as sharing with governmental or other legal authorities. When legal necessary, we ask your permission before sharing NPI about you our practices apply to our former, current and future customers. Please be assured we do not share your health NPI to market any product or service. We also do not share any NPI to market non financial products and services. For example, we do not sell your name to catalog companies. The law allows us to share NPI as described above (except health information) will affiliates to market financial products and services. The law does not allow you to restrict these disclosures. We may also share with companies that help us market our insurance products and services, such as vendors that provide mailing services to us. We may share with other financial institution to jointly market financial products and services. When required by law, we ask your permission before we share NPI for marketing purposes. When other companies help us conduct business, we expect them to follow applicable privacy laws. We do not authorize them to use or share NPI except when necessary to conduct the work they are performing for us or to meet regulatory or other governmental requirements.
Our affiliated companies, including insurers and insurance service providers, may share NPI about you with each other. The NPI might not be directly related to our transaction or experience with you. It may include financial or other personal information such as employment history. Consistent with the Fair Credit Reporting Act, we ask your permission before sharing NPI that is not directly related to our transaction or experience with you. We have physical, electronic and procedural safeguards that protect the confidentiality and security of NPI. We give access only to employees who need to know the NPI to provide insurance products or services to you. You may request access to certain NPI we collect to provide you with insurance products and services, You must make your request in writing and send it to the address, telephone number and policy number if we have issued a policy. If you request, we will send copies of the NPI to you. If the NPI includes health information, we may provide the health information to you through a health care provider you designate. We will also send you information related to disclosures. We may charge a reasonable fee to cover our copying costs. This section applies to NPI we collect tor provide you with coverage. It does not apply to NPI we collect in anticipation of a claim or civil or criminal proceeding.
in our files. We will file your statement with the disputed NPI. We will include your statement any time we disclose the disputed NPI. We will also give the statement to any person designated by your if we may have disclosed the disputed NPI to that person int he past two years.
Disclosure Notice Concerning The Medical Information Bureau Information regarding your insurability will be treated as confidential. Colonial or its reinsure(s) may, however, make a brief report thereon to the Medical Information Bureau, a nonprofit membership organization of life insurance companies which operates an information exchange on behalf of its members. If you apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such company, the Bureau, upon request, will supply such company with the information in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with the procedure set forth in the federal Fair If you believe NPI we have about you Credit Reporting Act. The address of is incorrect, please write us. Your letter the Bureau’s information office is: 50 should include your full name, address, Braintree Hill Park, Suite 400, Braintree, telephone number and policy number if we have issued a policy. Your letter should MA 02184-8734, telephone (617) 4263660. also explain why you believe the NPI is inaccurate. If we agree with you, we will Colonial or its reinsure may also correct the NPI and notify you of the release information in its file to other correction. We will also notify any person who may have received the incorrect NPI life insurance companies to whom you from us in the past two years if you ask us may apply for life or health insurance or to whom a claim for benefits may be to contact that person. submitted. If we disagree with you, we will tell you we are not going to make the correction, We will give the reason(s) for our refusal. We will also tell you that you may submit a statement to us. Your statement should include the NPI you believe is correct. It should also include the reasons(s) why you disagree with our decision not to correct the NPI 112
CONTINUATION OF COVERAGE We are committed to being there for you and your family at every stage of life. Pierce Group Benefits makes it easy to stay protected! The following benefits can be self-enrolled online or by contacting PGB Employee Services, with Individual and Family coverage options available for most plans. You are eligible to sign-up the first day after the end date of your employer-sponsored plan.
DENTAL BENEFITS
VISION BENEFITS
TELEMEDICINE BENEFITS
SUPPLEMENTAL/VOLUNTARY POLICIES Your individual supplemental/voluntary policies through Colonial Life are portable! To transfer your benefits from payroll deduction to direct billing or automatic bank draft, please call Employee Services at 800-387-5955 within 30 days of becoming unemployed, switching careers, or retiring.
TRANSFERRING EMPLOYERS? If you are transferring from a current PGB client to another, some benefits may be eligible for transfer. Please call Employee Services at 800-387-5955 for assistance.
Please visit www.piercegroupbenefits.com/individualcoverage or call 800-387-5955 for more information on these policies, as well as to enroll/continue your benefits.
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ABOUT PIERCE GROUP BENEFITS Pierce Group Benefits is a leading full-service employee benefits administration and consulting agency serving employer groups across the Southeast. By leveraging market strength, exclusive partnerships, and industry expertise, we deliver trusted advice, products, and solutions that benefit employers and employees alike; delivered by one team and driven by one purpose — together we can do more.
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