EMPLOYEE BENEFITS PLAN CITY OF DUNN PLAN YEAR: JANUARY 1, 2021 - DECEMBER 31, 2021
ARRANGED BY PIERCE GROUP BENEFITS WWW.PIERCEGROUPBENEFITS.COM
EMPLOYEE BENEFITS GUIDE
TABLE OF CONTENTS Welcome to the City of Dunn comprehensive benefits program. This booklet highlights the benefits offered to all eligible employees for the plan year listed below. Benefits described in this booklet are voluntary, employee-paid benefits unless otherwise noted.
ENROLLMENT PERIOD: OCTOBER 7, 2020 - OCTOBER 9, 2020 EFFECTIVE DATES: JANUARY 1, 2021 - DECEMBER 31, 2021 Benefits Plan Overview
page
2
Critical Care Benefits
page
24
Online Enrollment Instructions
page
5
Disability Benefits
page
28
State Of North Carolina Teachers’ And State Employees’ Health Plan – page Plan Comparison**
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Accident Benefits
page
32
Dental Benefits
page
9
Medical Bridge Benefits
page
36
Vision Benefits
page
10
Life Insurance
page
41
Group Term Life Insurance
page
12
Additional Benefits Available
page
43
Dental, Vision & Group Life Rates page
13
Cobra Continuation Of Coverage Rights
page
44
Authorization Form
page
47
Notice Of Insurance Information Practices
page
48
Continuation Of Coverage for Benefits Form
page
49
Flexible Spending Accounts
page
14
Telemedicine
page
18
Cancer Benefits
page
21 Rev. 09/24/2020
PRE-TAX & POST-TAX BENEFITS
CITY OF DUNN
ENROLLMENT PERIOD: OCTOBER 7, 2020 - OCTOBER 9, 2020 EFFECTIVE DATES: JANUARY 1, 2021 - DECEMBER 31, 2021
PRE-TAX BENEFITS Flexible Spending Accounts*
Ameriflex • Medical Reimbursement Maximum: $2,750/year • Dependent Care Reimbursement Maximum: $5,000/year
*You will need to re-sign for the spending accounts if you want them to continue next year. IF YOU DO NOT RE-SIGN, YOUR CONTRIBUTION WILL STOP EFFECTIVE DECEMBER 31, 2020.
Dental Insurance
Vision Insurance
Accident Benefits
Medical Bridge Benefits
Citizens Security
Colonial Life
Cancer Benefits
Colonial Life
EyeMed
Colonial Life
POST-TAX BENEFITS Disability Benefits
Colonial Life
Group Term Life Insurance USAble
Critical Care Benefits Colonial Life
Telemedicine
Call A Doctor Plus
Life Insurance
Colonial Life • Term Life Insurance • Whole Life Insurance
Please note your insurance products will remain in effect unless you speak with a representative to change them.
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QUALIFICATIONS & IMPORTANT INFO
THINGS YOU NEED TO KNOW QUALIFICATIONS: • Employees must work a minimum of 40 hours per week to participate in supplemental benefits. • New Employees must satisfy a 6-month probationary period before being eligible for Flexible Spending Accounts.
IMPORTANT FACTS: • The plan year for Citizens Security Dental, EyeMed Vision, USAble Group Term Life, Colonial Insurance products, Spending Accounts and Call A Doctor Plus Telemedicine lasts from January 1, 2021 through December 31, 2021. • Deductions for Citizens Security Dental, EyeMed Vision, USAble Group Term Life, Colonial Insurance products and Call A Doctor Plus Telemedicine will begin December 2020 (2nd payroll). Deductions for Spending Accounts will begin January 2021. • Health FSA Rollover Provision: Your employer provides the rollover option for your FSA plan. Please see the Flexible Spending Account section of your benefit booklet for more information on this provision. • 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. • 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. • Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as defined by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time, or vice-versa. • Once a family status change has occurred, an employee has 30 days to notify the North Carolina Service Center at 1-888-662-7500 to request a change in elections. • Flexible Spending Account expenses must be incurred during the Plan Year in order to be eligible for reimbursement. • An employee has 90 days after the plan year ends to submit claims for spending account expenses that were incurred during the plan year. Please note that if employment terminates during the plan year, that employee's plan year ends the day employment ends. The employee has 90 days after the termination date to submit claims. • With Dependent Care Flexible Spending Accounts, the maximum reimbursement you can request is equal to the current account balance in your Dependent Care account. You cannot be reimbursed more than has actually been deducted from your pay. • The Colonial Cancer plan and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until January 31, 2021. • Additionally, some policies may include a pre-existing condition clause. Please read your policy carefully for full details. • Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution. • 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 the next plan year. Please contact your Benefit Administrator for more information.
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EMPLOYEE BENEFITS GUIDE
CITY OF DUNN
IN PERSON
ONLINE
You may enroll or make changes online to your flexible benefits plan. To enroll online, please see the information below and on the following pages.
During your open enrollment period, a Pierce Group Benefits representative will be available by appointment to answer any questions you may have and to assist you in the enrollment process.
ENROLLMENT PERIOD: OCTOBER 7, 2020 - OCTOBER 9, 2020 YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT PERIOD: • • • • •
Enroll, change or cancel your Dental Insurance. Enroll, change or cancel your Vision Insurance. Enroll/Re-Enroll in Flexible Spending Accounts⁺ (Medical Reimbursement and Dependent Care). Enroll, change or cancel your Telemedicine coverage. Enroll, change or cancel your Colonial products (see the following pages for changes that can be completed online). ⁺You will need to re-sign for the spending accounts if you want them to continue each year.
THE FOLLOWING BENEFIT ELECTIONS MUST BE MADE WITH YOUR BENEFITS REPRESENTATIVE DURING THE ENROLLMENT PERIOD AND ARE NOT AVAILABLE FOR ONLINE ENROLLMENT. • Enroll, change or cancel your Group Term Life Insurance.
ACCESS YOUR BENEFITS ONLINE WHENEVER, WHEREVER. Benefits Details | Educational Videos | Download Forms | Online Chat with Service Center To view your personalized benefits website, go to:
www.piercegroupbenefits.com/cityofdunn or piercegroupbenefits.com and click “Find Your Benefits”.
IMPORTANT NOTE & DISCLAIMER
This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail. All information in this booklet including premiums quoted is subject to change. All policy descriptions are for information purposes only. Your actual policies may be different than those in this booklet.
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Harmony
HARMONY ONLINE ENROLLMENT: COMPLETE THE STEPS BELOW TO BEGIN THE ONLINE ENROLLMENT PROCESS
HELPFUL TIPS:
• If you are a new employee and unable to log into the online system, please speak with the Benefits Representative assigned to your location, or contact Human Resources. • If you are an existing employee and unable to log into the online system, please contact the Harmony Help Desk at 866-875-4772 between 8:30am and 6:00pm, or speak with the Benefits Representative assigned to your location. Go to https://harmonyenroll.coloniallife.com 1. • Enter your User Name: CIT5R5D- and then Last Name and then Last 4 of Social Security Number (CIT5R5D-SMITH6789) • Enter your Password: Four digit Year of Birth and then Last 4 of Social Security Number (19766789)
2.
The screen prompts you to create a NEW password [____________________________].
3.
Choose a security question and enter answer [______________________________________].
4.
Click on ‘I Agree’ and then “Enter My Enrollment”.
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The screen shows ‘Me & My Family’. Verify that the information is correct and enter the additional required information (title, marital status, work phone, e-mail address). Click ‘Save & Continue’ twice.
6.
The screen allows you to add family members. It is only necessary to enter family member information if adding or including family members in your coverage. Click ‘Continue’.
7.
The screen shows updated personal information. Verify that the information is correct and make changes if necessary. Click ‘Continue’.
8.
The screen shows ‘My Benefits’. Review your current benefits and make changes/selections for the upcoming plan year. • DENTAL: You may enroll online in Dental coverage. • VISION: You may enroll online in Vision coverage. • HEALTH CARE FSA: Enter annual amount. MAX $2,750/year • DEPENDENT CARE FSA: Enter annual amount. MAX $5,000/year • TELEMEDICINE: You may enroll online in Telemedicine coverage.
<<< enrollment instructions continued on next page >>>
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Harmony
HARMONY ONLINE ENROLLMENT CONT.:
• CANCER ASSIST You may enroll online in Cancer Assist coverage. • DISABILITY 3000 You may enroll online in Disability 3000 coverage. • ACCIDENT 1.0 You may enroll online in Accident 1.0; however persons over age 64 applying for coverage and employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative. • MEDICAL BRIDGE You may enroll online in Medical Bridge coverage. • CRITICAL CARE You may enroll online in Critical Care coverage. • TERM LIFE 5000 You may enroll online in Term Life 5000; however, employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative. • WHOLE LIFE 5000 You may enroll online in Whole Life 5000; however, employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative.
9.
Click ‘Finish’.
10.
Click ‘I Agree’ to electronically sign the authorization for your benefit elections.
11.
Click ‘Print a copy of your Elections’ to print a copy of your elections, or download and save the document. Please do not forget this important step!
12.
Click ‘Log out & close your browser window’ and click ‘Log Out’.
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202 STATE HEALTH PLAN COMPARISON Active and Non-Medicare Subscribers
80/20 PLAN
70/30 PLAN
PLAN DESIGN FEATURES IN-NETWORK
OUT-OFNETWORK
IN-NETWORK
OUT-OFNETWORK
$1,250 Individual $3,750 Family
$2,500 Individual $7,500 Family
$1,500 Individual $4,500 Family
$3,000 Individual $9,000 Family
Coinsurance
20% of eligible expenses after deductible is met
40% of eligible expenses after deductible and the difference between the allowed amount and the charge
30% of eligible expenses after deductible is met
50% of eligible expenses after deductible and the difference between the allowed amount and the charge
Out-of-Pocket Maximum (Combined Medical and Pharmacy)
$4,890 Individual $14,670 Family
$9,780 Individual $29,340 Family
$5,900 Individual $16,300 Family
$11,800 Individual $32,600 Family
Preventive Services
$0 (covered at 100%)
N/A
$0 (covered at 100%)
N/A
Annual Deductible
a
Office Visits
a
a
Speci i
40% after deductible is met
40% after deductible is met
a
i i
a
40% after deductible is met
Speech/Occu/Chiro/PT
Urgent Care
PCP: Primary Care Provider a
$70
a a
a
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50% after deductible is met
50% after deductible is met
50% after deductible is met
$100
80/20 PLAN
70/30 PLAN
PLAN DESIGN FEATURES OUT-OFNETWORK
IN-NETWORK Emergency Room (Copay waived w/admission or observation stay)
Inpatient Hospital
$300 copay, then 20% after deductible is met
$300 copay, then 20% after deductible is met
$300 copay, then 40% after deductible is met
IN-NETWORK
OUT-OFNETWORK
$337 copay, then 30% after deductible is met
$337 copay, then 30% after deductible is met
$337 copay, then 50% after deductible is met
PHARMACY BENEFITS Tier 1 (Generic)
$5 copay per 30-day supply
$16 copay per 30-day supply
$30 copay per 30-day supply
$47 copay per 30-day supply
Deductible/coinsurance
Deductible/coinsurance
Tier 4 (Low-Cost Generic Specialty)
$100 copay per 30-day supply
$200 copay per 30-day supply
Tier 5 (Preferred Specialty)
$250 copay per 30-day supply
$350 copay per 30-day supply
Tier 6 (Non-preferred Specialty)
Deductible/coinsurance
Deductible/coninsurance
Preferred Diabetic Testing Supplies**
$5 copay per 30-day supply
$10 copay per 30-day supply
Tier 2 (Preferred Brand & High-Cost Generic) Tier 3 (Non-preferred Brand)
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** Preferred Brand is the OneTouch Test Strips. Non-preferred diabetic testing supplies are considered a Tier 3 member copay.
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Plan Benefits For Employees Of CITY OF DUNN Benefit Overview Deductible (Calendar Year)
$ 50 Individual $150 Family
Diagnostic & Preventative Services - diagnostic or preventive nature Clinical Oral Examinations – One such examination in any six consecutive month period. Bitewing x-rays – one set in any twelve consecutive month period – periapical x-rays as required. Dental Prophylaxis – Two procedures in a 12 month period. A five month interval must exist between prophylaxes. Fluoride Treatments - Limited to children dependents age 16 and under. One treatment per calendar year. Sealants – Limited to children dependents age of 14 and under. Placement to the occlusal surface of permanent molars, once per lifetime. Space Maintainers – Limited to children dependents age 14 and under – for the premature loss of a primary tooth. Full Mouth X-rays – including panoramic films – once in a 5 year period.
Basic Services - basic restorative and corrective services Amalgam and Resin Restorations – Limited to one filling per 24 months per tooth surface. Maintenance Prosthodontics – Adjustments and repairs to dentures and fixed bridges. Limited to adjustments and repairs performed more than 12 months after initial insertion. Extractions – (Simple) Includes local anesthesia, suturing, if needed and routine follow-up care. Oral Surgery – Includes pre-operative and post-operative care. Anesthesia – General or IV sedation prompting a state of unconsciousness. Limited to eligible oral surgery procedures. Extractions – (Surgical) Includes impactions, residual roots and unerupted teeth. Emergency Care Treatment – Limited to the necessary procedures for the initial palliative treatment of pain and/or injury. Periodontics – Adjunctive Services – Includes diagnosis, scaling and root planning and periodontal prophylaxis (following active periodontal therapy). Limited to two prophylaxis procedures in a 12 month period, either periodontal or routine. Endodontics – Includes pulpotomy , apicoectomy, retrograde fillings and root canal therapy. (restrictions) Periodontics –Surgical Services. Maximum of 1 procedure per 36 months, per quadrant.
Major Restorative -major restorative and corrective services Gold Inlays and Onlays – Limited to teeth that cannot be restored by an amalgam or resin filling. Crowns – Benefits are provided only when the tooth, as the result of extensive decay or accidental injury, cannot be restored with a direct placement restoration. Crown replacements limited to more that five years after initial placement. Prosthodontics – Complete or partial dentures, bridge pontics and abutment crowns. Bridge replacements limited to more than 5 years after the initial placement. Denture replacements limited to more than 5 years after prior placement.
Deductible Waived No Waiting Period
100%
Subject to Deductible No Waiting Period
80%
Subject to Deductible No Waiting Period
50%
Annual Maximum for Type A-B-C
$1,000
Orthodontia Services
No Deductible No Waiting Period 50%
Applies to Dependent Children under the age of 19
Lifetime Maximum $1,000
Eligible Dependents are all children who are not married, who are less than 26 years of age and who live with you and are dependent on you for principal support and maintenance.
For providers list please visit our website at www.CiƟzensGroup.com Citizens Security Life Insurance Company ● PO Box 436149 ● Louisville, Kentucky 40253-6149 ● www.CitizensGroup.com This is only a brief summary of the benefits of your dental plan. Please refer to your Certificate for a complete description of covered services and any limitations or exclusions that may apply.
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City of Dunn SUMMARY OF BENEFITS
Additional discounts
40
%OFF
Complete pair of prescription eyeglasses
20%
OFF
Non-prescription sunglasses These discounts are not insured benefits and are for in-network providers only. For vision plans with qualified materials benefit only. Not applicable for exam only vision plans.
Take a sneak peek before enrolling • You’re on the Insight Network • For a complete list of in-network providers near you, use our Enhanced Provider Locator on eyemed.com or call 1.866.804.0982 • For LASIK providers, call 1.800.988.4221
VISION CARE SERVICES
IN-NETWORK MEMBER COST
OUT-OF-NETWORK MEMBER REIMBURSEMENT
EXAM SERVICES Exam Retinal Imaging
$15 copay Up to $39
Up to $40 Not covered
CONTACT LENS FIT AND FOLLOW-UP Fit and Follow-up - Standard Fit and Follow-up - Premium
$40 10% off retail price
Not covered Not covered
FRAME Any available frame at provider location
$0 copay; 20% off balance over $130 allowance
Up to $91
STANDARD PLASTIC LENSES Single Vision Bifocal Trifocal Lenticular Progressive - Standard Progressive - Premium Tier 1 Progressive - Premium Tier 2 Progressive - Premium Tier 3 Progressive - Premium Tier 4
$20 copay $20 copay $20 copay $20 copay $75 copay $105 copay $115 copay $130 copay $195 copay
Up to $40 Up to $55 Up to $90 Up to $90 Up to $55 Up to $55 Up to $55 Up to $55 Up to $55
LENS OPTIONS Anti Reflective Coating - Standard Anti Reflective Coating - Premium Tier 1 Anti Reflective Coating - Premium Tier 2 Anti Reflective Coating - Premium Tier 3
$45 copay $57 copay $68 copay $85 copay
Up to $5 Up to $5 Up to $5 Up to $5
Photochromic - Non-Glass
$75
Not covered
Scratch Coating - Standard Plastic Tint - Solid or Gradient UV Treatment
$15 $15 $15
Not covered Not covered Not covered
All Other Lens Options
20% off retail price
Not covered
$0 copay; 15% off balance over $130 allowance $0 copay; plus balance over $130 allowance $0 copay; Paid-In-Full
Up to $91 Up to $91 Up to $210
Discounts on hearing exam and aids; call 1.844.526.5432 15% off retail or 5% off promo price; call 1.800.988.4221
Not covered Not covered
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CONTACT LENSES Contacts - Conventional Contacts - Disposable Contacts - Medically Necessary OTHER Hearing Care from Amplifon NetworkCare Lasik or PRK from U.S. Laser Network
FREQUENCIES (Plan allows member to receive either contacts and frame, or frames and lens services) Exam Frame Lenses Contacts
Once every plan year Once every other plan year Once every plan year Once every plan year
QL-0000003737 Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on market conditions. Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels. Benefits are not provided from services or materials arising from: 1) Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 2) Medical and/or surgical treatment of the eye, eyes or supporting structures; 3) Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear; 4) Services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; 5) Plano (non-prescription) lenses; 6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals; 8) Services or materials provided by any other group benefit plan providing vision care 9) Services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order. 10) Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Standard/Premium Progressive lens not covered-fund as a Bifocal lens. Standard Progressive lens covered-fund Premium Progressive as a Standard. Benefit allowance provides no remaining balance for future use within the same benefit year. Fees charged for a non-insured benefit must be paid in full to the Provider. Such fees or materials are not covered. Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri, except in New York. Fidelity Security Life Policy number VC-19/VC-20, form number M9083. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer.
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City of Dunn January 1, 2021 - December 31, 2021 Employee Only
Employee + 1
Employee + Family
Monthly Premium
$28.67
$56.11
$101.96
City Monthly Contribution
$28.67
$28.67
$28.67
Employee Monthly Contribution
$0.00
$27.44
$73.29
Employee Contribution per 24 deductions
$0.00
$13.72
$36.65
Employee Only
Employee + Spouse
Employee + Family
Monthly Premium
$6.31
$9.15
$16.40
Employee Contribution per 24 deductions
$3.16
$4.58
$8.20
Employee Only
Dependent Life $2000
Dependent Life $10,000
$0.00
$0.35
$1.75
Citizen's Security Dental
EyeMed Vision
USAble Life Employee Contribution per 24 deductions
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FLEXIBLE SPENDING ACCOUNTS
You made a great decision by enrolling in a flexible spending account (FSA) and/or dependent care account (DCA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!
HOW YOUR FSA WORKS
Your FSA is a spending account that can be used to pay for a variety of healthcare expenses.
TWO GREAT PERKS COME WITH YOUR FSA: 1
You will have access to your entire election on the first day of the plan year.
2
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. That means you are increasing your take-home pay simply by participating!
WHAT CAN I SPEND MY FSA FUNDS ON? 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.
Certain over-the-counter (OTC) Diabetic equipment healthcare expenses such as and supplies, durable Band-aids, medicine, First Aid medical equipment, supplies, etc. Note: OTC and qualified medical medicines require a doctor’s products or services prescription to be eligible. provided by a doctor. ___________________________________________________________________________________________________________________ Routine exams, dental care, prescription drugs, eye care, and hearing aids.
Prescription glasses and sunglasses.
HOW YOUR DCA WORKS
Your DCA is a spending account that can be used to pay for services like daycare, nursery school, and elder care. By simply participating in a DCA, you get to experience benefits like:
1
A higher take-home pay thanks to your pre-tax payroll deductions
2
Savings on daycare and other dependent care services you’re already paying for
3
Easy-to-use MyAmeriflex Debit Mastercard to make purchases
WHAT CAN I SPEND MY DCA FUNDS ON?
The IRS determines what expenses are eligible under a DCA. Here are some examples of common eligible expenses
Summer day camp
Daycare Custodial care for dependent adults
Before and after school programs Nanny service
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Nursery school
Pre-school
GETTING STARTED CHECKLIST Use this checklist to take full advantage of all the great resources made available to you through your Flexible Spending Account and/or Dependent Care Account.
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Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).
Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.
Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.
Use your card You will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.
Enroll for direct deposit By enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.
Start spending You’re ready to make purchases! Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.
The “Use It or Lose It” 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 it or lose it” 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.
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How do I pay for eligible expenses?
•
Use of the MyAmeriflex Card is limited to day care providers; medical care providers such as hospitals, doctors’ offices, optometrists, dentist, orthodontists, pharmacies, or other merchants providing prescription and overthe-counter eligible products. Your card cannot be used at non-qualified businesses such as gas stations, retailers, convenience stores, etc.
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ALWAYS KNOW EXACTLY HOW MUCH IS IN YOUR ACCOUNT!
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Receive balance alerts straight to your cell phone upon your request. For instructions on how to set it up, visit:
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myameriflex.com/ text-my-balance
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FREQUENTLY ASKED QUESTIONS How do I check my account balance? You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account. How do I order a new card? You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App. What happens if I don’t use my FSA account balance by the end the year? By law, employers are not allowed to return leftover money to participants. Furthermore, funds are forfeited if you leave your employer. 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. How do these programs save me money on taxes? Since the accounts are tax-advantaged, you get to leverage pre-tax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan. Can I change my annual election amount? FSA elections are irrevocable and cannot be changed during the period of coverage unless there is a permitted change in election event, such as a change in marital status, birth or adoption of a child, change in an employment status, etc. The event and contribution change must coincide. How can I change my reimbursement setting to add direct deposit? To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information. We also offer a paper direct deposit form that can be mailed, faxed, or emailed to Ameriflex. Will pre-taxing have an impact on Social Security benefits? Reductions in your taxable pay may lead to a reduction in Social Security benefits; however, for most employees, the reduction in Social Security benefits is insignificant when compared to the value of paying lower taxes now. Tax Credits vs. Dependent Care Spending Accounts If you participate in a Dependent Care Spending Account, you cannot claim credits on your income tax return for the same expenses. Also, any amount reimbursed under this plan will reduce the amount of other dependent care expenses that you can claim for purposes of tax credits. Before you enroll in a Dependent Day Care Account, evaluate whether the federal income tax credit or the Dependent Care Spending Account is best for you. ONE-TIME CLAIM FOR DEPENDENT CARE SERVICES Ameriflex makes it easy to get reimbursed automatically from your account as your funds build up during the year. If you’re paying for childcare or elderly care each month, you can avoid submitting a manual claim every month to get reimbursed for expenses you paid out of pocket. All you have to do is submit one Claim Form for the entire year that shows the date range for which childcare/ eldercare services will be provided, along with a signature from the service provider on the designated line of the form. As long as the form is signed by the provider, no receipt is needed. Once the recurring claim has been processed, Ameriflex will automatically reimburse you every month with a check or direct deposit as funds in your Dependent Care Account become available.
MODIFICATION TO HEALTH FSA “USE IT OR LOSE IT” RULE • FSA plan participants should note that up to $550 of any unused funds from the current plan year will be rolled over into your FSA balance for the new plan year. • The rollover modification applies to Health FSA plans only (and not to other types of FSA plans such as dependent care). • The rollover does not affect the maximum contribution amount for the new plan year. In other words, even if you roll over the entire $550 from the previous plan year, you may still elect up to the maximum contribution limit allowed under your employer’s plan. For more information, please visit myameriflex.com or contact Ameriflex by calling 888.868.FLEX (3539).
17
24/7 access to quality care... on your schedule! City of Dunn Complete
Teladoc Connect in under 10 minutes to US-based, board certified physicians who can answer questions, diagnose and even prescribe when necessary.
Pharmacy Discount Card
Save up to 75% on your prescription medication using our pharmacy discount card. It’s easy to use and accepted at over 50,000 pharmacies nationwide!
Life Assistance
Access to professional Life Counselors and specialists who can help you achieve balance in your personal, family and work life is just a call away.
Bill Saver Our Bill Saver program can help reduce the amount you owe for medical and dental bills over $400, often resulting in savings between 25-50%.
$5.25 $6.75
For more information, please contact Pierce Group Benefits We Win When You Win.
18
Explanation of Benefits The Call A Doctor Plus program provides your team with fast, convenient, 24/7 access to quality care by phone, video or mobile app. Here is more information about each service offered, including how to access the benefit.
Teladoc – Talk to a doctor in minutes Teladoc provides your team with 24/7 phone or video access to doctors who can diagnose common medical conditions, provide treatment plans, and even write prescriptions when needed. Whether they’re on vacation or it’s 2 in the morning, your team can have access to the care they need, when they need it.
Key Benefits: ! ! ! ! ! !
Talk to a doctor in 10 minutes on average No co-pays, deductibles or per-call charges 92% of issues are resolved on the first call US-based, board-certified doctors Connect 24/7/365 by phone, video or app Get answers, prescriptions and treatment plans
Get Started in 3 Easy Steps! 1. Visit Teladoc.com or call (800) 835-2362 and select the option to ‘set up your account’. 2. Be prepared to provide the following information a. First Name b. Last Name c. Date of Birth d. Zip Code e. Email Address: your primary email address f. Preferred Language g. Gender h. The name of your employer 3. Follow the rest of the steps, complete your medical history and you’re all set! Note: if trying to register online and your account cannot be found, please call (800) 8352362 so that Teladoc’s Client Service team can help you locate and set up your account.
Once you are finished, you can add dependents and download the mobile app.
Contact Teladoc ! Phone: (800) 835-2362 ! Online: www.teladoc.com
Health Advocate – Help for life’s challenges Health Advocate gives your team 24/7 access to a Licensed Professional Counselor for help with personal, family, and work problems. They also have access to a work/life specialist who can help them find a wide range of support resources to help balance their work and life. All it takes is one phone call!
Key Benefits: ! ! ! ! ! !
Support for stress, depression or anxiety Help with work, marital or family issues Network attorneys to assist with legal issues Financial professionals for money matters Childcare and Eldercare services Thousands of online resources
Medical Bill Saver Your team also has access to Health Advocates Medical Bill Saver program. Medical Bill Saver can help your team reduce the cost of uncovered medical and dental bills over $400. It’s easy and can often result in 25 to 50% savings. ! We work directly with doctors and other providers on your behalf ! We have very high success rates of achieving significant savings ! Our work often results in lower out-of-pocket costs ! You become a savvier healthcare consumer through the process ! Everyone in your immediate family can use the service. ! …and much more!
Contact Health Advocate
! Phone: (877) 240-6863 ! Online: members.healthadvocate.com o Select ‘Complete Telehealth’
Pharmacy Discount Card – Save on prescription medication Our FREE pharmacy discount card allows your employees to save up to 75% on your prescription medication using the pharmacy discount card. It’s easy to use and accepted at over 50,000 pharmacies nationwide!
Key Benefits: ! ! ! ! !
Save up to 75% on prescriptions No claim forms to file No deductibles No limits or maximums No pre-existing conditions
Accessing the Discount Card
1. Register for a card at npsncard.com/teladoc a. Provide your personal information, including name, address, email and/or phone b. Click ‘submit’ and a card is sent to you by mail in 3 to 4 weeks c. If selected, your card will be immediately texted to your phone 2. Find a provider. a. Use searchrx.com to search local partners for the lowest possible price b. Search from over 50,000 pharmacies to find the best price 3. Go to your pharmacy of choice and present your card. a. You will pay the discounted rate at the time of purchase by showing your card. b. You will not have to fill out any reimbursement paperwork your savings are immediate!
Contact the Discount Card
! Online: npsncard.com/teladoc
Cancer Insurance Our Cancer Assist plan helps employees protect themselves and their loved ones through their diagnosis, treatment and recovery journey. This individual voluntary policy pays benefits that can be used for both medical and/or out-of-pocket, non-medical expenses traditional health insurance may not cover. Available exclusively at the workplace, Cancer Assist is an attractive addition to any competitive benefits package that won’t add costs to a company’s bottom line.
Competitive advantages n
Composite rates.
n
Four distinct plan levels, each featuring the same benefits with premiums and benefit amounts designed to meet a variety of budgets and coverage needs (benefits overview on reverse).
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Indemnity-based benefits pay exactly what’s listed for the selected plan level.
n
The plan’s Family Care Benefit provides a daily benefit when a covered dependent child receives inpatient or outpatient cancer treatment.
n
Employer-optional cancer wellness/health screening benefits available:
n
n
Part One covers 24 tests. If selected, the employer chooses one of four benefit amounts for employees: $25, $50, $75 or $100. This benefit is payable once per covered person per calendar year. Part Two covers an invasive diagnostic test or surgical procedure if an abnormal result from a Part One test requires additional testing. This benefit is payable once per calendar year per covered person and matches the Part One benefit.
Flexible family coverage options
n
Individual, Individual/Spouse, One-parent and Two-parent family policies.
n
Family coverage includes eligible dependent children (to age 26) for the same rate, regardless of the number of children covered.
Attractive features
Talk to your benefits representative today to learn more about this product and how it helps provide extra financial protection to employees who may be impacted by cancer.
n
Available for businesses with 3+ eligible employees.
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Broad range of policy issue ages, 17-75.
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Each plan level features full schedule of 30+ benefits and three optional riders (benefit amounts may vary based on plan level selected).
n
Benefits don’t coordinate with any other coverage from any other insurer.
n
HSA compliant.
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Guaranteed renewable.
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Portable.
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Waiver of premium if named insured is disabled due to cancer for longer than 90 consecutive days and the date of diagnosis is after the waiting period and while the policy is in force.
n
Form 1099s may not be issued in most states because all benefits require that a charge is incurred. Discuss details with your benefits representative, or consult your tax adviser if you have questions.
Optional riders (available at an additional cost/payable once per covered person)
n
Initial Diagnosis of Cancer Rider pays a one-time benefit for the initial diagnosis of cancer. A benefit amount in $1,000 increments from $1,000-$10,000 may be chosen. The benefit for covered dependent children is two and a half times ($2,500-25,000) the chosen benefit amount.
n
Initial Diagnosis of Cancer Progressive Payment Rider pays a $50 lump-sum payment for each month the rider has been in force, after the waiting period, once cancer is first diagnosed. The issue ages for this rider are 17-64.
n
Specified Disease Hospital Confinement Rider pays $300 per day for confinement to a hospital for treatment of one of 34 specified diseases covered under the rider.
21
INDIVIDUAL CANCER INSURANCE
Cancer Assist Benefits Overview
Radiation/Chemotherapy n n n n
This overview shows benefits available for all four plan levels and the range of benefit amounts payable for most common cancer treatments. Each benefit is payable for each covered person under the policy. Actual benefits vary based on the plan level selected.
n n n n
Injected chemotherapy by medical personnel: $250-$1,000 once per calendar week Radiation delivered by medical personnel: $250-$1,000 once per calendar week Self-injected chemotherapy: $150-$400 once per calendar month Topical chemotherapy: $150-$400 once per calendar month Chemotherapy by pump: $150-$400 once per calendar month Oral hormonal chemotherapy (1-24 months): $150-$400 once per calendar month Oral hormonal chemotherapy (25+ months): $75-$200 once per calendar month Oral non-hormonal chemotherapy: $150-$400 once per calendar month
Anti-nausea Medication
$25-$60 per day, up to $100-$240 per calendar month
Medical Imaging Studies
$75-$225 per study, up to $150-$450 per calendar year
Outpatient Surgical Center
$100-$400 per day, up to $300-$1,200 per calendar year
Skin Cancer Initial Diagnosis
$300-$600 payable once per lifetime
Surgical Procedures
Inpatient and Outpatient Surgeries: $40-$70 per surgical unit, up to $2,500-$6,000 per procedure
Reconstructive Surgery
$40-$60 per surgical unit, up to $2,500-$3,000 per procedure including 25% for general anesthesia
Anesthesia
General: 25% of Surgical Procedures Benefit Local: $25-$50 per procedure
Hospital Confinement Each benefit requires that charges are incurred for treatment. All benefits and riders are subject to a 30-day waiting period. Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. States without a waiting period will have a pre-existing condition limitation. Product has exclusions and limitations that may affect benefits payable. Benefits vary by state and may not be available in all states. See your Colonial Life benefits representative for complete details.
30 days or less: $100-$350 per day 31 days or more: $200-$700 per day
Family Care
Inpatient and outpatient treatment for a covered dependent child: $30-$60 per day, up to $1,500-$3,000 per calendar year
Second Medical Opinion on Surgery or Treatment $150-$300 once per lifetime
Home Health Care Services
Examples include physical therapy, speech therapy, occupational therapy, prosthesis and orthopedic appliances, durable medical equipment: $50-$150 per day, up to the greater of 30 days per calendar year or twice the number of days hospitalized per calendar year
Hospice Care
Initial: $1,000 once per lifetime Daily: $50 per day $15,000 maximum for initial and daily hospice care per lifetime
Transportation and Lodging n n
n
ColonialLife.com © 2014 Colonial Life & Accident Insurance Company Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 1-14 | 101478
Transportation for treatment more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip Companion Transportation (for any companion, not just a family member) for commercial travel when treatment is more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip Lodging for the covered person or any one adult companion or family member when treatment is more than 50 miles from the covered person’s home: $50-$80 per day, up to 70 days per calendar year
Benefits also included in each plan
Air Ambulance, Ambulance, Blood/Plasma/Platelets/Immunoglobulins, Bone Marrow or Peripheral Stem Cell Donation, Bone Marrow Donor Screening, Bone Marrow or Peripheral Stem Cell Transplant, Cancer Vaccine, Egg(s) Extraction or Harvesting/Sperm Collection and Storage (Cryopreservation), Experimental Treatment, Hair/External Breast/Voice Box Prosthesis, Private Full-time Nursing Services, Prosthetic Device/Artificial Limb, Skilled Nursing Facility, Supportive or Protective Care Drugs and Colony Stimulating Factors
22
INDIVIDUAL CANCER INSURANCE
Cancer Insurance Wellness Benefits
To encourage early detection, our cancer insurance offers benefits for wellness and health screening tests.
For more information, talk with your benefits counselor.
©2014 Colonial Life & Accident Insurance Company Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 1-14
Part One: Cancer Wellness/Health Screening Provided when one of the tests listed below is performed after the waiting period and while the policy is in force. Payable once per calendar year, per covered person.
Cancer Wellness Tests
Health Screening Tests
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Bone marrow testing
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Blood test for triglycerides
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Breast ultrasound
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Carotid Doppler
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CA 15-3 [blood test for breast cancer]
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Echocardiogram [ECHO]
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CA 125 [blood test for ovarian cancer]
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Electrocardiogram [EKG, ECG]
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CEA [blood test for colon cancer]
n
Fasting blood glucose test
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Chest X-ray
n
n
Colonoscopy
Serum cholesterol test for HDL and LDL levels
n
Flexible sigmoidoscopy
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Stress test on a bicycle or treadmill
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Hemoccult stool analysis
n
Mammography
n
Pap smear
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PSA [blood test for prostate cancer]
n
Serum protein electrophoresis [blood test for myeloma]
n
Skin biopsy
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Thermography
n
ThinPrep pap test
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Virtual colonoscopy
Part Two: Cancer Wellness — Additional Invasive Diagnostic Test or Surgical Procedure Provided when a doctor performs a diagnostic test or surgical procedure after the waiting period as the result of an abnormal result from one of the covered cancer wellness tests in Part One. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.
Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. The policy has exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable – for example: CanAssist-TX).
23
CANCER ASSIST WELLNESS – 101486
Group Specified Disease Insurance Plan 3 Full
If you’re diagnosed with a covered specified disease, group specified disease insurance* from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery. *The policy name is Specified Disease Group Insurance.
Face amount: $_______________ Plan features
A lump-sum payment that can be used as you see fit Adjustable face amount to best meet your personal needs May pay multiple times for a covered specified disease Guaranteed renewable Portable
Specified disease benefit For the diagnosis of this covered specified disease condition:1
For more information, talk with your benefits counselor.
ColonialLife.com
This percentage of the face amount is payable:
Heart attack (myocardial infarction)
100%
Stroke
100%
End-stage renal (kidney) failure
100%
Major organ failure
100%
Coma
100%
Permanent paralysis due to a covered accident
100%
Blindness
100%
Occupational infectious HIV or occupational infectious hepatitis B, C or D
100%
Coronary artery bypass graft surgery/disease2
25%
Subsequent diagnosis of a different specified disease3 If you receive a benefit for a specified disease, and later you are diagnosed with a different specified disease, the original percentage of the face amount is payable for that particular specified disease. Subsequent diagnosis of the same specified disease3 If you receive a benefit for a specified disease, and later you are diagnosed with the same specified disease, 25% of the original face amount is payable. Specified disease conditions that do not qualify are: coronary artery bypass graft surgery/coronary artery disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.
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GROUP CRITICAL CARE PLAN 3 FULL - GUARANTEED RENEWABLE
1 Please refer to the certificate for complete definitions of covered conditions.
ColonialLife.com
2 Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass graft surgery when health savings account (HSA) compliant plan is selected. 3 Dates of diagnoses of a covered specified disease must be separated by at least 180 days. THIS POLICY PROVIDES LIMITED BENEFITS.
EXCLUSIONS AND LIMITATIONS FOR SPECIFIED DISEASE We will not pay the Specified Disease Benefit or Benefit Payable Upon Subsequent Diagnosis of a Specified Disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; psychiatric or psychological conditions; suicide or injuries which any covered person intentionally does to himself; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a specified disease. This is not an insurance contract and only the actual certificate provisions will control. Applicable to certificate form GCC1.0-C-GR-NC. Please see your Colonial Life benefits counselor for details.
Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC Š2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
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2-17 | NS-15526
Group Specified Disease Insurance First Diagnosis Building Benefit Rider (Specified Disease)
A specified disease can have a big impact on your finances. To help protect your way of life, you can add the first diagnosis building benefit rider to your group specified disease coverage. Available at an additional cost, the rider provides a lump-sum benefit when a covered specified disease* is first diagnosed.
First diagnosis building benefit rider Payable once per covered person per lifetime
¾ Named insured ............................................................ Accumulates $1,000 each year ¾ Covered spouse/dependent child ..................................... Accumulates $500 each year
The rider covers the same family members as your group specified disease insurance. The benefit amount accumulates each year the rider is in force before a diagnosis is made, up to a maximum of 10 years. If you are diagnosed with a covered specified disease before the end of the first rider year, the rider will pay one-half of the annual building benefit amount.
For more information, talk with your benefits counselor.
ColonialLife.com
* Conditions that do not apply to the rider include coronary artery bypass graft surgery/coronary artery disease. Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass graft surgery when health savings account (HSA) compliant plan is selected.
The certificate to which the rider is attached has exclusions and limitations. This is not an insurance contract and only the actual certificate provisions will control. Applicable to rider form R-GCC1.0-BB-NC. Please see your Colonial Life benefits counselor for details. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. GROUP CRITICAL CARE FIRST DIAGNOSIS BUILDING BENEFIT RIDER – SPECIFIED DISEASE | 1-17 | 100584-1
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Specified Disease Insurance Health Screening Benefit
The optional health screening benefit can help you reduce the risk of serious illness through early detection. Health screening benefit ................................................................ $_______________ Maximum of one screening test per covered person per calendar year.
Blood test for triglycerides
Pap smear
Bone marrow testing
PSA (blood test for prostate cancer)
Breast ultrasound
Serum cholesterol test for HDL and LDL levels
CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) Carotid Doppler CEA (blood test for colon cancer) Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG)
For more information, talk with your benefits counselor.
Fasting blood glucose test
Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy
Flexible sigmoidoscopy Hemoccult stool analysis Mammography
ColonialLife.com
For cost and complete details, see your Colonial Life benefits counselor. Applicable to form CI-1.0-NC and GCC1.0-P-NC. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2016 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. GROUP CRITICAL CARE, CRITICAL ILLNESS 1.0 – HEALTH SCREENING BENEFIT | 12-16 | 100595-2
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Individual Short-Term Disability Insurance You never know when a disability could impact your way of life. Fortunately, there’s a way to help protect your income. If an accident or sickness prevents you from earning a paycheck, disability insurance can provide a monthly benefit to help you cover your ongoing expenses.
Can you afford to not protect your paycheck? You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs. After calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet. ESTIMATED MONTHLY EXPENSES
ColonialLife.com
AMOUNT
Mortgage or rent
$
Utilities (electric/gas, phone, water, TV, Internet)
$
Transportation costs (gas, car payments)
$
Food
$
Health (medical needs and prescription drugs)
$
Other
$
TOTAL
$
Benefits worksheet How much coverage do I need? Monthly benefit amount for off-job accident and off-job sickness: ______________ Choose a monthly benefit amount between $400 and $6,500.* If your plan includes on-job accident/sickness benefits, the benefit is 50% of the off-job amount.
How long will I receive benefits? Benefit period: _______ months The partial disability benefit period is three months.
When will my total disability benefits start? After an accident: _______ days
After a sickness: _______ days
*Subject to income requirements
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ISTD3000 BASE
Product information Total disability definition Totally disabled or total disability means you are: unable to perform the material and substantial duties of your job, not working at any job, and under the regular and appropriate care of a physician. How partial disability works If you are able to return to work part-time after at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit. Waiver of premium We will waive your premium payments after 90 consecutive days of a covered disability. Geographical limitations If you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits. Issue age Coverage is available from ages 17 to 74. Keep your coverage You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due. Premium Your premium is based on your age when you purchase coverage and the amount of coverage you are eligible to buy. Your premium will not change as you age.
For more information, talk with your benefits counselor.
EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: cosmetic surgery, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, psychiatric or psychological conditions, racing, semi-professional or professional sports, substance abuse, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for benefits due to being pregnant before the policy coverage effective date shown in the policy schedule, if medical advice, diagnosis, care or treatment was received or recommended within the one-year period immediately preceding the policy coverage effective date shown on the policy schedule. We will not pay for loss when the disability is a pre-existing condition as described in the policy. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000-NC and rider form ISTD3000-ADIB-NC. This is not an insurance contract and only the actual policy and rider provisions will control. Š2015 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.
29
7-15 | 101629-NC
Individual Short-Term Disability Insurance Health Screening Rider Benefit The optional health screening benefit can help you reduce the risk of serious illness through early detection.
Health screening benefit ..................................................................................... $50 Maximum of one health screening test per calendar year; subject to a 30-day waiting period following the effective date of the rider
Blood test for triglycerides
Pap smear
Bone marrow testing
PSA (blood test for prostate cancer)
Breast ultrasound
Serum cholesterol test for HDL and LDL levels
CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) Carotid Doppler CEA (blood test for colon cancer) Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test
For more information, talk with your benefits counselor.
Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy
Flexible sigmoidoscopy Hemoccult stool analysis Mammography
With the health screening benefit: You’re paid regardless of any insurance you have with other companies. You can keep coverage to age 75 as long as premiums are paid when they are due.
ColonialLife.com
Waiting period means the first 30 days following the rider coverage effective date, during which time no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider form ISTD3000-HS (including state abbreviations where used, for example: ISTD3000-HS-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual 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.
30
ISTD3000 – HEALTH SCREENING BENEFIT | 7-16 | 101634-1
Individual Short-Term Disability Insurance Psychiatric and Psychological Benefit
Although illnesses and accidents are often associated with disabilities, mental disorders can also leave you unable to earn an income. If you’re disabled with a covered psychiatric or covered psychological condition, disability insurance from Colonial Life & Accident Insurance Company pays a monthly benefit that can help provide financial support while you focus on recovery.
Psychiatric and psychological benefit There is a maximum six-month benefit period limitation for any one occurrence of a psychiatric or psychological condition. There is a three-month benefit period limitation if you have a three-month benefit period.
For more information, talk with your benefits counselor.
There is a 24-month cumulative lifetime maximum benefit period for all psychiatric or psychological conditions. This maximum includes a combination of total disability and partial disability occurrences.
ColonialLife.com
The psychiatric and psychological benefit is only applicable when combined with the ISTD3000 base policy. The exclusions listed on the ISTD3000 base policy apply, except for the psychiatric or psychological conditions exclusion. For cost and complete details, talk with your Colonial Life benefits counselor. Applicable to policy form ISTD3000 and rider form ISTD3000-ADIB (plus state abbreviations where applicable, for example: ISTD3000-TX and ISTD3000-ADIB-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 and rider provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. ISTD3000 – PSYCHIATRIC AND PSYCHOLOGICAL BENEFIT | 6-15 | 101630
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Accident Insurance
Accidents happen in places where you and your family spend the most time – at work, in the home and on the playground – and they’re unexpected. How you care for them shouldn’t be. In your lifetime, which of these accidental injuries have happened to you or someone you know? l
l
Sports-related accidental injury Broken bone Burn Concussion Laceration
l
Back or knee injuries
l l l
l
Car accidents l Falls & spills l Dislocation l Accidental injuries that send you to the Emergency Room, Urgent Care or doctor’s office
Accident 1.0-Preferred with Health Screening Benefit
Colonial Life’s Accident Insurance is designed to help you fill some of the gaps caused by increasing deductibles, co-payments and out-of-pocket costs related to an accidental injury. The benefit to you is that you may not need to use your savings or secure a loan to pay expenses. Plus you’ll feel better knowing you can have greater financial security.
What additional features are included? l
Worldwide coverage
l
Portable
l
Compliant with Healthcare Spending Account (HSA) guidelines
What if I change employers? If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable as long as you pay your premiums when they are due or within the grace period.
Can my premium change?
Will my accident claim payment be reduced if I have other insurance?
Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued.
You’re paid regardless of any other insurance you may have with other insurance companies, and the benefits are paid directly to you (unless you specify otherwise).
How do I file a claim? Visit coloniallife.com or call our Customer Service Department at 1.800.325.4368 for additional information.
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Benefits listed are for each covered person per covered accident unless otherwise specified.
Initial Care l
Accident Emergency Treatment........... $150
l
Ambulance........................................$400
l
X-ray Benefit....................................................$50
l Air
Ambulance.............................. $2,000
Common Accidental Injuries Dislocations (Separated Joint) Hip Knee (except patella) Ankle – Bone or Bones of the Foot (other than Toes) Collarbone (Sternoclavicular) Lower Jaw, Shoulder, Elbow, Wrist Bone or Bones of the Hand Collarbone (Acromioclavicular and Separation) One Toe or Finger Fractures Depressed Skull Non-Depressed Skull Hip, Thigh Body of Vertebrae, Pelvis, Leg Bones of Face or Nose (except mandible or maxilla) Upper Jaw, Maxilla Upper Arm between Elbow and Shoulder Lower Jaw, Mandible, Kneecap, Ankle, Foot Shoulder Blade, Collarbone, Vertebral Process Forearm, Wrist, Hand Rib Coccyx Finger, Toe
Non-Surgical
Surgical
$6,600 $3,300 $2,640 $1,650 $990 $990 $330 $330
$13,200 $6,600 $5,280 $3,300 $1,980 $1,980 $660 $660
Non-Surgical
Surgical
$5,500 $2,200 $3,300 $1,650 $770 $770 $770 $660 $660 $660 $550 $440 $220
$11,000 $4,400 $6,600 $3,300 $1,540 $1,540 $1,540 $1,320 $1,320 $1,320 $1,100 $880 $440
Your Colonial Life policy also provides benefits for the following injuries received as a result of a covered accident. l
Burn (based on size and degree).....................................................................................$1,000 to $12,000
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Coma..............................................................................................................................................................$10,000
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Concussion........................................................................................................................................................$150
Emergency Dental Work........................................$75 Extraction, $300 Crown, Implant, or Denture l Lacerations (based on size)............................................................................................................$50 to $800 l
Requires Surgery l
Eye Injury............................................................................................................................................................$300
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Tendon/Ligament/Rotator Cuff...........................................................$500 - one, $1,000 - two or more
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Ruptured Disc...................................................................................................................................................$500
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Torn Knee Cartilage........................................................................................................................................$500
Surgical Care Surgery (cranial, open abdominal or thoracic)................................................................................. $1,500
l l
Surgery (hernia)...............................................................................................................................................$150
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Surgery (arthroscopic or exploratory).....................................................................................................$250
l
Blood/Plasma/Platelets.................................................................................................................................$300
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Transportation/Lodging Assistance If injured, covered person must travel more than 50 miles from residence to receive special treatment and confinement in a hospital. Transportation..............................................................................$500 per round trip up to 3 round trips
l
Lodging (family member or companion)................................................$125 per night up to 30 days for a hotel/motel lodging costs
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Accident Hospital Care Hospital Admission*......................................................................................................... $1,500 per accident
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Hospital ICU Admission*................................................................................................. $3,000 per accident * We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both. l
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Hospital Confinement.......................................................... $250 per day up to 365 days per accident
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Hospital ICU Confinement ....................................................$500 per day up to 15 days per accident
Accident Follow-Up Care l
Accident Follow-Up Doctor Visit........................................................... $50 (up to 3 visits per accident)
Medical Imaging Study.......................................................................................................$250 per accident (limit 1 per covered accident and 1 per calendar year)
l
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Occupational or Physical Therapy...................................................... $35 per treatment up to 10 days
l
Appliances ........................................................................................... $125 (such as wheelchair, crutches)
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Prosthetic Devices/Artificial Limb .....................................................$500 - one, $1,000 - more than 1
Rehabilitation Unit..................................................$100 per day up to 15 days per covered accident, and 30 days per calendar year. Maximum of 30 days per calendar year
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Accidental Dismemberment l
Loss of Finger/Toe..................................................................................$750 – one, $1,500 – two or more
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Loss or Loss of Use of Hand/Foot/Sight of Eye......................$7,500 – one, $15,000 – two or more
Catastrophic Accident For severe injuries that result in the total and irrecoverable: l
Loss of one hand and one foot
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Loss of the sight of both eyes
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Loss of both hands or both feet
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Loss of the hearing of both ears
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Loss or loss of use of one arm and one leg or
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Loss of the ability to speak
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Loss or loss of use of both arms or both legs
Named Insured................. $25,000 Spouse...............$25,000 Child(ren)..........$12,500 365-day elimination period. Amounts reduced for covered persons age 65 and over. Payable once per lifetime for each covered person.
Accidental Death Accidental Death
Common Carrier
l
Named Insured
$25,000
$100,000
l
Spouse
$25,000
$100,000
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Child(ren)
$5,000
$20,000
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Health Screening Benefit
l
$50 per covered person per calendar year
Provides a benefit if the covered person has one of the health screening tests performed. This benefit is payable once per calendar year per person and is subject to a 30-day waiting period.
Tests include: l.
Blood test for triglycerides
l.
Hemoccult stool analysis
l.
Bone marrow testing
l.
Mammography
l.
Breast ultrasound
l.
Pap smear
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CA 15-3 (blood test for breast cancer)
l.
PSA (blood test for prostate cancer)
l.
CA125 (blood test for ovarian cancer)
l.
l.
Carotid doppler
Serum cholesterol test to determine level of HDL and LDL
l.
CEA (blood test for colon cancer)
l.
l.
Chest x-ray
Serum protein electrophoresis (blood test for myeloma)
Colonoscopy
l.
l.
Stress test on a bicycle or treadmill
Echocardiogram (ECHO)
l.
l.
Skin cancer biopsy
Electrocardiogram (EKG, ECG)
l.
l.
Thermography
Fasting blood glucose test
l.
l.
ThinPrep pap test
Flexible sigmoidoscopy
l.
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Virtual colonoscopy
My Coverage Worksheet (For use with your Colonial Life benefits counselor) Who will be covered? (check one) Employee Only
Spouse Only
One-Parent Family, with Employee
One Child Only
One-Parent Family, with Spouse
Employee & Spouse Two-Parent Family
On and Off -Job Benefits
Off -Job Only Benefits
EXCLUSIONS We will not pay benefits for losses that are caused by or are the result of: hazardous avocations; felonies or illegal occupations; racing; semi-professional or professional sports; sickness; suicide or self-inflicted injuries; war or armed conflict; in addition to the exclusions listed above, we also will not pay the Catastrophic Accident benefit for injuries that are caused by or are the result of: birth; intoxication. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form Accident 1.0-HS-NC. This is not an insurance contract and only the actual policy provisions will control.
Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com
©2014 Colonial Life & Accident Insurance Company | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 6-14
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71740-NC
Accident 1.0-Preferred with Health Screening Benefit
When are covered accident benefits available? (check one)
Hospital Confinement Indemnity Insurance Plan 3 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement. ......................................................................... $_______________ Maximum of one benefit per covered person per calendar year
Observation room................................................................................... $100 per visit Maximum of two visits per covered person per calendar year
Rehabilitation unit confinement. ................................................................. $100 per day Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year
Waiver of premium
Available after 30 continuous days of a covered hospital confinement of the named insured
Diagnostic procedure Tier 1. . . . . .......................................................................................... ................. $250 Tier 2. . . . . .......................................................................................... ................. $500 Maximum of $500 per covered person per calendar year for all covered diagnostic procedures combined
Outpatient surgical procedure Tier 1. . . . . .......................................................................................... . $_______________ Tier 2. . . . . ............................................................................................ $_______________
For more information, talk with your benefits counselor.
Maximum of $___________ per covered person per calendar year for all covered outpatient surgical procedures combined
The following is a list of common diagnostic procedures that may be covered.
Tier 1 diagnostic procedures Breast – Biopsy (incisional, needle, stereotactic) Diagnostic radiology – Nuclear medicine test Digestive – Barium enema/lower GI series – Barium swallow/upper GI series – Esophagogastroduodenoscopy (EGD) Ear, nose, throat, mouth – Laryngoscopy Gynecological – Hysteroscopy – Amniocentesis – Loop electrosurgical – Cervical biopsy excisional procedure – Cone biopsy (LEEP) – Endometrial biopsy
Liver – biopsy Lymphatic – biopsy Miscellaneous – Bone marrow aspiration/biopsy Renal – biopsy Respiratory – Biopsy – Bronchoscopy – Pulmonary function test (PFT) Skin – Biopsy – Excision of lesion Thyroid – biopsy Urologic – Cystoscopy
Tier 2 diagnostic procedures Cardiac – Angiogram – Arteriogram – Thallium stress test – Transesophageal echocardiogram (TEE)
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Diagnostic radiology – Computerized tomography scan (CT scan) – Electroencephalogram (EEG) – Magnetic resonance imaging (MRI) – Myelogram – Positron emission tomography scan (PET scan) IMB7000 – PLAN 3
The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.
Tier 1 outpatient surgical procedures Breast
Gynecological
Cardiac
Liver
Digestive
Musculoskeletal system
– Axillary node dissection – Breast capsulotomy – Lumpectomy
– Dilation and curettage (D&C) – Endometrial ablation – Lysis of adhesions
– Pacemaker insertion
– Paracentesis
– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions
– Carpal/cubital repair or release – Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair) – Removal of orthopedic hardware – Removal of tendon lesion
Skin
– Laparoscopic hernia repair – Skin grafting
Ear, nose, throat, mouth – Adenoidectomy – Removal of oral lesions – Myringotomy – Tonsillectomy – Tracheostomy – Tympanotomy
Tier 2 outpatient surgical procedures Breast
Gynecological
Cardiac
Musculoskeletal system
– Breast reconstruction – Breast reduction
– Hysterectomy – Myomectomy
– Angioplasty – Cardiac catheterization
Digestive
– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy
Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty
Thyroid
– Excision of a mass
Eye
ColonialLife.com
– Arthroscopic knee surgery with meniscectomy (knee cartilage repair) – Arthroscopic shoulder surgery – Clavicle resection – Dislocations (open reduction with internal fixation) – Fracture (open reduction with internal fixation) – Removal or implantation of cartilage – Tendon/ligament repair
– Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy) – Vitrectomy
Urologic
– Lithotripsy
EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. Pre-exisiting conditions are those conditions whether diagnosed or not, for which a covered person received medical advice, diagnosis or care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the policy. If a covered person is 65 or older when the policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-NC. This is not an insurance contract and only the actual policy provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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7-15 | 101581-NC
Hospital Confinement Indemnity Insurance Health Screening Individual Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.
Health screening .............................................................................. $_____________ Maximum of one health screening test per covered person per calendar year; subject to a 30-day waiting period
Blood test for triglycerides Bone marrow testing Breast ultrasound CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) CEA (blood test for colon cancer) Carotid Doppler
Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy
Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy
For more information, talk with your benefits counselor.
Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels
ColonialLife.com
Waiting period means the first 30 days following any covered person’s policy coverage effective date, during which no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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IMB7000 – HEALTH SCREENING BENEFIT | 2-15 | 101579
Hospital Confinement Indemnity Insurance Medical Treatment Package The medical treatment package for Individual Medical BridgeSM coverage can help pay for deductibles, co-payments and other out-of-pocket expenses related to a covered accident or covered sickness.
The medical treatment package paired with Plan 3 provides the following benefits: Air ambulance ............................................................................................. $1,000 Maximum of one benefit per covered person per calendar year
Ambulance .................................................................................................... $100 Maximum of one benefit per covered person per calendar year
Appliance ...................................................................................................... $100 Maximum of one benefit per covered person per calendar year
Doctor’s office visit ................................................................................... $25 per visit Maximum of three visits per calendar year for named insured coverage or maximum of five visits per calendar year for all covered persons combined
Emergency room visit ............................................................................. $100 per visit
For more information, talk with your benefits counselor.
Maximum of two visits per covered person per calendar year
X-ray ................................................................................................ $25 per benefit Maximum of two benefits per covered person per calendar year
THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS
ColonialLife.com
We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-NC. This is not an insurance contract and only the actual policy provisions will control. Š2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. IMB7000-MEDICAL TREATMENT PACKAGE NORTH CAROLINA EDUCATORS | 1-16 | NS-15014-NC
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Hospital Confinement Indemnity Insurance Optional Riders Individual Medical BridgeSM offers two optional benefit riders – the daily hospital confinement rider and the enhanced intensive care unit confinement rider. For an additional cost, these riders can help provide extra financial protection to help with out-of-pocket medical expenses.
Daily hospital confinement rider ................................................................. $100 per day Per covered person per day of hospital confinement Maximum of 365 days per covered person per confinement
Enhanced intensive care unit confinement rider .............................................. $500 per day Per covered person per day of intensive care unit confinement Maximum of 30 days per covered person per confinement
Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.
For more information, talk with your benefits counselor.
EXCLUSIONS
ColonialLife.com
We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. Pre-exisiting conditions are those conditions whether diagnosed or not, for which a covered person received medical advice, diagnosis or care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the policy. If a covered person is 65 or older when the policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000-NC and R-EIC7000-NC. This is not an insurance contract and only the actual policy or rider provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 7-15 | 101582-NC
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Term Life Insurance Life insurance protection when you need it most Life insurance needs change as life circumstances change. You may need different coverage if you’re getting married, buying a home or having a child. Term life insurance from Colonial Life provides protection for a specified period of time, typically offering the greatest amount of coverage for the lowest initial premium. This fact makes term life insurance a good choice for supplementing cash value coverage during life stages when obligations are higher, such as while children are younger. It’s also a good option for families on a tight budget — especially since you can convert it to a permanent cash value plan later.
With this coverage: A beneficiary can receive a benefit that is typically free from income tax. The policy’s accelerated death benefit can pay a percentage of the death benefit if the covered person is diagnosed with a terminal illness. You can convert it to a Colonial Life cash value insurance plan, with no proof of good health, to age 75. Coverage is guaranteed renewable up to age 95 as long as premiums are paid when due. Portability allows you to take it with you if you change jobs or retire.
Talk with your Colonial Life benefits counselor to learn more.
ColonialLife.com
Spouse coverage options
Dependent coverage options
Two options are available for spouse coverage at an additional cost:
You may add a Children’s Term Life Rider to cover all of your eligible dependent children with up to $20,000 in coverage each for one premium.
1. Spouse Term Life Policy: Offers guaranteed premiums and level death benefits equivalent to those available to you –whether or not you buy a policy for yourself. 2. Spouse Term Life Rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).
The Children’s Term Life Rider may be added to either the primary or spouse policy, not both.
If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 7-19 | NS-16570-1
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Whole Life Insurance Life insurance that comes with guarantees — because life doesn’t You can’t predict the future, but you can rest easier knowing you have life insurance with lifelong guarantees. Whole life insurance provides guaranteed features – cash value accumulation, premium rates and a death benefit (minus any loans and loan interest) – that help ensure those benefits will be there to help protect your family’s way of life.
With this coverage: Life insurance benefits for the beneficiary are typically tax-free. You have three opportunities to purchase additional coverage with no proof of good health required if you are 50 or younger with the Guaranteed Purchase Option Rider. The policy’s built-in terminal illness accelerated death benefit provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness.1 A $3,000 immediate claim payment that can help your designated beneficiary pay for funeral costs or other expenses.
Talk with your Colonial Life benefits counselor to learn more.
ColonialLife.com
You can take the policy with you even if you change jobs or retire; with no increase in premium.
Paid-Up at Age 70 or Paid-Up at Age 100 These two plan options allow you to select what age your premium payments will end. You can choose to have your policy paid up when you reach age 70 or 100.
1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits. If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 7-19 | NS-16576-1
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Accessing FSA Store is easy. Simply visit FSAstore.com/PGBFL for the largest selection of guaranteed FSA-eligible products with zero guesswork. Get $20 off $200+ with code PGBF20. One use per customer.
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General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction You are receiving this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.” Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to the City of Dunn, 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.
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When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Anne Thompson at the City of Dunn. 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, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov. Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
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Plan contact information COBRA Administrator for Dental Coverage Interactive Medical Systems – Dental PO Box 1349 Wake Forest, NC 27588 Phone: (919) 877-9933 Ext: 5054 Fax: (919)562-0021 Email: cobradept@ims-tpa.com COBRA Administrator for FSA Coverage Ameriflex 2508 Highlander Way, Suite 200 Carrollton, TX 75006 Fax: 609-257-0136 COBRA Administrator for Vision Coverage City of Dunn c/o Forrest T Jones & Company, Inc. PO Box 418131 Kansas City, MO 64141-8131 Plan contact information City of Dunn Attn: Anne Thompson PO Box 1065 Dunn, NC 28335 Phone: 910.230.3545 athompson@dunn-nc.org
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Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives. Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments. Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by those laws. This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202. You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, or Conservator. ________________________ (Printed name of individual subject to this disclosure)
_____________ (Social Security Number)
___________________ (Signature)
________________ (Date Signed)
If applicable, I signed on behalf of the proposed insured as __________________________ (indicate relationship). If legal Guardian, Power or Attorney Designee, or Conservator.
________________________________ (Printed name of legal representative)
_____________________________ (Signature of legal representative)
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___________ (Date Signed)
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I’m Leaving, Now What? State Health Insurance Under certain qualifying events, employees and dependents have the opportunity to continue coverage for 18-36 months under the COBRA Act. Please contact the State Health Plan at 1-888-234-2416. If you are retiring, you must either log in to www.myncretirement.com or call 1-888-234-2416.
Other Benefits If you wish to continue coverage of any of the following benefits, Pierce Group Benefits will be happy to serve you:
• • • •
Dental and Vision Insurance Group Term Life Insurance Supplemental/Voluntary Insurances - Cancer, Disability, Life, etc. Flexible Spending Accounts
Please visit
www.piercegroupbenefits.com/individualfamily
or call 888-662-7500 for more information on these policies, as well as to enroll/continue your benefits. You may also click on the “Individual & Family” button on the Pierce Group Benefits homepage, www.piercegroupbenefits.com to access this information.
Transferring from one Employer to Another? If you are transferring from a current PGB client to another, some benefits may be eligible for transfer. Please call 888-662-7500 and a Service Specialist will be glad to help you.
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CONTACT INFORMATION: NORTH CAROLINA STATE HEALTH PLAN
AMERIFLEX - FLEXIBLE SPENDING ACCOUNTS
• Customer Service: 1-888-234-2416 • Website: http://shpnc.org
• Customer Service: 1-888-868-3539 • Website: www.myameriflex.com • Claims Mailing Address: P.O. Box 269009, Plano, TX 75026
CITIZENS SECURITY - DENTAL INSURANCE • Customer Service: 1-800-843-7752 • Website: www.citizensgroup.com
MANAGE YOUR ACCOUNT ONLINE OR DOWNLOAD THE MYAMERIFLEX MOBILE APP • • • •
Check your Balance Submit a Claim Check Claim Status Mark Your Card Lost or Stolen
EYEMED - VISION INSURANCE HARMONY ONLINE ENROLLMENT
• Customer Service: 1-866-804-0982 • Website: www.eyemed.com
• See pages 5-6 for online enrollment instructions • Technical Help Desk: 1-866-875-4772
USABLE - TERM LIFE INSURANCE TO VIEW YOUR BENEFITS ONLINE
• Customer Service: 1-800-370-5856 • Website: www.usablelife.com
Visit www.piercegroupbenefits.com/
cityofdunn
CALL A DOCTOR PLUS - TELEMEDICINE See the inside of your benefit booklet for information on how to set up your account and contact Call A Doctor Plus!
For additional information concerning plans offered to employees of the City of Dunn, please contact our North Carolina Service Center at 1-888-662-7500, ext. 100
COLONIAL LIFE VISIT COLONIALLIFE.COM TO SET UP YOUR PERSONAL ACCOUNT • Website: www.coloniallife.com • Claims Fax: 1-800-880-9325
• Customer Service & Wellness Screenings: 1-800-325-4368 • TDD for hearing impaired customers call: 1-800-798-4040
If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 18 months, you need the name and date of the test performed as well as your doctor’s name and phone number. Colonial also needs to know if this is for you or another covered individual and their name and social security number. You may: • FILE BY PHONE! Call 1-800-325-4368 and provide the information requested by Colonial’s Automated Voice Response System, 24 hours per day, 7 days a week, or • SUBMIT ON THE INTERNET using the Wellness Claim Form at www.coloniallife.com, or • Write your name, address, social security number and/or policy/certificate number on your bill and indicate “Wellness Test.” Fax this to Colonial at 1-800-880-9325 or MAIL to PO Box 100195, Columbia, SC 29202 If your Wellness/Cancer Screening test was more than 18 months ago, you must fax or mail Colonial a copy of the bill or statement from your doctor indicating the type of procedure performed, the charge incurred and the date of service. Please write your full name, social security number, and current address on the bill. Please Note: If your cancer policy includes a second part to the screening benefit, bills for tests covered and a copy of the diagnostic report (reflecting the abnormal reading of your first test) must be mailed or faxed to us for benefits to be provided.
When you terminate employment, you have the opportunity to continue your Colonial coverage either through direct billing or automatic payment through your bank account. Please contact Colonial at 1-800-325-4368 to request the continuation of benefits form.