EMPLOYEE BENEFITS GUIDE 2025 PLAN YEAR:
JULY 1, 2025 - JUNE 30, 2026
KING AND QUEEN COUNTY PUBLIC SCHOOLS
WWW.PIERCEGROUPBENEFITS.COM
EMPLOYEE SERVICES: 800-387-5955
TABLE OF CONTENTS
EMPLOYEE BENEFITS GUIDE TABLE OF CONTENTS Welcome to King and Queen County Public Schools’ comprehensive benefits program. This guide highlights the benefits offered to all eligible employees for the plan year listed below. Benefits described in this guide are voluntary, employee-paid benefits unless otherwise noted.
ENROLLMENT DATES: May 1, 2025 - May 13, 2025 PLAN YEAR & EFFECTIVE DATES: July 1, 2025 - June 30, 2026
Click on the video below to help you prepare for annual enrollment and learn about the benefits available to you!
Important Contact Information............................... 3 Eligibility Requirements......................................... 4 Overview Of Benefits............................................. 5 Important Notices................................................. 6 Mid-Year Events..................................................... 7 Enrollment Information.......................................... 9 BenSelect Enrollment Instructions......................... 10 Health Insurance................................................... 12 Contribution Schedule For TLC Coverage................ 15 Dental Insurance................................................... 19 Vision Insurance.................................................... 21 Health Savings Account......................................... 26 The HSA Store....................................................... 28 Flexible Spending Account..................................... 29 The FSA Store....................................................... 33 Dependent Care Account....................................... 34 Cancer Benefits..................................................... 37 Critical Illness Benefits.......................................... 48 Disability Benefits................................................. 59 Accident Benefits.................................................. 71 Medical Bridge Benefits......................................... 77 Term Life Insurance............................................... 85 Whole Life Insurance............................................. 89 Legal Benefits....................................................... 93 Colonial Life Policyholder Service Guide................. 96 Authorization For Colonial Life Insurance Form....... 97 Required Health Care Notices................................ 98 COBRA Continuation Of Coverage.......................... 103 Privacy Notices..................................................... 105 Continuation Of Coverage...................................... 106
IMPORTANT NOTE & DISCLAIMER This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail.
KING AND QUEEN COUNTY PUBLIC SCHOOLS 2025 Benefits Plan July 1, 2025 - June 30, 2026
All information in this guide, including premiums quoted, is subject to change. All policy descriptions are for informational purposes only. Your actual policies may be different than those in this guide. Rev: 4/17/2025
IMPORTANT CONTACT INFORMATION Carrier
Phone/Fax
Website
The Local Choice (Health, Dental, Vision)
The Local Choice Anthem
P: 800-552-2682
-
www.thelocalchoice.virginia.gov
Flexible Spending Accounts
Ameriflex
P: 888-868-3539
service@myameriflex.com
www.myameriflex.com
Health Savings Account
HealthEquity
P: 866-346-5800 F: 801-999-7829
-
www.myhealthequity.com
Legal Benefits
Legal Resources
P: 800-728-5768 F: 757-498-4114
info@legalresources.com
www.legalresources.com
Student Loan Assistance Program
GradFin
P: 844-472-3346
-
www.gradfin.com
BenSelect Online Enrollment
BenSelect
P: 888-662-7500
-
harmony.benselect.com/kqcps
To View Your Benefits Online
Pierce Group Benefits
P: 1-800-387-5955 F: 984-225-2605
service@ piercegroupbenefits.com
www.PierceGroupBenefits.com/ KingandQueenCountyPublicSchools
-
www.coloniallife.com
Customer Service & Wellness Screenings
Supplemental Benefits
Colonial Life
1-800-325-4368 F:1-800-880-9325 TDD For Hearing Impaired Customers
1-800-798-4040
Under certain qualifying events, employees and dependents may have the opportunity to continue coverage for 18-36 months under the COBRA Act. 3
ELIGIBILITY REQUIREMENTS CURRENT EMPLOYEE? ANNUAL ENROLLMENT DATES: May 1, 2025 - May 13, 2025
PLAN YEAR & EFFECTIVE DATES: July 1, 2025 - June 30, 2026
ELIGIBILITY • Contract employees working 30 hours or more per week are eligible for benefits.
NEW HIRE? Congratulations on your new employment! Your employment means more than just a paycheck. Your employer also provides eligible employees with a valuable benefits package. Above you will find eligibility requirements and below you will find information about how to enroll in these benefits as a new employee. The Local Choice Benefits, Health Savings Accounts and Flexible Spending Accounts - Please reach out to your Benefits Department within 30 days of your date of hire. Colonial Life Insurance Products - Please call PGB’s Employee Services within 30 days of your date of hire and a PGB Benefits Representative will help you enroll in benefits. The Employee Services number is located in the contact section of this guide. You also have the option to self-enroll, if you choose, within 30 days of your date of hire. Please see the self-enrollment instructions in this guide for more information. Be sure to also review your group’s custom benefits website, that allows for easy, year-round access to benefit information, live chat support, benefit explainer videos, plan certificates and documents, and carrier contacts and forms.
www.PierceGroupBenefits.com/KingandQueenCountyPublicSchools 4
OVERVIEW OF BENEFITS PRE – TAX BENEFITS Health Insurance The Local Choice - Anthem
POST – TAX BENEFITS Disability Benefits Colonial Life
- Anthem Health - Delta Dental of VA - Anthem Blue View Vision
Health Savings Account HealthEquity - Individual Maximum: $4,300/year Max -Family Maximum: $8,550/year Max HSA plans can only be established in conjunction with a qualified High-Deductible Health Plan (HDHP)
Critical Illness Benefits Colonial Life
Life Insurance Colonial Life - Term Life Insurance - Whole Life Insurance
Flexible Spending Accounts Ameriflex - Medical Reimbursement: $3,300/year Max - Dependent Care Reimbursement: $5,000/year Max - Limited Medical Reimbursement: $3,300/year Max
*You will need to re-enroll in the Flexible Spending Accounts if you want them to continue next year. If you do not re-enroll, your contribution will stop effective June 30, 2025.
Cancer Benefits Colonial Life
ADDITIONAL BENEFITS Student Loan Assistance Program GradFin
Legal Benefits Legal Resources
Accident Benefits Colonial Life
Medical Bridge Benefits Colonial Life
Please note your insurance products will remain in effect unless you speak with a representative to change them. 5
IMPORTANT NOTICES When do my benefits start? The plan year for The Local Choice Benefits (Anthem Health, Delta Dental and Anthem Blue View Vision), Colonial Life Insurance Products, HealthEquity Savings Accounts and Ameriflex Spending Accounts runs from July 1, 2025, through June 30, 2026. When do my deductions start? Deductions for The Local Choice Benefits (Anthem Health, Delta Dental and Anthem Blue View Vision) and Colonial Life Insurance Products start June 2025 for all eligible employees. Deductions for HealthEquity Savings Accounts and Ameriflex Spending Accounts start July 2025 for all eligible employees. The Legal Resources Legal Select Plan is available by Direct Billing only. No deductions will be taken via payroll deduction. Why have my Accident or Medical Bridge benefits not started yet? The Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan has a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until July 31, 2025. How do Flexible Spending Account (FSA) funds work, and do my FSA funds have to be used by a specific deadline? Flexible Spending Account expenses must be incurred during the plan year to be eligible for reimbursement. After the plan year ends, an employee has 3 months to submit claims for incurred qualified spending account expenses (or 3 months after employment termination date). If employment is terminated before the plan year ends, the spending account also ends. Failure to use all allotted funds in the FSA account will result in a “Use It or Lose It” scenario. Your plan also includes a rollover provision! This means that if you have money left in your FSA at the end of the plan year, you can carryover up to $500 into the next plan year. Any remaining funds beyond $500 is forfeited under the “Use It or Lose It” rule. My spouse is enrolled in an Health Savings Account (HSA), am I eligible for an FSA? As a married couple, one spouse cannot be enrolled in a Medical Reimbursement FSA at the same time the other opens or contributes to an HSA. How do Dependent Care Account (DCA) funds work and when do they need to be used? Dependent Care Accounts are like FSA accounts and allow you to request reimbursement up to your current balance. However, you cannot receive more reimbursement than what has been deducted from your pay. Any remaining funds in your DCA account must be utilized before the deadline. Failure to use all allotted funds in the DCA account will result in a “Use It or Lose It” scenario. Your plan includes a grace period which is an additional 2.5 months (running July 1, 2026, through September 15, 2026), during which you can incur eligible expenses that can be reimbursed. Therefore, you have from July 1, 2025, through September 15, 2026, to incur qualified expenses eligible for reimbursement. If you do not incur qualified expenses by September 15, 2026, and/or file by September 30, 2026, any contributions are forfeited under the “Use It or Lose It” rule. When will I get my card? If you will be receiving a new debit card, whether you are a new participant or to replace your expired card, please be aware that it may take up to 30 days following your plan effective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses. Please note that your debit card is good through the expiration date printed on the card. I want to sign my family up for benefits as well, what information will I need? If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking with the Benefits Representative. What does Pre-Tax vs. Post-Tax Change? Pre-Tax benefits take funds directly from your paycheck to cover benefits before going through State and Federal taxing process. Post-Tax collects funds for benefits after taxes have been taken out. Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution. Can I change my benefit elections outside of the enrollment period? Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change, otherwise known as a qualifying life event (Mid-Year Events), as defined by the Internal Revenue Code. Examples of Mid-Year Events can be found in the chart on the next page. Once a Mid-Year Event has occurred, an employee has 30 days to notify PGB’s VA Employee Services at 1-800-387-5955 to request a change in elections. I have a pre-existing condition. Will I still be covered? Some policies may include a pre-existing condition clause. Please read your policy carefully for full details. 6
MID-YEAR EVENTS The benefit elections you make during Annual Enrollment or as a New Hire will remain in effect for the entire plan year. You will not be able to change or revoke your elections once they have been made unless a Mid-Year Event (status change) occurs. The summary of events that allow an employee to make benefit changes and instructions for processing those life event changes can be reviewed in the chart below.
Mid-Year Event
Action Required
Result If Action Is Not Taken
New Hire
Make elections within 30 days of hire date. Documentation is required.
You and your dependents are not eligible until the next Annual Enrollment period.
Marriage
Add your new spouse to your elections within 30 days of the marriage date. A copy of the marriage certificate must be presented.
Your spouse is not eligible until the next Annual Enrollment period.
Divorce
Remove the former spouse within 30 days of the divorce. Proof of the divorce will be required. A copy of the divorce decree must be presented.
Benefits are not available for the divorced spouse and will be recouped if paid erroneously.
Enroll the new dependent in your elections within 30 days of the birth or adoption date, even if you already have family coverage. A copy of the birth certificate, mother’s copy of birth certificate, or hospital discharge papers must be presented. Once you receive the child’s Social Security Number, don’t forget to update your child’s insurance information record.
The new dependent will not be covered until the next Annual Enrollment period.
Remove or update dependent elections within 30 days of the dependent aging out. For more information and assistance, please call PGB Employee Services at 800-387-5955.
Coverage for the dependent will end at the time of the dependent aging out and the policyholder must remove/update the dependent elections in order for the change to be reflected in the employee’s deductions.
Death of a Spouse or Dependent
Remove the dependent from your elections within 30 days from the date of death. Death certificate must be presented.
You could pay a higher premium than required and you may be overpaying for coverage required.
Change in Spouse’s Employment or Coverage
Add or drop benefits from your elections within 30 days of the event date. A letter from the employer or insurance company must be presented.
You will not be able to make changes until the next Annual Enrollment period.
Birth or Adoption of a Child
Dependent Aging Out
The examples included in this chart are not all-inclusive. Please speak to a Benefits Representative to learn more. 7
MID-YEAR EVENTS Mid-Year Event
Action Required
Result If Action Is Not Taken
Part-Time to Full-Time or Vice Versa
Change your elections within 30 days from the employment status change to receive COBRA information or to enroll in benefits as a full-time employee. Documentation from the employer must be provided.
Benefits may not be available to you or your dependents if you wait to enroll in COBRA. Full-time employees will have to wait until the next Annual Enrollment period.
Transferring Employers
If you are transferring from one PGB client to another, some benefits may be eligible for transfer. Please call PGB Employee Services at 800-387-5955 for more information and assistance.
You may lose the opportunity to transfer benefits.
Loss of Government or Education Sponsored Health Coverage
If you, your spouse, or a dependent loses coverage under any group health coverage sponsored by a governmental or educational institution, you may be eligible to add additional coverage for eligible benefits.
You and your dependents are not eligible until the next Annual Enrollment period.
Entitlement to Medicare or Medicaid
If you, your spouse, or dependent becomes entitled to or loses coverage under Medicare or Medicaid, you may be able to change coverage under the accident or health plan.
You and your dependents are not eligible until the next Annual Enrollment period.
Non-FMLA Leave
An employee taking a leave of absence, other than under the Family & Medical Leave Act, may not be eligible to re-enter the Flexible Benefits program until next plan year. Please contact your Benefit Administrator for more information.
You and your dependents are not eligible until the next Annual Enrollment period.
Retiring
Your individual supplemental/voluntary policies through Colonial Life are portable! To move them from payroll deduction to direct billing, please complete and submit the Payment Method Change Form to Colonial Life within 30 days of retiring. You are also eligible for post-employment Dental, Vision, and Telemedicine benefits through PGB. Please visit: www.piercegroupbenefits.com/ individualcoverage or call our Employee Services at 800-387-5955 for more information and assistance.
If you do not transfer your policies from payroll deduction to direct billing, Colonial Life will terminate your policies resulting in a loss of coverage.
The examples included in this chart are not all-inclusive. Please speak to a Benefits Representative to learn more. 8
ENROLLMENT INFORMATION IN-PERSON & SELF-ENROLL During your annual enrollment period, a PGB Benefits Representative will be available by appointment to meet with you one-on-one to help you evaluate your benefits based on your individual and family needs, answer any questions you may have, and assist you in the enrollment process. If you prefer, you may also self-enroll online following the instructions on the next page of this guide.
ANNUAL ENROLLMENT PERIOD:
MAY 1, 2025 - MAY 13, 2025 BENEFIT ELECTION OPTIONS YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS DURING THE ANNUAL ENROLLMENT PERIOD: • • • • •
Enroll in, change, or cancel The Local Choice benefits (Anthem Health, Dental Dental of VA, and Anthem Blue View Vision).** Enroll in, change, or cancel Health Savings Accounts. Enroll/Re-Enroll in Flexible Spending Accounts.+ Enroll in, change, or cancel Legal Benefits (DIRECT BILLING ONLY*). Enroll in, change, or cancel Colonial coverage.
+You will need to re-enroll in the Flexible Spending Accounts if you want them to continue each year. *The Legal plan is available by Direct Billing only. No deductions will be taken via payroll deduction. **The Local Choice Benefits are included in this booklet for informational purposes only. You will need to meet with a Benefits Representative in order to sign up for these benefits.
ACCESS YOUR BENEFIT OPTIONS WHENEVER, WHEREVER You can view details about what benefits your employer offers, view educational videos about all of your benefits, download forms, chat with one of our knowledgeable Benefits Representatives, and more on your personalized benefits website. To view your custom benefits website, visit: www.PierceGroupBenefits.com/KingandQueenCountyPublicSchools 9
BENSELECT ENROLLMENT INSTRUCTIONS
• • • •
Below is a series of instructions outlining the enrollment process. Please have the following information available before you begin: Username, pin, and enrollment website URL from this page Social security numbers of the spouse or any dependents you wish to enroll Dates of birth for the spouse and any dependents you wish to enroll Beneficiary names and social security numbers
HELPFUL TIPS : • If you are a new employee, please refer to the New Hire information on the Eligibility Requirements page of this guide or contact PGB Employee Services at 800-3875955 between 8:30am and 5:00pm for assistance. • If you are an existing employee and unable to log into the online system, please contact PGB Employee Services at 800-387-5955, or speak with the Benefits Representative assigned to your location.
1. LOGGING IN Enter your Username: Social Security Number with or without dashes (ex. 123-45-6789 or 123456789) Enter your Pin: Last 4 numbers of your Social Security Number followed by last 2 numbers of your Date of Birth year (ex. 678970)
To login, visit: harmony.benselect.com/kqcps
1. 2. NEW PIN The screen prompts you to create a NEW PIN.
3. SECURITY QUESTIONS Choose a security question and enter answer.
4. CONFIRM Confirm (or enter) an email address.
NEXT
5. SAVE NEW PIN Click on ‘Save New PIN’ to continue to the enrollment welcome screen.
6. CLICK NEXT
7. PERSONAL INFORMATION
From the welcome screen click ‘Next’.
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The screen shows ‘Personal Information’. Verify that the information is correct and enter the additional required information (marital status, work phone, e-mail address). Click ‘Next’. Enrollment instructions continued on next page >>>
BENSELECT ENROLLMENT INSTRUCTIONS
8. ADDING FAMILY MEMBER
9. BENEFIT SUMMARY
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 ‘Next’.
The screen shows ‘Benefit Summary’. Review your current benefits and make changes, and selections for the upcoming plan year.
11. REVIEW
10. SIGN & SUBMIT Click ‘Sign & Submit’ once you have decided which benefits to enroll in.
Review your coverage. If any items are ‘Pending’, you will need to decide whether to enroll or decline this benefit.
NEXT
13. SIGN FORM
12. NEXT Click ‘Next’ to review and electronically sign the authorization for your benefit elections.
Review the confirmation, then if you are satisfied with your elections, enter your PIN and click ‘Sign Form’.
14. DOWNLOAD & PRINT Click ‘Download & Print’ to print a copy of your elections, or download and save the document. Please do not forget this important step! Click ‘Log Out’. 11
Click on the video below to learn more about Health Insurance!
HEALTH INSURANCE
King and Queen County Schools 2025-2026 High Deductible Health Plan Plan Year Deductible (applies as indicated) One Person Family (two or more people)
In-Network
Plan Year Out-of-Pocket Expense Limit Individual Out-of-Pocket Maximum Family Out-of-Pocket Maximum
In-Network
$5,000 $10,000
Out-of-Network
Key Advantage 1000 In-Network
Out-of-Network
$1,000 $2,000
$2,000 $4,000
Out-of-Network
In-Network
Out-of-Network
$10,000 $20,000
$5,000 $10,000
$9,000 $18,000
$3,300 $6,600
Unlimited For All Plans In-Network Benefits Only
Lifetime Maximum Covered Services Doctor's Visits (Outpatient or In-Office) Primary Care Physician Visits Chiropractic, Spinal Manipulations (30 visit limit)
20% Coinsurance, after deductible
$25 Copayment
Specialist Visits Chiropractic, Spinal Manipulations (30 visit limit)
20% Coinsurance, after deductible
$40 Copayment
Shots - Allergy or Therapeutic Injections Doctor's Office, ER, or Outpatient Setting Diagnostic Tests, Labs, and X-Rays Specific conditions/diseases at doctor's office, ER, or Outpatient Setting
20% Coinsurance, after deductible
20% Coinsurance, after deductible
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Preventive Care Visits
Covered at 100%
Covered at 100%
Emergency Room Visits
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Ambulance Services
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Inpatient Hospital Services
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Outpatient Hospital Services
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Outpatient Diagnostic Test, Labs, and X-Rays
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Outpatient Therapy Services - Occupational, Speech, Physical, Cardiac, Chemotherapy, Radiation, Infusion, & Respiratory
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Diabetic Equipment
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Hospital & Other Services (Pre-certification may be required)
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King and Queen County Schools 2025-2026 High Deductible Health Plan
Key Advantage 1000
Prenatal & Provider Services- PCP
20% Coinsurance, after deductible
$25 Copayment
Prenatal & Provider Services - Specialist
20% Coinsurance, after deductible
$40 Copayment
Hospital Services for Delivery
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Diagnostic Tests, Labs, and X-Rays
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Inpatient Treatment/Residential Treatment
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Partial Hospitalization (Day) Program
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Outpatient Professional Provider Services
20% Coinsurance, after deductible
$25 Copayment
Tier 1
20% Coinsurance, after deductible
$10 Copayment
Tier 2
20% Coinsurance, after deductible
$30 Copayment
Tier 3
20% Coinsurance, after deductible
$45 Copayment
Tier 4
20% Coinsurance, after deductible
$55 Copayment
Home Delivery Services-Mail Order (90-day supply)
20% Coinsurance, after deductible
2x Retail Copay
Diabetic Supplies
20% Coinsurance, after deductible
20% Coinsurance, no deductible
Maternity
Behavioral Health
Prescription Drug Benefit* Retail Pharmacy (up to a 34-day supply)
*You have a mandatory generic drug program. However, if there is no generic equivalent for the drug, you may get the brand and pay only the applicable benefit level. If there is a generic equivalent available, you may opt to use the brand but you'll pay the applicable brand level plus the difference between the brand and generic allowable charge. ** This plan will waive the hospital Copayment if the member enrolls in the maternity management pre-natal program within the first trimester of pregnancy, has a dental cleaning during pregnancy and satisfactorily completes the program.
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King and Queen County Schools July 1, 2025 - June 30, 2026 Contribution Schedule
The Local Choice Package includes health, dental, and vision coverage High Deductible Health Plan (HDHP) Employee Only
Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution
Employee + Child
Employee + Children
Employee + Spouse
Prev. Dental
Comp. Dental
Prev. Dental
Comp. Dental
Prev. Dental
Comp. Dental
Prev. Dental
Comp. Dental
$865.00
$1,563.00
$1,601.00
$2,281.00
$2,336.00
$1,563.00
$1,601.00
$2,281.00
$2,336.00
$771.08
$775.08
$1,357.80
$1,366.80
$1,840.31
$1,852.31
$1,074.00
$1,083.00
$1,499.39
$1,511.39
$73.92
$89.92
$205.20
$234.20
$440.69
$483.69
$489.00
$518.00
$781.61
$824.61
Prev. Dental
Comp. Dental
$845.00
Employee + Family
Key Advantage 1000 Employee Only
Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution
Employee + Child
Employee + Children
Employee + Spouse
Employee + Family
Prev. Dental
Comp. Dental
Prev. Dental
Comp. Dental
Prev. Dental
Comp. Dental
Prev. Dental
Comp. Dental
Prev. Dental
Comp. Dental
$904.00
$925.00
$1,673.00
$1,712.00
$2,443.00
$2,497.00
$1,673.00
$1,712.00
$2,443.00
$2,497.00
$785.00
$790.00
$1,386.54
$1,395.54
$1,891.51
$1,901.51
$1,078.80
$1,093.00
$1,482.34
$1,492.34
$119.00
$135.00
$286.46
$316.46
$551.49
$595.49
$594.20
$619.00
$960.66
$1,004.66
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Anthem Health & Wellness Programs Anthem can help you make the most of your benefts so you can be your healthiest. Take advantage of these wellness programs and services included in your health plan.
Sydney Health mobile app The SydneySM Health mobile app gives you a quick connection to beneft information, tools, and helpful resources. Download the app today and log in using your anthem.com username and password to: • View your ID card. • See all your medical and pharmacy benefts and
claims.
Simplify your healthcare by downloading Sydney Health today
• Easily chat with customer service. • Connect quickly to virtual care and wellness
resources. • Track your health goals and ftness.
Anthem Health Guide Anthem Health Guides are specially trained to answer your health plan questions and steer you to the right programs and support for your unique needs. Your guide will also remind you of any screenings or routine exams that are due, help you save money on your prescription drugs, compare costs for care, and fnd in-network doctors in your area. Call 800-552-2682, Monday to Friday 8:00 a.m. to 6:00 p.m.
Employee Assistance Program (EAP) Life can be challenging, and Anthem EAP is here to help. Your EAP includes up to 4 free, confdential counseling sessions per issue per plan year for you, your covered dependents, and members of your household. It’s also a valuable source for information about emotional well-being, childcare and elder care resources, fnancial and legal issues, and smoking cessation. Go to anthemeap.com, and log in using Commonwealth of Virginia as your company, and then select The Local Choice, or call 855-223-9277. 16
LiveHealth Online Using the Sydney Health app, you can have a private, secure, video visit wherever you are with a doctor. Urgent care virtual visits are available on demand 24/7. Virtual appointments can also be scheduled to meet with a therapist, psychologist, psychiatrist, or a sleep specialist, Monday to Friday 9 a.m. to 9 p.m. Eastern time. No cost for Key Advantage Plans. Twenty percent coinsurance, after deductible for HDHP plans.
24/7 NurseLine 24/7 NurseLine has registered nurses ready and willing to help you at any time of the day. They are excellent resources for: • Minor health issues that can be handled at home. • Directing you to the correct doctor, health professional, or specialist. • Determining which facility type is the best choice for your issue.
Call 800-337-4770 anytime day or night. Your call is always free and completely confdential.
Future Moms Enroll in Future Moms by calling 800-828-5891 within the frst 16 weeks of pregnancy for free pre- and post-natal support that can help ensure a healthy pregnancy. Once your baby is born, use LiveHealth Online for virtual visits with a certifed lactation consultant, counselor, or registered dietitian at no extra cost through the Future Moms with Breastfeeding Support program. Key Advantage Expanded or Key Advantage 250 members: Enroll within the frst 16 weeks and your plan will waive the hospital copayment for delivery.
ConditionCare Extra support for members with: • Asthma • Diabetes • Coronary artery disease • Heart failure • Chronic obstructive pulmonary disease (COPD) • Hypertension ConditionCare provides Nurse Care Managers who work with you or a covered family member to help you better understand and manage a condition and meet personalized health goals. Call 844-507-8472 to enroll or we may call you to see if you would like to participate.
Sydney Health is offered through an arrangement with Carelon Digital Platforms, a separate company offering mobile application services on behalf of your health plan. ©2020-2022 Commonwealth of Virginia complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Independent licensee of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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A10625 (11/2022)
Life just got easier When life throws you curve balls, your Anthem Employee Assistance Program (EAP) is here to help you balance your life like a pro. We’re all ears. Sometimes meeting face to face with a professional is the best way to resolve a personal, financial or emotional issue. Your EAP covers up to 4 free counseling visits per issue per plan year. Just call 1-855-223-9277 to get started with complete confidentiality. Think of your EAP as an extra set of hands. Your EAP goes beyond free counseling. It’s a resource for so much more, including:
Visit AnthemEAP.com to learn about all the things your EAP can do for you. (login: Commonwealth of Virginia then select The Local Choice)
Anthem EAP is available to Anthem-covered employees, covered dependents, and any household members.
||Financial counseling and free online resources ||Legal services and free forms including wills, advance directives,
bills of sale, etc. ||Child and elder care referral resources ||Parenting guidance ||Career development ||Pet care resources ||Online seminars for many topics
1-855-223-9277 AnthemEAP.com Log in: Commonwealth of Virginia then select The Local Choice Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. ©2013 Anthem Blue Cross and Blue Shield. A10164 (8/2015)
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Click on the video below to learn more about Dental Insurance!
DENTAL INSURANCE
You Have Two Choices for Dental Benefits Comprehensive Dental Option Comprehensive Dental
You Pay
Dental Plan Year Deductible
$25/one person $50/two people $75/family
Plan Year Maximum (except Orthodontics)
OR Preventive Dental Option This covers only preventive services, and is available for a lower premium. Preventive Dental
Preventive Dental Care $0 (No dental (routine oral exam and deductible or plan cleaning twice per plan year, year maximum) x-rays, sealants and fluoride for children)
$1,500
Preventive Dental Care (routine oral exam and cleaning twice per plan year, x-rays, sealants and fluoride for children)
$0
Primary Dental Care (fillings, root canal, simple extractions, periodontic services, etc.)
20% coinsurance after dental deductible
Major Dental Care (crowns, inlays, onlays, dentures and fixed bridges)
50% coinsurance after dental deductible
Orthodontic Services (for children and adults)
50% coinsurance, no dental deductible, with $1,500 lifetime maximum
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. ©2013 Anthem Blue Cross and Blue Shield.
A10284 (7/2017)
You Pay
20
To change your current dental option, you must complete an enrollment form at open enrollment or with a qualifying event.
Click on the video below to learn more about Vision Insurance!
VISION INSURANCE
TLC HDHP Blue View VisionSM
Your Blue View Vision network Your routine vision benefit uses the Blue View Vision network – one of the largest vision care networks in the industry with a wide selection of ophthalmologists, optometrists and opticians. The network also includes convenient retail locations, many with evening and weekend hours, including 1-800 CONTACTS, LensCrafters®, Sears OpticalSM, Target Optical®, and JCPenney® Optical.
WELCOME TO BLUE VIEW VISION! Good news—your vision plan is flexible and easy to use. This benefit summary outlines the basic components of your plan, including quick answers about what’s covered, discounts, and much more!
Go to www.anthem.com/tlc to find a Blue View Vision provider near you. Out-of-network services You can choose to receive care outside of the Blue View Vision network. You simply get an allowance toward services and you pay the rest. Just pay in full at the time of service and then file a claim for reimbursement. In-network benefits and discounts will not apply.
YOUR BLUE VIEW VISION PLAN AT-A-GLANCE ROUTINE VISION CARE SERVICES Routine eye exam (once per plan year) Eyeglass frames you may select any eyeglass frame1 and receive the Once following allowance toward the purchase price:
IN-NETWORK
OUT-OF-NETWORK
$15 copayment
$50 allowance
$100 allowance then 20% off remaining balance
$80 allowance
Standard Eyeglass Lenses Polycarbonate lenses included for children under 19 years old. you may receive any one of the following lens options: Once Standard plastic single vision lenses (1 pair) Standard plastic bifocal lenses (1 pair) Standard plastic trifocal lenses (1 pair)
$20 copay; then covered in full $20 copay; then covered in full $20 copay; then covered in full
$50 allowance $75 allowance $100 allowance
Upgrade Eyeglass Lenses (available for additional cost) When receiving services from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lenses copayment applies, plus the cost of the upgrade.
Member cost for upgrades $15 $15 $15 $40 $65 $45 20% off retail price
Discounts on lens upgrades are not available out-of-network
Contact lenses Prefer contact lenses over glasses? You may choose to receive contact lenses instead of eyeglasses and receive an allowance toward the cost of a supply of contact lenses . once
Lens Options UV Coating Tint (Solid and Gradient) Standard Scratch-Resistance Standard Polycarbonate Standard Progressive (add-on to bifocal) Standard Anti-Reflective Coating Other Add-ons and Services
Elective Conventional Lenses2
$100 allowance then 15% off the remaining balance
$80 allowance
Elective Disposable Lenses2
$100 allowance (no additional discount)
$80 allowance
Non-Elective Contact Lenses2
$250 allowance
$210 allowance
1
Discount is not available on certain frame brands in which the manufacturer imposes a no discount policy.
2
Elective contact lenses are in lieu of eyeglass lenses. Non-elective lenses are medically necessary when glasses are not an option for vision correction, such as after cataract surgery.
22
ROUTINE VISION CARE SERVICES (continued)
Contact lens fitting and follow-up A contact lens fitting, and up to two follow-up visits are available to you once a comprehensive eye exam has been completed. Standard contact fitting* Premium contact lens fitting**
IN-NETWORK
OUT-OF NETWORK
You pay up to $55
Discounts not available out-of-network
10% off retail price
*A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement. **A premium contact lens fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal.
ADDITIONAL SAVINGS ON EYEWEAR & ACCESSORIES After you use your initial frame or contact lens benefit allowance, you can take advantage of discounts on additional prescription eyeglasses, contact lenses, and eyewear accessories courtesy of Blue View Vision network providers. MEMBER DISCOUNTS Additional Pairs of Complete Eyeglasses
40% discount off retail*
Conventional Contact Lenses
15% off retail price
As many pairs as you like Materials Only
Additional Eyewear & Accessories
Includes eyeglass frames and eyeglass lenses purchased separety, some nonprescription sunglasses, eye glass cases, lens cleaning supplies, contact lens solutions, etc.
20% off retail price
The Additional Savings Program is subject to change without notice.
LASIK VISION CORRECTION Glasses or contacts may not be the answer for everyone. That’s why we offer further savings with discounts on refractive surgery. Pay a discounted amount per eye for LASIK Vision correction. For more information, go to www.anthem.com/tlc and select Discounts under the Health and Wellness tab. NON-ROUTINE VISION SERVICES The Blue View Vision network is for routine eye care only. Non-routine vision care is covered under your medical benefits. Refer to your COVA Care member handbook for more information. OUT-OF-NETWORK If you choose an out-of-network provider, you must complete the Blue View out-ofnetwork claim form and submit it with your receipt. You will be reimbursed according to the out-of-network reimbursement schedule. Go to www.anthem.com/tlc and select Forms under the Resources & Tools tab. Your out-of-pocket expenses related to the vision benefits do not count toward your annual out of pocket limit and are never waived, even if your annual out-ofpocket limit is reached.
QUESTIONS? Contact Anthem member services at 1-800-552-2682.
This benefit overview insert is only one piece of your entire enrollment package. Exclusions and limitations are listed in the enrollment brochure. The in-network providers referred to in this communication are independently contracted providers who exercise independent professional judgment. They are not agents or employees of Anthem. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. An independent licensee of the Blue Cross and Blue Shield Association. *Registered marks Blue Cross and Blue Shield Association. Blue View Vision is a service mark of the Blue Cross and Blue Shield Association.
T206
/2015 Blue View Vision
23
Key Advantage 1000 Blue View VisionSM
Your Blue View Vision network Your routine vision benefit uses the Blue View Vision network – one of the largest vision care networks in the industry with a wide selection of ophthalmologists, optometrists and opticians. The network also includes convenient retail locations, many with evening and weekend hours, including 1-800 CONTACTS, LensCrafters®, Sears OpticalSM, Target Optical®, and JCPenney® Optical.
WELCOME TO BLUE VIEW VISION! Good news—your vision plan is flexible and easy to use. This benefit summary outlines the basic components of your plan, including quick answers about what’s covered, discounts, and much more!
Go to www.anthem.com/tlc to find a Blue View Vision provider near you. Out-of-network services You can choose to receive care outside of the Blue View Vision network. You simply get an allowance toward services and you pay the rest. Just pay in full at the time of service and then file a claim for reimbursement. In-network benefits and discounts will not apply.
YOUR BLUE VIEW VISION PLAN AT-A-GLANCE ROUTINE VISION CARE SERVICES Routine eye exam (once per plan year) Eyeglass frames you may select any eyeglass frame1 and receive the Once following allowance toward the purchase price:
IN-NETWORK
OUT-OF-NETWORK
$40 copayment
$50 allowance
$100 allowance then 20% off remaining balance
$80 allowance
Standard Eyeglass Lenses Polycarbonate lenses included for children under 19 years old. you may receive any one of the following lens options: Once Standard plastic single vision lenses (1 pair) Standard plastic bifocal lenses (1 pair) Standard plastic trifocal lenses (1 pair)
$20 copay; then covered in full $20 copay; then covered in full $20 copay; then covered in full
$50 allowance $75 allowance $100 allowance
Upgrade Eyeglass Lenses (available for additional cost) When receiving services from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lenses copayment applies, plus the cost of the upgrade.
Member cost for upgrades $15 $15 $15 $40 $65 $45 20% off retail price
Discounts on lens upgrades are not available out-of-network
Contact lenses Prefer contact lenses over glasses? You may choose to receive contact lenses instead of eyeglasses and receive an allowance toward the cost of a supply of contact lenses . once
Lens Options UV Coating Tint (Solid and Gradient) Standard Scratch-Resistance Standard Polycarbonate Standard Progressive (add-on to bifocal) Standard Anti-Reflective Coating Other Add-ons and Services
Elective Conventional Lenses2
$100 allowance then 15% off the remaining balance
$80 allowance
Elective Disposable Lenses2
$100 allowance (no additional discount)
$80 allowance
Non-Elective Contact Lenses2
$250 allowance
$210 allowance
1
Discount is not available on certain frame brands in which the manufacturer imposes a no discount policy.
2
Elective contact lenses are in lieu of eyeglass lenses. Non-elective lenses are medically necessary when glasses are not an option for vision correction, such as after cataract surgery.
24
ROUTINE VISION CARE SERVICES (continued)
Contact lens fitting and follow-up A contact lens fitting, and up to two follow-up visits are available to you once a comprehensive eye exam has been completed. Standard contact fitting* Premium contact lens fitting**
IN-NETWORK
OUT-OF NETWORK
You pay up to $55
Discounts not available out-of-network
10% off retail price
*A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement. **A premium contact lens fitting includes all lens designs, materials and specialty fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal.
ADDITIONAL SAVINGS ON EYEWEAR & ACCESSORIES After you use your initial frame or contact lens benefit allowance, you can take advantage of discounts on additional prescription eyeglasses, contact lenses, and eyewear accessories courtesy of Blue View Vision network providers. MEMBER DISCOUNTS Additional Pairs of Complete Eyeglasses
40% discount off retail*
Conventional Contact Lenses
15% off retail price
As many pairs as you like Materials Only
Additional Eyewear & Accessories
Includes eyeglass frames and eyeglass lenses purchased separety, some nonprescription sunglasses, eye glass cases, lens cleaning supplies, contact lens solutions, etc.
20% off retail price
The Additional Savings Program is subject to change without notice.
LASIK VISION CORRECTION Glasses or contacts may not be the answer for everyone. That’s why we offer further savings with discounts on refractive surgery. Pay a discounted amount per eye for LASIK Vision correction. For more information, go to www.anthem.com/tlc and select Discounts under the Health and Wellness tab. NON-ROUTINE VISION SERVICES The Blue View Vision network is for routine eye care only. Non-routine vision care is covered under your medical benefits. Refer to your COVA Care member handbook for more information. OUT-OF-NETWORK If you choose an out-of-network provider, you must complete the Blue View out-ofnetwork claim form and submit it with your receipt. You will be reimbursed according to the out-of-network reimbursement schedule. Go to www.anthem.com/tlc and select Forms under the Resources and Tools tab. Your out-of-pocket expenses related to the vision benefits do not count toward your annual out of pocket limit and are never waived, even if your annual out-ofpocket limit is reached.
QUESTIONS? Contact Anthem member services at 1-800-552-2682.
This benefit overview insert is only one piece of your entire enrollment package. Exclusions and limitations are listed in the enrollment brochure. The in-network providers referred to in this communication are independently contracted providers who exercise independent professional judgment. They are not agents or employees of Anthem. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. An independent licensee of the Blue Cross and Blue Shield Association. *Registered marks Blue Cross and Blue Shield Association. Blue View Vision is a service mark of the Blue Cross and Blue Shield Association.
T20690
/2015
Key Advantage 1000 Blue View Vision
25
Click on the video below to learn more about Health Savings Accounts!
HEALTH SAVINGS ACCOUNT
HSA
Health Savings Account An HSA lets you save money for future healthcare costs while also saving on taxes. How? HSAs are the only benefit with a triple-tax advantage:1 Tax-free contributions. Tax-free account growth. And tax-free spending on HSA-qualified expenses. It’s your healthcare emergency safety net. No use-it-or-lose-it rule, HSAs rollover every year Available tax-free investing, just like a 401(k)2 Requires an eligible high-deductible health plan (HDHP)
Don’t tax your money. Max your money.
Spend tax-free.
Get $20 tax savings for every $100 you contribute. 3
expenses. Here are just few:
HSA
There are thousands of HSA-qualified
• Medical
Tax-free
• Dental
Taxed
No HSA
• Vision • Pharmacy • Over-the-counter (OTC) medications
2025 HSA Contribution Limits
• Mental health services
$4,300
$8,550
Individual plan
Family plan
Members 55+ can contribute an extra $1,000.
See how much you can save. HealthEquity.com/Learn/HSA 1 HSAs are never taxed at a federal income tax level when used appropriately for qualified medical expenses. Also, most states recognize HSA funds as tax-deductible with very few exceptions. Please consult a tax advisor regarding your state’s specific rules. | 2Investments made available to HSA members are subject to risk, including the possible loss of the principal invested, and are not FDIC or NCUA insured, or guaranteed by HealthEquity, Inc. | 3Example for illustration only. Estimated savings are based on an assumed combined federal and state income tax bracket of 20%. Actual savings will depend on your taxable income and tax status. HealthEquity does not provide legal, tax or financial advice.
Copyright © 2024 HealthEquity, Inc. All rights reserved. OE HSA Standard Flyer 5.14.2024
27
• Lab fees
THE HSA STORE Save even more with your HSA through our partnership.
$20 OFF *Limit one per customer
Get $20 off any order of $150 with code PBG20HSA
Shop Now
Resources Available Through The HSA Store • The largest selection of guaranteed HSA-eligible products • Phone and live chat support available 24 hours a day / 7 days a week
Eligibility List
HSA Calculator
Search comprehensive list of eligible products and services.
Estimate how much you can save with an HSA.
Learning Center
Savings Center
Easy tips and resources for utilizing an HSA.
Your funds go further with the HSA Store rewards program.
• Fast and free shipping on orders over $50 • Use your HSA card or any other major credit card for purchases
Your Health, Your Funds, Your Choice Take control of your health and wellness with guaranteed HSA-eligible essentials. Pierce Group Benefits partners with the HSA store to provide one convenient location for Heath Savings Account holders. 28
Click or Scan to Shop Now
Click on the video below to learn more about Flexible Spending Accounts!
FLEXIBLE SPENDING ACCOUNT
Flexible Spending Account An account for setting aside tax-free money for healthcare expenses Use the below information to determine if a Flexible Spending Account (FSA) is right for you and how to best take advantage of an FSA account.
How It Works When you enroll in a Flexible Spending Account (FSA) you get to experience tax savings on qualified expenses such as copays, deductibles, prescriptions, over-the-counter drugs and medications, and thousands of other everyday items. Can I have an FSA and an HSA? You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses. As per IRS Publication 969, an employee covered by an HDHP and a health FSA or an HRA that pays or reimburses qualified medical expenses generally can’t make contributions to an HSA. An employee is also not HSA-eligible during an FSA Grace Period. An employee enrolled in a Limited Purpose FSA is HSA-eligible. As a married couple, one spouse cannot be enrolled in an FSA at the same time the other is contributing to an HSA. FSA coverage extends tax benefits to family members allowing the FSA holder to be reimbursed for medical expenses for themselves, their spouse, and their dependents.
The Value & Perks • Election Accessibility: You will have access to your entire election on the first day of the plan year. • Save On Eligible Expenses: You can save up to 40% on thousands of eligible everyday expenses such as prescriptions, doctor’s visits, dental services, glasses, over-the-counter medicines, and copays.
• Keep More Money: The funds are taken out of your paycheck "pre-tax" (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. Let’s say you earn $40,000 a year and contribute $1,500 to an FSA; so, only $38,500 of your income gets taxed. That means you are increasing your take-home pay simply by participating!
• Easy Spending and Account Management: You will receive an Ameriflex Debit Mastercard linked to your FSA. You can use your card for eligible purchases everywhere Mastercard is accepted. Account information can be securely accessed 24/7 online and through the mobile app.
Learn more at myameriflex.com | 844.423.4636 | info@myameriflex.com 30
Eligible FSA Expenses The IRS determines what expenses are eligible under an FSA. Below are some examples of common eligible expenses.
Copays, deductibles, and other payments you are responsible for under your health plan.
Routine exams, dental care, prescription drugs, eye care, hearing aids, etc.
Prescription glasses and sunglasses, contact lenses and solution, LASIK, and eye exams.
Certain OTC expenses such as Band-aids, medicine, First Aid supplies, etc. (prescription required).
Diabetic equipment and supplies, durable medical equipment, and qualified medical products or services.
For a full list of eligible expenses, go to myameriflex.com/eligibleexpenses.
The “Use-or-Lose” Rule If you contribute dollars to a reimbursement account and do not use all the money you deposit, you will lose any remaining balance in the account at the end of the eligible claims period. This rule, established by the IRS as a component of tax-advantaged plans, is referred to as the “use-or-lose” rule. To avoid losing any of the funds you contribute to your FSA, it’s important to plan ahead as much as possible to estimate what your expenditures will be in a given plan year. Modification to the Health FSA "Use-or-Lose" Rule:
• FSA plan participants should note that up to $500 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 $500 from the previous plan year, you may still elect up to the maximum contribution limit allowed under your employer’s plan.
Learn more at myameriflex.com | 844.423.4636 | info@myameriflex.com 31
Limited Purpose FSA Set aside tax-free money for dental and vision expenses Use the below information to determine if a Limited Purpose Flexible Spending Account (LPFSA) is right for you and how to best take advantage of an LPFSA account.
How It Works A Limited Purpose Flexible Spending Account (LPFSA) is a special type of FSA that allows you to set aside tax-free money to pay for eligible dental and vision expenses. What makes an LPFSA unique is that it can be used in conjunction with a Health Savings Account (HSA), allowing you to grow your HSA funds while using the LPFSA to pay for immediate dental and vision needs. Other than the restriction of eligible expenses to vision, dental, and orthodontia, the rules governing the LPFSA are the same as those that apply to an FSA.
The Value & Perks • Save On Eligible Expenses: You can save up to 40% on qualifying expenses such as vision
appointments, LASIK, contact lenses and solution, glasses, teeth cleaning, dentures, and dental and vision copays. You can contribute to an LPFSA and HSA in the same plan year, allowing you to save and grow your HSA balance, while using the LPFSA to pay for everyday expenses.
• Keep More Money: The funds are taken out of your paycheck "pre-tax" (meaning they are subtracted
from your gross earnings before taxes) throughout the course of the year. Let’s say you earn $40,000 a year and contribute $1,500 to an LPFSA; so, only $38,500 of your income gets taxed. That means you are increasing your take-home pay simply by participating!
• Easy Spending and Account Management: You will receive an Ameriflex Debit Mastercard linked to your LPFSA. You can use your card for eligible purchases everywhere Mastercard is accepted. Account information can be securely accessed 24/7 online and through the mobile app.
Eligible LPFSA Expenses You can use your LPFSA to pay for expenses related to dental and vision. Below are some examples of common eligible expenses:
Vision exams, co-payments, and deductibles
LASIK, eyeglasses, contact lenses, and lens solution
Dental cleanings, dentures, and orthodontia work
Dental x-ray, co-payments, and deductibles
For a full list of eligible expenses, go to myameriflex.com/eligibleexpenses.
Learn more at myameriflex.com | 844.423.4636 | info@myameriflex.com 32
THE FSA STORE Save even more with your FSA through our partnership.
$20 OFF *Limit one per customer
Get $20 off any order of $150 with code PBG20FSA
Shop Now
Resources Available Through The FSA Store • The largest selection of guaranteed FSA-eligible products • Phone and live chat support available 24 hours a day / 7 days a week
Eligibility List
FSA Calculator
Search comprehensive list of eligible products and services.
Estimate how much you can save with an FSA.
Learning Center
Savings Center
Easy tips and resources for utilizing an FSA.
Your funds go further with the FSA Store rewards program.
• Fast and free shipping on orders over $50 • Use your FSA card or any other major credit card for purchases
Your Health, Your Funds, Your Choice Take control of your health and wellness with guaranteed FSA-eligible essentials. Pierce Group Benefits partners with the FSA store to provide one convenient location for Flexible Spending Account holders. 33
Click or Scan to Shop Now
Click on the video below to learn more about Dependent Care Accounts!
DEPENDENT CARE ACCOUNT
Dependent Care Account Set aside tax-free money for daycare and dependent care services Use the below information to determine if a Dependent Care Account (DCA) is right for you and how to best take advantage of an DCA account.
How It Works When you enroll in a Dependent Care Account (DCA) you get to experience tax savings on expenses like daycare, elderly care, summer day camp, preschool, and other services that allow you to work full time.
The Value & Perks • Save On Eligible Expenses: You can use a DCA to pay for qualifying expenses such as daycare, summer day care, elder care, before and after school programs, and pre-school.
• Keep More Money: The funds are taken out of your paycheck "pre-tax" (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. Let’s say you earn $40,000 a year and contribute $1,500 to an DCA; so, only $38,500 of your income gets taxed. That means you are increasing your take-home pay simply by participating!
• Easy Spending and Account Management: You will receive an Ameriflex Debit Mastercard linked to your DCA. You can use your card for eligible purchases everywhere Mastercard is accepted. Account information can be securely accessed 24/7 online and through the mobile app.
Eligible DCA Expenses The IRS determines what expenses are eligible under a DCA. Below are some examples of common eligible expenses:
Private sitter
Daycare and elder care
Before- and after-school care
Summer day camp
Nanny service
Nursery school & Pre-school
For a full list of eligible expenses, go to myameriflex.com/eligibleexpenses.
Learn more at myameriflex.com | 844.423.4636 | info@myameriflex.com 35
www.myameriflex.com
Online Account Instructions How to Access Your Ameriflex Account: Go to MyAmeriflex.com and click “Login” from the upper right hand corner. When prompted, select “Participant.”
How to Register Online For Your Ameriflex Spending Account: Click the register button atop the right corner of the home screen. 1. As the primary account holder, enter your personal information. • Choose a unique User ID and create a password (if you are told that your username is invalid or already taken, you must select another). • Enter your first and last name. • Enter your email address. • Enter your Employee ID, which in most cases, will be the account holder’s Social Security Number(no dashes or spaces needed). 2. Check the box if you accept the terms of use. 3. Click 'register'. This process may take a few seconds. Do not click your browser’s back button or refresh the page. 4. Last, you must complete your Secure Authentication setup. Implemented to protect your privacy and help us prevent fraudulent activity, setup is quick and easy. After the registration form is successfully completed, you will be prompted to complete the secure authentication setup process: Step 1: Select a Security Question option, and type in a corresponding answer. Step 2: Repeat for the following three Security Questions, then click next. Step 3: Verify your email address, and then click next. Step 4: Verify and submit setup information, 5. The registration process is complete! Should you receive an information error message that does not easily guide you through the information correction process, please feel free to contact our dedicated Member Services Team at 888.868.FLEX (3539).
36
Want to Manage Your Account on the go? Download the MyAmeriflex mobile app, available through the App Store or Google Play. Your credentials for the MyAmeriflex Portal and the MyAmeriflex Mobile App are the same; there is no need for separate login information!
Click on the video below to learn more about Cancer Benefits!
CANCER BENEFITS
Cancer Insurance How would cancer impact your way of life? Hopefully, you and your family will never face cancer. If you do, a financial safety net can help you and your loved ones focus on what matters most — recovery. If you were diagnosed with cancer, you could have expenses that medical insurance doesn’t cover. In addition to your regular, ongoing bills, you could have indirect treatment and recovery costs, such as child care and home health care services.
Help when you need it most Cancer coverage from Colonial Life & Accident Insurance Company can help protect the lifestyle you’ve worked so hard to build. It provides benefits you can use to help cover: ■ Loss of income ■ Out-of-network treatment ■ Lodging and meals ■ Deductibles and co-pays
38
CANCER ASSIST
One family’s journey
DOCTOR’S SCREENING
Paul and Kim were preparing for their second child when they learned Paul had cancer. They quickly realized their medical insurance wouldn’t cover everything. Thankfully, Kim’s job enabled her to have a cancer insurance policy on Paul to help them with expenses.
SECOND OPINION
SURGERY
Wellness benefit
Travel expenses
Out-of-pocket costs
Paul’s wellness benefit helped pay for the screening that discovered his cancer.
When the couple traveled several hundred miles from their home to a top cancer hospital, they used the policy’s lodging and transportation benefits to help with expenses.
The policy’s benefits helped with deductibles and co-pays related to Paul’s surgery and hospital stay.
For illustrative purposes only
With cancer insurance: ■ Coverage options are available for you
and your eligible dependents. ■ Benefits are paid directly to you, unless
you specify otherwise. ■ You’re paid regardless of any insurance
you may have with other companies. ■ You can take coverage with you, even if you
change jobs or retire.
ONLY of ALL
CANCERS are
hereditary.
American Cancer Society, Cancer Facts & Figures, 2013
39
Cancer insurance provides benefits to help with cancer expenses — from diagnosis to recovery.
TREATMENT
RECOVERY
Experimental care
Follow-up evaluations
Paul used his plan’s benefits to help pay for experimental treatments not covered by his medical insurance.
Paul has been cancer-free for more than four years. His cancer policy provides a benefit for periodic scans to help ensure the cancer stays in check.
Our cancer insurance offers more than 30 benefits that can help you with costs that may not be covered by your medical insurance. Treatment benefits
(inpatient or outpatient)
Surgery benefits ■ Surgical procedures
■ Radiation/chemotherapy
■ Anesthesia
■ Anti-nausea medication
■ Reconstructive surgery
■ Medical imaging studies
■ Outpatient surgical center
■ Supportive or protective care drugs
■ Prosthetic device/artificial limb
and colony stimulating factors ■ Second medical opinion
Travel benefits
■ Blood/plasma/platelets/
■ Transportation
immunoglobulins ■ Bone marrow or peripheral stem
■ Companion transportation ■ Lodging
LIFETIME RISK OF DEVELOPING CANCER
MEN 1 in 2
cell donation ■ Bone marrow or peripheral stem
cell transplant ■ Egg(s) extraction or harvesting/
sperm collection and storage ■ Experimental treatment ■ Hair/external breast/voice
box prosthesis ■ Home health care services ■ Hospice (initial or daily care)
Inpatient benefits ■ Hospital confinement ■ Private full-time nursing services ■ Skilled nursing care facility ■ Ambulance ■ Air ambulance
Additional benefits WOMEN
■ Family care
1 in 3
■ Cancer vaccine ■ Bone marrow donor screening ■ Skin cancer initial diagnosis ■ Waiver of premium
40
American Cancer Society, Cancer Facts & Figures, 2013
Optional riders For an additional cost, you may have the option of purchasing additional riders for even more financial protection against cancer. Talk with your benefits counselor to find out which of these riders are available for you to purchase. ■ Diagnosis of cancer rider — Pays a one-time, lump-sum benefit for the
ColonialLife.com
initial diagnosis of cancer. You may choose a benefit amount in $1,000 increments between $1,000 and $10,000. If your dependent child is diagnosed with cancer, we will pay two and a half times ($2,500 - $25,000) the chosen benefit amount. ■ Diagnosis of cancer progressive payment rider — Provides a lump-sum
payment of $50 for each month the rider has been in force and before cancer is first diagnosed. ■ Specified disease hospital confinement rider — Pays $300 per day if
you or a covered family member is confined to a hospital for treatment for one of the 34 specified diseases covered under the rider.
If cancer impacts your life, you should be able to focus on getting better — not on how you’ll pay your bills. Talk with your Colonial Life benefits counselor about how cancer insurance can help provide financial security for you and your family.
PRE-EXISTING CONDITION LIMITATION We will not pay benefits for the diagnosis of internal cancer or skin cancer that is a pre-existing condition, nor will we pay benefits for the treatment of internal cancer or skin cancer that is a pre-existing condition unless the covered person has satisfied the six-month pre-existing condition limitation period shown on the Policy Schedule. Pre-existing condition means a condition for which a covered person was diagnosed prior to the effective date of this policy, and for which medical advice or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of this policy. EXCLUSIONS We will not pay benefits for cancer or skin cancer: ■ If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or ■ For other conditions or diseases, except losses due directly from cancer. The policy and its riders may have additional exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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1-16 | 101481-VA
Cancer Insurance Level 4 Benefits BENEFIT DESCRIPTION
Cancer insurance helps provide financial protection through a variety of benefits. These benefits are not only for you but also for your covered family members.
BENEFIT AMOUNT
Air ambulance . . . .............................................................................. $2,000 per trip
Transportation to or from a hospital or medical facility [max. of two trips per confinement]
Ambulance . . . . . . ............................................................................... $250 per trip Transportation to or from a hospital or medical facility [max. of two trips per confinement]
Anesthesia
Administered during a surgical procedure for cancer treatment ■ General anesthesia ......................................................................... 25% of surgical procedures benefit ■ Local anesthesia............................................................................ $50 per procedure
Anti-nausea medication ..................................................................... $60 per day administered or Doctor-prescribed medication for radiation or chemotherapy [$240 monthly max.]
per prescription filled
Blood/plasma/platelets/immunoglobulins .............................................. $250 per day A transfusion required during cancer treatment [$10,000 calendar year max.]
Bone marrow donor screening ............................................................. $50 Testing in connection with being a potential donor [once per lifetime]
Bone marrow or peripheral stem cell donation ......................................... $1,000 Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]
Bone marrow or peripheral stem cell transplant ....................................... $10,000 per transplant
Transplant you receive in connection with cancer treatment [max. of two bone marrow transplant benefits per lifetime]
Cancer vaccine. . . .............................................................................. $50 An FDA-approved vaccine for the prevention of cancer [once per lifetime]
Companion transportation ................................................................. $0.50 per mile
Companion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,500 per round trip]
Egg(s) extraction or harvesting/sperm collection and storage
Extracted/harvested or collected before chemotherapy or radiation [once per lifetime] ■ Egg(s) extraction or harvesting/sperm collection ......................................... $1,500 ■ Egg(s) or sperm storage (cryopreservation) ............................................... $500
Experimental treatment ..................................................................... $300 per day Hospital, medical or surgical care for cancer [$15,000 lifetime max.]
For more information, talk with your benefits counselor.
Family care . . . . . . ............................................................................... $60 per day Inpatient or outpatient treatment for a covered dependent child [$3,000 calendar year max.]
Hair/external breast/voice box prosthesis ............................................... $500 per calendar year Prosthesis needed as a direct result of cancer
Home health care services .................................................................. $175 per day Examples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 100 days per covered person per lifetime]
Hospice (initial or daily care)
An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both] ■ Initial hospice care [once per lifetime] ..................................................... $1,000 ■ Daily hospice care .......................................................................... $50 per day
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CANCER ASSIST – LEVEL 4
BENEFIT DESCRIPTION
BENEFIT AMOUNT
Hospital confinement
Hospital stay (including intensive care) required for cancer treatment ■ 30 days or less . . ........................................................................................ $350 per day ■ 31 days or more ........................................................................................ $700 per day
Lodging . . . . . . . . . . . . ......................................................................................... $80 per day Hotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]
Medical imaging studies ................................................................................. $225 per study
Specific studies for cancer treatment [$450 calendar year max.]
Outpatient surgical center .............................................................................. $400 per day Surgery at an outpatient center for cancer treatment [$1,200 calendar year max.]
Private full-time nursing services ...................................................................... $150 per day Services while hospital confined other than those regularly furnished by the hospital
Prosthetic device/artificial limb ........................................................................ $3,000 per device or limb A surgical implant needed because of cancer surgery [payable one per site, $6,000 lifetime max.]
Radiation/chemotherapy
[per day with a max. of one per calendar week] ■ Injected chemotherapy by medical personnel ........................................................ $1,000 ■ Radiation delivered by medical personnel ............................................................ $1,000 [per day with a max. of one per calendar month] ■ Self-injected . . . ......................................................................................... $400 ■ Pump . . . . . . . . . . ......................................................................................... $400 ■ Topical . . . . . . . . . . ........................................................................................ $400 ■ Oral hormonal [1-24 months] .......................................................................... $400 ■ Oral hormonal [25+ months] ........................................................................... $350 ■ Oral non-hormonal ..................................................................................... $400
Reconstructive surgery .................................................................................. $60 per surgical unit
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A surgery to reconstruct anatomic defects that result from cancer treatment [min. $350 per procedure, up to $3,000, including 25% for general anesthesia]
Second medical opinion ................................................................................. $300
A second physician’s opinion on cancer surgery or treatment [once per lifetime]
Skilled nursing care facility ............................................................................. $175 per day Confinement to a covered facility after hospital release [up to 100 days per covered person per lifetime]
Skin cancer diagnosis .................................................................................... $600 A skin cancer diagnosis while the policy is in force [once per lifetime]
Supportive or protective care drugs and colony stimulating factors ........................... $200 per day Doctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,600 calendar year max.]
Surgical procedures ...................................................................................... $70 per surgical unit Inpatient or outpatient surgery for cancer treatment [min. $350 per procedure, up to $6,000]
Transportation . . . . ........................................................................................ $0.50 per mile
Travel expenses when being treated for cancer more than 50 miles from home [up to $1,500 per round trip]
Waiver of premium ....................................................................................... Is available No premiums due if the named insured is disabled longer than 90 consecutive days
The policy has limitations and exclusions that may affect benefits payable. Most benefits require that a charge be incurred. Coverage may vary by state and may not be available in all states. For cost and complete details, see your benefits counselor. This chart highlights the benefits of policy forms CanAssist-NJ and CanAssist-VA. This chart is not complete without form 101505-NJ or 101481-VA.
©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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1-16 | 101485-NJ-VA
Cancer Insurance Wellness Benefits
To encourage early detection, our cancer insurance offers benefits for wellness and health screening tests.
Part one: Cancer wellness/health screening Provided when one of the tests listed below is performed while the policy is in force. Payable once per calendar year, per covered person.
Cancer wellness tests
Health screening tests
■ Bone marrow testing
■ Blood test for triglycerides
■ Breast ultrasound
■ Carotid Doppler
■ CA 15-3 (blood test for breast cancer)
■ Echocardiogram (ECHO)
■ CA 125 (blood test for ovarian cancer)
■ Electrocardiogram (EKG, ECG)
■ CEA (blood test for colon cancer)
■ Fasting blood glucose test
■ Chest X-ray
■ Serum cholesterol test for HDL
and LDL levels
■ Colonoscopy ■ Flexible sigmoidoscopy
■ Stress test on a bicycle or treadmill
■ Hemoccult stool analysis ■ Mammography ■ Pap smear ■ PSA (blood test for prostate cancer) ■ Serum protein electrophoresis
(blood test for myeloma)
■ Skin biopsy ■ Thermography ■ ThinPrep pap test ■ Virtual colonoscopy
For more information, talk with your benefits counselor.
Part two: Cancer wellness — additional invasive diagnostic test or surgical procedure Provided when a doctor performs a diagnostic test or surgical procedure 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.
ColonialLife.com 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). ©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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CANCER ASSIST WELLNESS | 8-15 | 101506-2
Individual Cancer Insurance Description of Benefits THE POLICY PROVIDES LIMITED BENEFITS. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Coverage is dependent on answers to health questions. Applicable to policy forms CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA. Cancer Insurance Benefits Level 1 Level 2 Level 3 Level 4 Air Ambulance, per trip $2,000 $2,000 $2,000 $2,000 Maximum trips per confinement 2 2 2 2 Ambulance, per trip $250 $250 $250 $250 Maximum trips per confinement 2 2 2 2 Anesthesia, General 25% of Surgical Procedures Benefit Anesthesia, Local, per procedure $25 $30 $40 $50 Anti-Nausea Medication, per day $25 $40 $50 $60 Maximum per month $100 $160 $200 $240 Blood/Plasma/Platelets/Immunoglobulins, per day $150 $150 $175 $250 Maximum per year $10,000 $10,000 $10,000 $10,000 Bone Marrow or Peripheral Stem Cell Donation, per lifetime $500 $500 $750 $1,000 Bone Marrow or Peripheral Stem Cell Transplant, per transplant $3,500 $4,000 $7,000 $10,000 Maximum transplants per lifetime 2 2 2 2 Companion Transportation, per mile $0.50 $0.50 $0.50 $0.50 Maximum per round trip $1,000 $1,000 $1,200 $1,500 Egg(s) Extraction or Harvesting or Sperm Collection, per lifetime $500 $700 $1,000 $1,500 Egg(s) or Sperm Storage, per lifetime $175 $200 $350 $500 Experimental Treatment, per day $200 $250 $300 $300 Maximum per lifetime $10,000 $12,500 $15,000 $15,000 Family Care, per day $30 $40 $50 $60 Maximum per year $1,500 $2,000 $2,500 $3,000 Hair/External Breast/Voice Box Prosthesis, per year $200 $200 $350 $500 Home Health Care Services, per day $50 $75 $125 $175 Benefit payable for at least and not more than 100 days per covered person per lifetime Hospice, Initial, per lifetime $1,000 $1,000 $1,000 $1,000 Hospice, Daily $50 $50 $50 $50 Maximum combined Initial and Daily per lifetime $15,000 $15,000 $15,000 $15,000 Hospital Confinement, 30 days or less, per day $100 $150 $250 $350 Hospital Confinement, 31 days or more, per day $200 $300 $500 $700 Benefit payable for up to 365 days per covered person per calendar year. Lodging, per day $50 $50 $75 $80 Maximum days per year 70 70 70 70 Medical Imaging Studies, per study $75 $125 $175 $225 Maximum per year $150 $250 $350 $450 Outpatient Surgical Center, per day $100 $200 $300 $400 Maximum per year $300 $600 $900 $1,200 Private Full-time Nursing Services, per day $50 $75 $125 $150 Prosthetic Device/Artificial Limb, per device or limb $1,000 $1,500 $2,000 $3,000 Maximum per lifetime $2,000 $3,000 $4,000 $6,000
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Cancer Insurance Benefits Level 1 Level 2 Level 3 Level 4 Radiation/Chemotherapy Benefit payable period can exceed but will not be less than 365 days per covered person per lifetime Injected chemotherapy by medical personnel, per day with a $250 $500 $750 $1,000 maximum of one per calendar week Radiation delivered by medical personnel, per day with a $250 $500 $750 $1,000 maximum of one per calendar week Self-Injected Chemotherapy, per day with a maximum of one per $150 $200 $300 $400 calendar month Pump Chemotherapy, per day with a maximum of one per $150 $200 $300 $400 calendar month Topical Chemotherapy, per day with a maximum of one per $150 $200 $300 $400 calendar month Oral Hormonal Chemotherapy (1-24 months), per day with a $150 $200 $300 $400 maximum of one per calendar month Oral Hormonal Chemotherapy (25+ months), per day with a $100 $150 $250 $350 maximum of one per calendar month Oral Non-Hormonal Chemotherapy, per day with a maximum of $150 $200 $300 $400 one per calendar month Reconstructive Surgery, per surgical unit $40 $40 $60 $60 Minimum per procedure $100 $150 $250 $350 Maximum per procedure, including 25% for general anesthesia $2,500 $2,500 $3,000 $3,000 Second Medical Opinion, per lifetime $150 $200 $300 $300 Skilled Nursing Care Facility, per day, up to days confined $50 $75 $125 $175 Benefit payable for at least and not more than 100 days per covered person per lifetime Skin Cancer Initial Diagnosis $300 $300 $400 $600 Supportive/Protective Care Drugs/Colony Stimulating Factors, per day $50 $100 $150 $200 Maximum per year $400 $800 $1,200 $1,600 Surgical Procedures $40 $50 $60 $70 Minimum per procedure $100 $150 $250 $350 Maximum per procedure $2,500 $3,000 $5,000 $6,000 Transportation $0.50 $0.50 $0.50 $0.50 Maximum per round trip $1,000 $1,000 $1,200 $1,500 Waiver of Premium Yes Yes Yes Yes Policy-Wellness Benefits Bone Marrow Donor Screening, per lifetime $50 $50 $50 $50 Cancer Vaccine, per lifetime $50 $50 $50 $50 One amount per account: $0, $25, $50, Part 1: Cancer Wellness/Health Screening, per year $75 or $100 Part 2: Cancer Wellness/Health Screening, per year Same as Part 1 Additional Riders may be available at an additional cost What is not covered by the policy Pre-Existing Condition Limitation We will not pay benefits for the diagnosis of internal cancer or skin cancer that is a pre-existing condition nor will we pay benefits for the treatment of internal cancer or skin cancer that is a pre-existing condition, unless the covered person has satisfied the six-month pre-existing condition limitation period. Pre-existing condition means a condition for which a covered person was diagnosed prior to the effective date of the policy and for which medical advice or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of the policy. We will not pay benefits for cancer or skin cancer: ■ If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or ■ For other conditions or diseases, except losses due directly from cancer. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. ADR1962-2018
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CANCER BENEFIT PREMIUMS LEVEL 1 - Composite Rates Employee
Employee/Spouse
One-Parent Family
Two-Parent Family
$18.25
$28.75
One-Parent Family
Two-Parent Family
$21.95
$34.15
One-Parent Family
Two-Parent Family
$27.10
$44.85
One-Parent Family
Two-Parent Family
$36.20
$60.00
One-Parent Family
Two-Parent Family
$1.75
$1.25
$1.75
$2.50
$1.60
$2.60
$7.80
$17.05
Level 1 with $100 Cancer Wellness/Health Screening 12-Pay Premium
$18.10
$28.60 LEVEL 2 - Composite Rates
Employee
Employee/Spouse
Level 2 with $100 Cancer Wellness/Health Screening 12-Pay Premium
$21.65
$33.85 LEVEL 3 - Composite Rates
Employee
Employee/Spouse
Level 3 with $100 Cancer Wellness/Health Screening 12-Pay Premium
$26.65
$44.40 LEVEL 4 - Composite Rates
Employee
Employee/Spouse
Level 4 with $100 Cancer Wellness/Health Screening 12-Pay Premium
$35.60
$59.40 OPTIONAL RIDERS
Employee
Employee/Spouse
Specified Disease Hospital Confinement Rider 12-Pay Premium
$1.25
Initial Diagnosis of Cancer Rider (per $1,000) 12-Pay Premium
$1.50
Initial Diagnosis of Cancer Progressive Payment Rider 12-Pay Premium
$7.80
$17.05
Sample rates only. Multiple choices and options available and rates may vary.
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Click on the video below to learn more about Critical Illness Benefits!
CRITICAL ILLNESS BENEFITS
Group Critical Illness Insurance Plan 1
When life takes an unexpected turn due to a critical illness diagnosis, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps provide financial support by providing a lump-sum benefit payable directly to you for your greatest needs.
An unexpected moment changes life forever
Coverage amount: ____________________________
Chris was mowing the lawn when he suffered a stroke. His recovery will be challenging and he's worried, since his family relies on his income.
Critical illness benefit
HOW CHRIS’S COVERAGE HELPED
The lump-sum payment from his critical illness insurance helped pay for: Co-payments and hospital bills not covered by his medical insurance Physical therapy to get back to doing what he loves Household expenses while he was unable to work
For illustrative purposes only.
COVERED CONDITION¹
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Benign brain tumor
100%
Coma
100%
End stage renal (kidney) failure
100%
Heart attack (myocardial infarction)
100%
Loss of hearing
100%
Loss of sight
100%
Loss of speech
100%
Major organ failure requiring transplant
100%
Occupational infectious HIV or occupational infectious hepatitis B, C, or D
100%
Permanent paralysis due to a covered accident
100%
Stroke
100%
Sudden cardiac arrest
100%
Coronary artery disease
25%
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GCI6000 – PLAN 1 – CRITICAL ILLNESS
KEY BENEFITS
Available coverage for spouse and eligible dependent children at 50% of your coverage amount Cover your eligible dependent children at no additional cost Receive coverage regardless of medical history, within specified limits Works alongside your health savings account (HSA) Benefits payable regardless of other insurance
For more information, talk with your benefits counselor.
Subsequent diagnosis of a different critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with a different critical illness, 100% of the coverage amount may be payable for that particular critical illness.
Subsequent diagnosis of the same critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with the same critical illness,3 25% of the coverage amount may be payable for that critical illness.
Additional covered conditions for dependent children PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
COVERED CONDITION¹
Cerebral palsy
100%
Cleft lip or palate
100%
Cystic fibrosis
100%
Down syndrome
100%
Spina bifida
100%
Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.
1. Refer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D. THIS INSURANCE PROVIDES LIMITED BENEFITS Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.
EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS
We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; 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 critical illness.
ColonialLife.com
PRE-EXISTING CONDITION LIMITATION
We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 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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5-20 | 385403
Group Critical Illness Insurance Plan 2
When life takes an unexpected turn, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps relieve financial worries by providing a lump-sum benefit payable directly to you to use as needed.
Preparing for a lifelong journey Rebecca was born with Down syndrome. Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs. HOW THEIR COVERAGE HELPED
The lump-sum amount from the family coverage benefit helped pay for:
A hospital stay and treatment for corrective heart surgery Physical therapy to build muscle strength
Special needs daycare
Coverage amount: ____________________________
Critical illness and cancer benefits COVERED CRITICAL ILLNESS CONDITION¹
Benign brain tumor
100%
Coma
100%
End stage renal (kidney) failure
100%
Heart attack (myocardial infarction)
100%
Loss of hearing
100%
Loss of sight
100%
Loss of speech
100%
Major organ failure requiring transplant
100%
Occupational infectious HIV or occupational infectious hepatitis B, C, or D
100%
Permanent paralysis due to a covered accident
100%
Stroke
100%
Sudden cardiac arrest
100%
Coronary artery disease
25%
COVERED CANCER CONDITION¹ For illustrative purposes only.
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Invasive cancer (including all breast cancer)
100%
Non-invasive cancer
25%
Skin cancer initial diagnosis ............................................................ $400 per lifetime 51
GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCER
KEY BENEFITS
Available coverage for spouse and eligible dependent children at 50% of your coverage amount Cover your eligible dependent children at no additional cost Receive coverage regardless of medical history, within specified limits Works alongside your health savings account (HSA) Benefits payable regardless of other insurance
Subsequent diagnosis of a different critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with a different critical illness, 100% of the coverage amount may be payable for that particular critical illness.
Subsequent diagnosis of the same critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with the same critical illness,3 25% of the coverage amount is payable for that critical illness.
Reoccurrence of invasive cancer (including all breast cancer) If you receive a benefit for invasive cancer and are later diagnosed with a reoccurrence of invasive cancer, 25% of the coverage amount is payable if treatment-free for at least 12 months and in complete remission prior to the date of reoccurrence; excludes non-invasive or skin cancer.
Additional covered conditions for dependent children PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
COVERED CONDITION¹
Cerebral palsy
100%
Cleft lip or palate
100%
Cystic fibrosis
100%
Down syndrome
100%
Spina bifida
100%
Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges. 1. Refer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D.
For more information, talk with your benefits counselor.
THIS INSURANCE PROVIDES LIMITED BENEFITS Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.
EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS
We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; 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 critical illness.
EXCLUSIONS AND LIMITATIONS FOR CANCER
We will not pay the Invasive Cancer (including all Breast Cancer) Benefit, Non-Invasive Cancer Benefit, Benefit Payable Upon Reoccurrence of Invasive Cancer (including all Breast Cancer) or Skin Cancer Initial Diagnosis Benefit for a covered person’s invasive cancer or non-invasive cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a 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 initially diagnosed as having invasive or non-invasive cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while the named insured is covered under the certificate, and who are continuously covered from the date of birth or adoption.
PRE-EXISTING CONDITION LIMITATION
We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.
ColonialLife.com
This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
52
5-20 | 387100
Group Critical Illness Insurance First Diagnosis Building Benefit Rider
The first diagnosis building benefit rider provides a lump-sum payment in addition to the coverage amount when you are diagnosed with a covered critical illness or invasive cancer (including all breast cancer). This benefit is for you and all your covered family members.
First diagnosis building benefit Payable once per covered person per lifetime
¾ Named insured ............................................................ Accumulates $1,000 each year ¾ Covered spouse/dependent children ............................... Accumulates $500 each year The benefit amount accumulates each rider year the rider is in force before a diagnosis is made, up to a maximum of 10 years.
For more information, talk with your benefits counselor.
If diagnosed with a covered critical illness or invasive cancer (including all breast cancer) before the end of the first rider year, the rider will provide one-half of the annual building benefit amount. Coronary artery disease is not a covered critical illness. Non-invasive and skin cancer are not covered cancer conditions.
ColonialLife.com
THIS INSURANCE PROVIDES LIMITED BENEFITS. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-BB. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 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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GCI6000 – FIRST DIAGNOSIS BUILDING BENEFIT RIDER | 5-20 | 387381
Group Critical Illness Insurance Infectious Diseases Rider
The sudden onset of an infectious or contagious disease can create unexpected circumstances for you or your family. The infectious diseases rider provides a lump sum which can be used toward health care expenses or meeting day-today needs. These benefits are for you as well as your covered family members.
Payable for each covered infectious disease once per covered person per lifetime COVERED INFECTIOUS DISEASE¹
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Hospital confinement for seven or more consecutive days for treatment of the disease
For more information, talk with your benefits counselor.
ColonialLife.com
Antibiotic resistant bacteria (including MRSA)
50%
Cerebrospinal meningitis (bacterial)
50%
Diphtheria
50%
Encephalitis
50%
Legionnaires’ disease
50%
Lyme disease
50%
Malaria
50%
Necrotizing fasciitis
50%
Osteomyelitis
50%
Poliomyelitis
50%
Rabies
50%
Sepsis
50%
Tetanus
50%
Tuberculosis
50%
Hospital confinement for 14 or more consecutive days for treatment of the disease Coronavirus disease 2019 (COVID-19)
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25%
GCI6000 – INFECTIOUS DISEASES RIDER
1. Refer to the certificate for complete definitions of covered diseases. THIS INSURANCE PROVIDES LIMITED BENEFITS.
EXCLUSIONS AND LIMITATIONS FOR INFECTIOUS DISEASES RIDER
ColonialLife.com
We will not pay benefits for a covered infectious disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; 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 covered infectious disease.
PRE-EXISTING CONDITION LIMITATION
We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-INF. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
55
5-20 | 387523
Group Critical Illness Insurance Progressive Diseases Rider
The debilitating effects of a progressive disease not only impact you physically, but financially as well. Changes in lifestyle may require home modification, additional medical treatment and other expenses. These benefits are for you as well as your covered family members. Payable for each covered progressive disease once per covered person per lifetime PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
COVERED PROGRESSIVE DISEASE¹
This benefit is payable if the covered person is unable to perform two or more activities of daily living2 and the 90-day elimination period has been met.
For more information, talk with your benefits counselor.
ColonialLife.com
Amyotrophic Lateral Sclerosis (ALS)
25%
Dementia (including Alzheimer’s disease)
25%
Huntington’s disease
25%
Lupus
25%
Multiple sclerosis (MS)
25%
Muscular dystrophy
25%
Myasthenia gravis (MG)
25%
Parkinson’s disease
25%
Systemic sclerosis (scleroderma)
25%
1. Refer to the certificate for complete definitions of covered diseases. 2. Activities of daily living include bathing, continence, dressing, eating, toileting and transferring. THIS INSURANCE PROVIDES LIMITED BENEFITS.
EXCLUSIONS AND LIMITATIONS FOR PROGRESSIVE DISEASES RIDER
We will not pay benefits for a covered progressive disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the preexisting condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a covered progressive disease.
PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-PD. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
56
GCI6000 – PROGRESSIVE DISEASES RIDER | 5-20 | 387594
CRITICAL ILLNESS BENEFIT PREMIUMS Plan 1 - Critical Illness Rates illustrated per unit. Named Insured unit value = $1000
Issue Age
Deduction
Named Insured
Employee & Spouse
One-Parent Family
Two Parent Family
Non-Tobacco 17-24
12-Pay Premium
$0.22
$0.31
$0.22
$0.31
25-29
12-Pay Premium
$0.30
$0.43
$0.30
$0.43
30-34
12-Pay Premium
$0.38
$0.55
$0.38
$0.55
35-39
12-Pay Premium
$0.57
$0.85
$0.57
$0.85
40-44
12-Pay Premium
$0.77
$1.14
$0.77
$1.14
45-49
12-Pay Premium
$1.08
$1.65
$1.08
$1.65
50-54
12-Pay Premium
$1.44
$2.23
$1.44
$2.23
55-59
12-Pay Premium
$1.90
$2.94
$1.90
$2.94
60-64
12-Pay Premium
$2.60
$4.02
$2.60
$4.02
65-69
12-Pay Premium
$2.84
$4.38
$2.84
$4.38
70-74
12-Pay Premium
$3.27
$5.04
$3.27
$5.04
One-Parent Family $6.65
Two Parent Family $10.35
Wellbeing Assistance Benefit Rates by wellbeing amount = 1 unit Wellbeing Amount $100
12-Pay Premium
Named Insured $6.65
Employee & Spouse $10.35
Sample rates only. Multiple choices and options available and rates may vary.
57
CRITICAL ILLNESS BENEFIT PREMIUMS Plan 2 - Critical Illness & Cancer Benefits Rates illustrated per unit. Named Insured unit value = $1000
Issue Age
Deduction
Named Insured
Employee & Spouse
One-Parent Family
Two Parent Family
Non-Tobacco 17-24
12-Pay Premium
$0.40
$0.57
$0.40
$0.57
25-29
12-Pay Premium
$0.57
$0.83
$0.57
$0.83
30-34
12-Pay Premium
$0.75
$1.09
$0.75
$1.09
35-39
12-Pay Premium
$1.15
$1.70
$1.15
$1.70
40-44
12-Pay Premium
$1.55
$2.30
$1.55
$2.30
45-49
12-Pay Premium
$2.21
$3.32
$2.21
$3.32
50-54
12-Pay Premium
$2.86
$4.34
$2.86
$4.34
55-59
12-Pay Premium
$3.76
$5.71
$3.76
$5.71
60-64
12-Pay Premium
$5.13
$7.79
$5.13
$7.79
65-69
12-Pay Premium
$6.29
$9.57
$6.29
$9.57
70-74
12-Pay Premium
$6.29
$9.57
$6.29
$9.57
One-Parent Family $6.65
Two Parent Family $10.35
Wellbeing Assistance Benefit Rates by wellbeing amount = 1 unit Wellbeing Amount $100
12-Pay Premium
Named Insured $6.65
Employee & Spouse $10.35
Sample rates only. Multiple choices and options available and rates may vary.
58
Click on the video below to learn more about Disability Benefits!
DISABILITY BENEFITS
Educator Disability Income Insurance
How long could you afford to go without a paycheck? Help protect your paycheck with Colonial Life’s short-term disability insurance. You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you couldn’t go to work due to an accident or sickness? Monthly Expenses:
$_________________
$_________________
$_________________
$_________________
$_________________
$_________________ Total $_________________
My Coverage Worksheet (For use with your Colonial Life Benefits Counselor) Who’s being covered?
You only You and your spouse You and your dependent children You, your spouse and your dependent children
How much coverage do I need? On-Job Accident/On-Job Sickness $______________ Off-Job Accident/Off-Job Sickness $______________ Select One Benefit Period Option:
On-Job
Off-Job
First 3 months
$_____________/month
$_____________/month
Next 9 months
$_____________/month
$_____________/month
First 6 months
$_____________/month
$_____________/month
Next 6 months
$_____________/month
$_____________/month
$_____________/month
$_____________/month
= Total Disability
Educator Disability 1.0-VA
Option A Option B = Partial Disability Up to 3 months
When will my benefits start? After an Accident: ___________ days
After a Sickness: ___________ days
How much will it cost? Your cost will vary based on the level of coverage you select. 60
Employee Coverage In addition to disability coverage, this plan also provides employees with benefits for medical fees related to accidents, hospital confinement, accidental death and dismemberment, as well as fractures and dislocations. Even if you’re not disabled, the following benefits are payable for covered accidental injuries:
Medical Fees for Accidents Only Doctor’s Office or Urgent Care Facility Visit (Once per covered accident) ..................................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident) .............................................................................$75 Emergency Room Visit (Once per covered accident) ...................................................................................................... $150
Hospital Confinement Benefit for Accident or Sickness Pays in addition to disability benefit. l
Benefits begin on the first day of confinement in a hospital for a covered accident or sickness. Up to 3 months .................................................................................................................... $1,200/month ($40/day) The Hospital Confinement benefit increases to $6,000/month ($200/day) when the Total Disability benefit ends at age 70
Accidental Death and Dismemberment Benefits Benefits payable for death or dismemberment. l l
l
l
Accidental Death .............................................................................................................................................................. $25,000 Loss of a Finger or Toe Single Dismemberment ................................................................................................................................................. $750 Double Dismemberment ............................................................................................................................................$1,500 Loss of a Hand, Foot or Sight of an Eye Single Dismemberment ..............................................................................................................................................$7,500 Double Dismemberment ......................................................................................................................................... $15,000 Accidental Death Common Carrier ........................................................................................................................... $50,000
Complete Fractures Complete Fractures requiring closed reduction Hip, Thigh ....................................................................................................................................................................................$1,500 Vertebrae ....................................................................................................................................................................................... 1,350 Pelvis ............................................................................................................................................................................................... 1,200 Skull (depressed) ......................................................................................................................................................................... 1,125 Leg .......................................................................................................................................................................................................900 Foot, Ankle, Kneecap .....................................................................................................................................................................750 Forearm, Hand, Wrist .....................................................................................................................................................................750 Lower Jaw ..........................................................................................................................................................................................600 Shoulder Blade, Collarbone ........................................................................................................................................................600 Skull (simple) ....................................................................................................................................................................................525 Upper Arm, Upper Jaw .................................................................................................................................................................525 Facial Bones ......................................................................................................................................................................................450 Vertebral Processes ........................................................................................................................................................................300 Coccyx, Rib, Finger, Toe ................................................................................................................................................................120 61
Complete Dislocations Complete Dislocations requiring closed reduction with anesthesia Hip ..................................................................................................................................................................................................$1,350 Knee .....................................................................................................................................................................................................975 Collarbone - sternoclavicular ......................................................................................................................................................750 Shoulder ............................................................................................................................................................................................750 Collarbone - acromioclavicular separation ............................................................................................................................675 Ankle, Foot ........................................................................................................................................................................................600 Hand ....................................................................................................................................................................................................525 Lower Jaw ..........................................................................................................................................................................................450 Wrist ....................................................................................................................................................................................................375 Elbow ..................................................................................................................................................................................................300 One Finger, Toe ................................................................................................................................................................................120 For a fracture or dislocation requiring an open reduction, your benefit would be 11/2 times the amount shown.
Additional Features l
Waiver of Premium
l
Worldwide Coverage
Optional Spouse and Dependent Coverage You may cover one or all of the eligible dependent members of your family for an additional premium.
Medical Fees for Accidents Only Doctor’s Office or Urgent Care Facility Visit (Once per covered accident) ..........................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident) .....................................................................$75 Emergency Room Visit (Once per covered accident) .............................................................................................. $150
Hospital Confinement Benefit for Accident or Sickness l
Up to 3 months ....................................................................................................................... $1,200/month ($40/day)
Accidental Death and Dismemberment Benefits l
l
Accidental Death .................................................................................................................................... Spouse $10,000 Child(ren) $5,000 Loss of a Finger or Toe Single Dismemberment ...........................................................................................................................................$75 Double Dismemberment ..................................................................................................................................... $150
l
Loss of a Hand, Foot or Sight of an Eye Single Dismemberment ........................................................................................................................................ $750 Double Dismemberment ..................................................................................................................................$1,500
l
Accidental Death Common Carrier .................................................................................................Spouse $20,000 Child(ren) $10,000
62
Here are some
Colonial Life’s frequently asked questions about disability insurance: Will my disability income payment be reduced if I have other insurance?
What if I change employers?
You’re paid regardless of any other insurance you may have with other insurance companies. Benefits are paid directly to you (unless you specify otherwise).
If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable for life as long as you continue to pay your premiums when they are due.
When am I considered totally disabled?
Can my premium change?
Totally disabled means you are: l
l
l
Unable to perform the material and substantial duties of your job; Not, in fact, engaged in any employment or occupation for wage or profit for which you are qualified by reason of education, training or experience; and Under the regular and appropriate care of a doctor.
What if I want to return to work part-time after I am totally disabled? You may be able to return to work part-time and still receive benefits. We call this “Partial Disability.” This means you may be eligible for coverage if: l You are unable to perform the material and substantial duties of your job for more than 20 hours per week, l You are able to work at your job or your place of employment for 20 hours or less per week, l Your employer will allow you to return to your job or place of employment for 20 hours or less per week; and l You are under the regular and appropriate care of a doctor. The total disability benefit must have been paid for at least one full month immediately prior to your being partially disabled.
When do disability benefits end? The Total Disability Benefit will end on the policy anniversary date on or after your 70th birthday. The Hospital Confinement benefit increases when the Total Disability Benefit ends. A pre-existing condition is when you have a sickness or physical condition for which you were treated, had medical testing, received medical advice, or had taken medication within 12 months testing, or before the effective date of your policy.
What is a covered accident or a covered sickness? A covered accident is an accident. A covered sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an injury. A covered accident or covered sickness: l Occurs after the effective date of the policy; l Occurs while the policy is in force; l Is of a type listed on the Policy Schedule; and l Is not excluded by name or specific description in the policy. EXCLUSIONS We will not pay benefits for injuries received in accidents or sicknesses which are caused by or are the result of: alcoholism or drug addiction; flying; giving birth within the first nine months after the effective date of the policy; felonies or illegal occupations; having a pre-existing condition as described and limited by the policy; psychiatric or psychological condition; committing or trying to commit suicide or injuring yourself intentionally; being exposed to war or any act of war or serving in the armed forces of any country or authority. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ED DIS 1.0-VA. Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control.
If you become disabled because of a pre-existing condition, Colonial Life will not pay for any disability period if it begins during the first 12 months the policy is in force. Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 6/11
©2011 Colonial Life & Accident Insurance Company. Colonial Life products are underwritten by Colonial Life & Accident Insurance Life products underwritten Colonial Life & Accident Company, for Colonial which Colonial Life are is the marketingbybrand. Insurance Company, for which Colonial Life is the marketing brand.
Colonial Life and Making benefits count are registered service marks of Colonial Life &71381-1 Accident Insurance Company. 100252 63
Educator Disability 1.0-VA
What is a pre-existing condition?
You may choose the amount of coverage to meet your needs (subject to your income). You can elect more or less coverage which will change your premium. Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued.
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SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 1: On- & Off-Job Coverage
Teacher, Principal, T.A., Clerical, Café Manager Monthly premium Premiums are for base plan and disability benefits
Benefit Amount
Elimination Period
First 3 months
Next 9 Months
Units
0/7
0/14
14/14
0/30
30/30
400
200
4
$18.40
$16.00
$15.00
$14.80
$12.80
600
300
6
$24.30
$20.70
$19.20
$18.90
$15.90
800
400
8
$30.20
$25.40
$23.40
$23.00
$19.00
1000
500
10
$36.10
$30.10
$27.60
$27.10
$22.10
1200
600
12
$42.00
$34.80
$31.80
$31.20
$25.20
1400
700
14
$47.90
$39.50
$36.00
$35.30
$28.30
1600
800
16
$53.80
$44.20
$40.20
$39.40
$31.40
1800
900
18
$59.70
$48.90
$44.40
$43.50
$34.50
2000
1000
20
$65.60
$53.60
$48.60
$47.60
$37.60
2200
1100
22
$71.50
$58.30
$52.80
$51.70
$40.70
2400
1200
24
$77.40
$63.00
$57.00
$55.80
$43.80
2600
1300
26
$83.30
$67.70
$61.20
$59.90
$46.90
2800
1400
28
$89.20
$72.40
$65.40
$64.00
$50.00
3000
1500
30
$95.10
$77.10
$69.60
$68.10
$53.10
3200
1600
32
$101.00
$81.80
$73.80
$72.20
$56.20
3400
1700
34
$106.90
$86.50
$78.00
$76.30
$59.30
3600
1800
36
$112.80
$91.20
$82.20
$80.40
$62.40
3800
1900
38
$118.70
$95.90
$86.40
$84.50
$65.50
4000
2000
40
$124.60
$100.60
$90.60
$88.60
$68.60
4200
2100
42
$130.50
$105.30
$94.80
$92.70
$71.70
4400
2200
44
$136.40
$110.00
$99.00
$96.80
$74.80
4600
2300
46
$142.30
$114.70
$103.20
$100.90
$77.90
4800
2400
48
$148.20
$119.40
$107.40
$105.00
$81.00
5000
2500
50
$154.10
$124.10
$111.60
$109.10
$84.10
Spouse and Dependent Premiums Rider
Monthly Premium
Spouse Accident & Sickness Benefit Coverage
$5.50
Child(ren) Accident & Sickness Benefit Coverage
$7.50
Sample rates only. Multiple choices and options available and rates may vary.
65
SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 1: On- & Off-Job Coverage
Café Staff, Custodian Super, Custodian Staff, Maintaince Super, Maintenance Staff Monthly premium Premiums are for base plan and disability benefits
Benefit Amount
Elimination Period
First 3 months
Next 9 Months
Units
0/7
0/14
14/14
0/30
30/30
400
200
4
$23.60
$21.40
$19.40
$18.80
$16.00
600
300
6
$32.10
$28.80
$25.80
$24.90
$20.70
800
400
8
$40.60
$36.20
$32.20
$31.00
$25.40
1000
500
10
$49.10
$43.60
$38.60
$37.10
$30.10
1200
600
12
$57.60
$51.00
$45.00
$43.20
$34.80
1400
700
14
$66.10
$58.40
$51.40
$49.30
$39.50
1600
800
16
$74.60
$65.80
$57.80
$55.40
$44.20
1800
900
18
$83.10
$73.20
$64.20
$61.50
$48.90
2000
1000
20
$91.60
$80.60
$70.60
$67.60
$53.60
2200
1100
22
$100.10
$88.00
$77.00
$73.70
$58.30
2400
1200
24
$108.60
$95.40
$83.40
$79.80
$63.00
2600
1300
26
$117.10
$102.80
$89.80
$85.90
$67.70
2800
1400
28
$125.60
$110.20
$96.20
$92.00
$72.40
3000
1500
30
$134.10
$117.60
$102.60
$98.10
$77.10
3200
1600
32
$142.60
$125.00
$109.00
$104.20
$81.80
3400
1700
34
$151.10
$132.40
$115.40
$110.30
$86.50
3600
1800
36
$159.60
$139.80
$121.80
$116.40
$91.20
3800
1900
38
$168.10
$147.20
$128.20
$122.50
$95.90
4000
2000
40
$176.60
$154.60
$134.60
$128.60
$100.60
4200
2100
42
$185.10
$162.00
$141.00
$134.70
$105.30
4400
2200
44
$193.60
$169.40
$147.40
$140.80
$110.00
4600
2300
46
$202.10
$176.80
$153.80
$146.90
$114.70
4800
2400
48
$210.60
$184.20
$160.20
$153.00
$119.40
5000
2500
50
$219.10
$191.60
$166.60
$159.10
$124.10
Spouse and Dependent Premiums Rider
Monthly Premium
Spouse Accident & Sickness Benefit Coverage
$5.50
Child(ren) Accident & Sickness Benefit Coverage
$7.50
Sample rates only. Multiple choices and options available and rates may vary.
66
SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 1: On- & Off-Job Coverage
Bus Driver, Mechanic Monthly premium Premiums are for base plan and disability benefits
Benefit Amount
Elimination Period
First 3 months
Next 9 Months
Units
0/7
0/14
14/14
0/30
30/30
400
200
4
$27.00
$23.60
$21.80
$21.60
$17.80
600
300
6
$37.20
$32.10
$29.40
$29.10
$23.40
800
400
8
$47.40
$40.60
$37.00
$36.60
$29.00
1000
500
10
$57.60
$49.10
$44.60
$44.10
$34.60
1200
600
12
$67.80
$57.60
$52.20
$51.60
$40.20
1400
700
14
$78.00
$66.10
$59.80
$59.10
$45.80
1600
800
16
$88.20
$74.60
$67.40
$66.60
$51.40
1800
900
18
$98.40
$83.10
$75.00
$74.10
$57.00
2000
1000
20
$108.60
$91.60
$82.60
$81.60
$62.60
2200
1100
22
$118.80
$100.10
$90.20
$89.10
$68.20
2400
1200
24
$129.00
$108.60
$97.80
$96.60
$73.80
2600
1300
26
$139.20
$117.10
$105.40
$104.10
$79.40
2800
1400
28
$149.40
$125.60
$113.00
$111.60
$85.00
3000
1500
30
$159.60
$134.10
$120.60
$119.10
$90.60
3200
1600
32
$169.80
$142.60
$128.20
$126.60
$96.20
3400
1700
34
$180.00
$151.10
$135.80
$134.10
$101.80
3600
1800
36
$190.20
$159.60
$143.40
$141.60
$107.40
3800
1900
38
$200.40
$168.10
$151.00
$149.10
$113.00
4000
2000
40
$210.60
$176.60
$158.60
$156.60
$118.60
4200
2100
42
$220.80
$185.10
$166.20
$164.10
$124.20
4400
2200
44
$231.00
$193.60
$173.80
$171.60
$129.80
4600
2300
46
$241.20
$202.10
$181.40
$179.10
$135.40
4800
2400
48
$251.40
$210.60
$189.00
$186.60
$141.00
5000
2500
50
$261.60
$219.10
$196.60
$194.10
$146.60
Spouse and Dependent Premiums Rider
Monthly Premium
Spouse Accident & Sickness Benefit Coverage
$5.50
Child(ren) Accident & Sickness Benefit Coverage
$7.50
Sample rates only. Multiple choices and options available and rates may vary.
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SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 2: Off-Job Coverage
Teacher, Principal, T.A., Clerical, Café Manager Monthly premium Premiums are for base plan and disability benefits Benefit Amount
Elimination Period
First 3 months
Next 9 Months
Units
0/7
0/14
14/14
0/30
30/30
400
200
4
$14.45
$12.05
$10.85
$10.05
$9.25
600
300
6
$19.35
$15.75
$13.95
$12.75
$11.55
800
400
8
$24.25
$19.45
$17.05
$15.45
$13.85
1000
500
10
$29.15
$23.15
$20.15
$18.15
$16.15
1200
600
12
$34.05
$26.85
$23.25
$20.85
$18.45
1400
700
14
$38.95
$30.55
$26.35
$23.55
$20.75
1600
800
16
$43.85
$34.25
$29.45
$26.25
$23.05
1800
900
18
$48.75
$37.95
$32.55
$28.95
$25.35
2000
1000
20
$53.65
$41.65
$35.65
$31.65
$27.65
2200
1100
22
$58.55
$45.35
$38.75
$34.35
$29.95
2400
1200
24
$63.45
$49.05
$41.85
$37.05
$32.25
2600
1300
26
$68.35
$52.75
$44.95
$39.75
$34.55
2800
1400
28
$73.25
$56.45
$48.05
$42.45
$36.85
3000
1500
30
$78.15
$60.15
$51.15
$45.15
$39.15
3200
1600
32
$83.05
$63.85
$54.25
$47.85
$41.45
3400
1700
34
$87.95
$67.55
$57.35
$50.55
$43.75
3600
1800
36
$92.85
$71.25
$60.45
$53.25
$46.05
3800
1900
38
$97.75
$74.95
$63.55
$55.95
$48.35
4000
2000
40
$102.65
$78.65
$66.65
$58.65
$50.65
4200
2100
42
$107.55
$82.35
$69.75
$61.35
$52.95
4400
2200
44
$112.45
$86.05
$72.85
$64.05
$55.25
4600
2300
46
$117.35
$89.75
$75.95
$66.75
$57.55
4800
2400
48
$122.25
$93.45
$79.05
$69.45
$59.85
5000
2500
50
$127.15
$97.15
$82.15
$72.15
$62.15
Spouse and Dependent Premiums Rider
Monthly Premium
Spouse Accident & Sickness Benefit Coverage
$5.50
Child(ren) Accident & Sickness Benefit Coverage
$7.50
Sample rates only. Multiple choices and options available and rates may vary.
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SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 2: Off-Job Coverage
Café Staff, Custodian Super, Custodian Staff, Maintaince Super, Maintenance Staff Monthly premium Premiums are for base plan and disability benefits Benefit Amount
Elimination Period
First 3 months
Next 9 Months
Units
0/7
0/14
14/14
0/30
30/30
400
200
4
$19.65
$16.05
$14.45
$12.85
$11.65
600
300
6
$27.15
$21.75
$19.35
$16.95
$15.15
800
400
8
$34.65
$27.45
$24.25
$21.05
$18.65
1000
500
10
$42.15
$33.15
$29.15
$25.15
$22.15
1200
600
12
$49.65
$38.85
$34.05
$29.25
$25.65
1400
700
14
$57.15
$44.55
$38.95
$33.35
$29.15
1600
800
16
$64.65
$50.25
$43.85
$37.45
$32.65
1800
900
18
$72.15
$55.95
$48.75
$41.55
$36.15
2000
1000
20
$79.65
$61.65
$53.65
$45.65
$39.65
2200
1100
22
$87.15
$67.35
$58.55
$49.75
$43.15
2400
1200
24
$94.65
$73.05
$63.45
$53.85
$46.65
2600
1300
26
$102.15
$78.75
$68.35
$57.95
$50.15
2800
1400
28
$109.65
$84.45
$73.25
$62.05
$53.65
3000
1500
30
$117.15
$90.15
$78.15
$66.15
$57.15
3200
1600
32
$124.65
$95.85
$83.05
$70.25
$60.65
3400
1700
34
$132.15
$101.55
$87.95
$74.35
$64.15
3600
1800
36
$139.65
$107.25
$92.85
$78.45
$67.65
3800
1900
38
$147.15
$112.95
$97.75
$82.55
$71.15
4000
2000
40
$154.65
$118.65
$102.65
$86.65
$74.65
4200
2100
42
$162.15
$124.35
$107.55
$90.75
$78.15
4400
2200
44
$169.65
$130.05
$112.45
$94.85
$81.65
4600
2300
46
$177.15
$135.75
$117.35
$98.95
$85.15
4800
2400
48
$184.65
$141.45
$122.25
$103.05
$88.65
5000
2500
50
$192.15
$147.15
$127.15
$107.15
$92.15
Spouse and Dependent Premiums Rider
Monthly Premium
Spouse Accident & Sickness Benefit Coverage
$5.50
Child(ren) Accident & Sickness Benefit Coverage
$7.50
Sample rates only. Multiple choices and options available and rates may vary.
69
SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 2: Off-Job Coverage
Bus Driver, Mechanic Monthly premium Premiums are for base plan and disability benefits Benefit Amount
Elimination Period
First 3 months
Next 9 Months
Units
0/7
0/14
14/14
0/30
30/30
400
200
4
$22.25
$17.45
$16.05
$14.25
$12.65
600
300
6
$31.05
$23.85
$21.75
$19.05
$16.65
800
400
8
$39.85
$30.25
$27.45
$23.85
$20.65
1000
500
10
$48.65
$36.65
$33.15
$28.65
$24.65
1200
600
12
$57.45
$43.05
$38.85
$33.45
$28.65
1400
700
14
$66.25
$49.45
$44.55
$38.25
$32.65
1600
800
16
$75.05
$55.85
$50.25
$43.05
$36.65
1800
900
18
$83.85
$62.25
$55.95
$47.85
$40.65
2000
1000
20
$92.65
$68.65
$61.65
$52.65
$44.65
2200
1100
22
$101.45
$75.05
$67.35
$57.45
$48.65
2400
1200
24
$110.25
$81.45
$73.05
$62.25
$52.65
2600
1300
26
$119.05
$87.85
$78.75
$67.05
$56.65
2800
1400
28
$127.85
$94.25
$84.45
$71.85
$60.65
3000
1500
30
$136.65
$100.65
$90.15
$76.65
$64.65
3200
1600
32
$145.45
$107.05
$95.85
$81.45
$68.65
3400
1700
34
$154.25
$113.45
$101.55
$86.25
$72.65
3600
1800
36
$163.05
$119.85
$107.25
$91.05
$76.65
3800
1900
38
$171.85
$126.25
$112.95
$95.85
$80.65
4000
2000
40
$180.65
$132.65
$118.65
$100.65
$84.65
4200
2100
42
$189.45
$139.05
$124.35
$105.45
$88.65
4400
2200
44
$198.25
$145.45
$130.05
$110.25
$92.65
4600
2300
46
$207.05
$151.85
$135.75
$115.05
$96.65
4800
2400
48
$215.85
$158.25
$141.45
$119.85
$100.65
5000
2500
50
$224.65
$164.65
$147.15
$124.65
$104.65
Spouse and Dependent Premiums Rider
Monthly Premium
Spouse Accident & Sickness Benefit Coverage
$5.50
Child(ren) Accident & Sickness Benefit Coverage
$7.50
Sample rates only. Multiple choices and options available and rates may vary.
70
Click on the video below to learn more about Accident Benefits!
ACCIDENT BENEFITS
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
Sports-related accidental injury Broken bone Burn Concussion Laceration
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Back or knee injuries
l l l l
l l l l
Car accidents Falls & spills Dislocation Accidental injuries that send you to the Emergency Room, Urgent Care or doctor’s office
Accident 1.0-Preferred with Health Screening Benefit-VA
Colonial Life’s Accident Insurance is designed to help you fill some of the gaps caused by increasing deductibles, co-payments and out-of-pocket costs related to an accidental injury. The benefit to you is that you may not need to use your savings or secure a loan to pay expenses. Plus you’ll feel better knowing you can have greater financial security.
What additional features are included? l
Worldwide coverage
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Portable
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What if I change employers? If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable for life as long as you pay your premiums when they are due or within the grace period.
Compliant with Healthcare Spending Account (HSA) guidelines
Can my premium change?
Will my accident claim payment be reduced if I have other insurance?
Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued.
You’re paid regardless of any other insurance you may have with other insurance companies, and the benefits are paid directly to you (unless you specify otherwise).
How do I file a claim? Visit coloniallife.com or call our Customer Service Department at 1.800.325.4368 for additional information.
72
Benefits listed are for each covered person per covered accident unless otherwise specified.
Initial Care l
Accident Emergency Treatment........... $125
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Ambulance .......................................$200
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X-ray Benefit ...................................................$30
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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
$2,200 $1,100 $880 $550 $330 $330 $110 $110
$4,400 $2,200 $1,760 $1,100 $660 $660 $220 $220
Non-Surgical
Surgical
$2,750 $1,100 $1,650 $825 $385 $385 $385 $330 $330 $330 $275 $220 $110
$5,500 $2,200 $3,300 $1,650 $770 $770 $770 $660 $660 $660 $550 $440 $220
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 ......................................................................................................................................................... $60
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Emergency Dental Work .......................................$75 Extraction, $300 Crown, Implant, or Denture Lacerations (based on size) ...........................................................................................................$30 to $500
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 l
Surgery (cranial, open abdominal or thoracic) ................................................................................ $1,500
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Surgery (hernia) ..............................................................................................................................................$150
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Surgery (arthroscopic or exploratory) ....................................................................................................$200
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Blood/Plasma/Platelets ................................................................................................................................$300 73
Transportation/Lodging Assistance If injured, covered person must travel more than 50 miles from residence to receive special treatment and confinement in a hospital. l l
Transportation .............................................................................$500 per round trip up to 3 round trips Lodging (family member or companion) ...............................................$125 per night up to 30 days for a hotel/motel lodging costs
Accident Hospital Care l
Hospital Admission* ........................................................................................................ $1,000 per accident
Hospital ICU Admission* ................................................................................................ $2,000 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 ......................................................... $225 per day up to 365 days per accident
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Hospital ICU Confinement ...................................................$450 per day up to 15 days per accident
Accident Follow-Up Care l l
Accident Follow-Up Doctor Visit .......................................................... $50 (up to 3 visits per accident) Medical Imaging Study ......................................................................................................$150 per accident (limit 1 per covered accident and 1 per calendar year)
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Occupational or Physical Therapy ..................................................... $25 per treatment up to 10 days
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Appliances .......................................................................................... $100 (such as wheelchair, crutches)
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Prosthetic Devices/Artificial Limb ....................................................$500 - one, $1,000 - more than 1
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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
Accidental Dismemberment l
Loss of Finger/Toe .................................................................................$750 – one, $1,500 – two or more
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Loss or Loss of Use of Hand/Foot/Sight of Eye .....................$7,500 – one, $15,000 – two or more
Catastrophic Accident For severe injuries that result in the total and irrecoverable: l
Loss of one hand and one foot
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Loss of the sight of both eyes
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Loss of both hands or both feet
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Loss of the hearing of both ears
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Loss or loss of use of one arm and one leg or
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Loss of the ability to speak
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Loss or loss of use of both arms or both legs Named Insured ................ $25,000
Spouse ..............$25,000
Child(ren) .........$12,500
365-day elimination period. Amounts reduced for covered persons age 65 and over. Payable once per lifetime for each covered person.
Accidental Death Accidental Death
Common Carrier
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Named Insured
$25,000
$100,000
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Spouse
$25,000
$100,000
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Child(ren)
$5,000
$20,000
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Health Screening Benefit
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.
Tests include: l.
Blood test for triglycerides
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Hemoccult stool analysis
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Bone marrow testing
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Mammography
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Breast ultrasound
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Pap smear
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CA 15-3 (blood test for breast cancer)
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PSA (blood test for prostate cancer)
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CA125 (blood test for ovarian cancer)
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Carotid doppler
Serum cholesterol test to determine level of HDL and LDL
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Serum protein electrophoresis (blood test for myeloma)
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Stress test on a bicycle or treadmill
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Skin cancer biopsy
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Thermography
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ThinPrep pap test
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Virtual colonoscopy
l. CEA (blood test for colon cancer) l.
Chest x-ray
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Colonoscopy
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Echocardiogram (ECHO)
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Electrocardiogram (EKG, ECG)
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Fasting blood glucose test
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Flexible sigmoidoscopy
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 Spouse
Employee & Spouse Two-Parent Family
When are covered accident benefits available? (check one) 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: felonies or illegal occupations; 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 -VA. 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 10/11
©2011 Colonial Life & Accident Insurance Company. Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. Colonial Life and Making benefits count are registered service marks of Colonial Life & Accident Insurance Company.
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74231-2
Accident 1.0-Preferred with Health Screening Benefit-VA
One-Parent Family, with Employee
One Child Only
ACCIDENT BENEFIT PREMIUMS Preferred with HealthScreening - On/Off-Job Accident Coverage 12-Pay Premium Named Insured
$21.15
Employee & Spouse
$28.97
One-Parent Family
$32.67
Two-Parent Family
$40.48
Preferred with HealthScreening - Off-Job Only Accident Coverage 12-Pay Premium Named Insured
$17.92
Employee & Spouse
$23.96
One-Parent Family
$26.56
Two-Parent Family
$32.61
Sample rates only. Multiple choices and options available and rates may vary.
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Click on the video below to learn more about Medical Bridge Benefits!
MEDICAL BRIDGE BENEFITS
Hospital Confinement Indemnity Insurance Plan 1 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.
Hospital confinement ..................................................................... $__________________ Maximum of one benefit per covered person per calendar year
Observation room.................................................................................. $100 per visit Maximum of two visits per covered person per calendar year
Rehabilitation unit confinement ................................................................. $100 per day Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year
Waiver of premium Available after 30 continuous days of a covered hospital confinement of the named insured
Health savings account (HSA) compatible
For more information, talk with your benefits counselor.
ColonialLife.com
This plan is compatible with HSA guidelines. This plan may also be offered to employees who do not have HSAs. Colonial Life & Accident Insurance Company’s Individual Medical Bridge offers an HSA compatible plan in most states.
THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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IMB7000 – PLAN 1 | 5-16 | 101576-1
Hospital Confinement Indemnity Insurance Plan 3 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement ......................................................................... $_______________ Maximum of one benefit per covered person per calendar year
Observation room.................................................................................. $100 per visit Maximum of two visits per covered person per calendar year
Rehabilitation unit confinement ................................................................. $100 per day Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year
Waiver of premium
Available after 30 continuous days of a covered hospital confinement of the named insured
Diagnostic procedure Tier 1. . . . . . ......................................................................................... ................. $250 Tier 2. . . . . . ......................................................................................... ................. $500 Maximum of $500 per covered person per calendar year for all covered diagnostic procedures combined
Outpatient surgical procedure Tier 1. . . . . . ......................................................................................... . $_______________ Tier 2. . . . . . ......................................................................................... .. $_______________
For more information, talk with your benefits counselor.
Maximum of $___________ per covered person per calendar year for all covered outpatient surgical procedures combined
The following is a list of common diagnostic procedures that may be covered.
Tier 1 diagnostic procedures Breast – Biopsy (incisional, needle, stereotactic) Diagnostic radiology – Nuclear medicine test Digestive – Barium enema/lower GI series – Barium swallow/upper GI series – Esophagogastroduodenoscopy (EGD) Ear, nose, throat, mouth – Laryngoscopy Gynecological – Hysteroscopy – Amniocentesis – Loop electrosurgical – Cervical biopsy excisional procedure – Cone biopsy (LEEP) – Endometrial biopsy
Liver – biopsy Lymphatic – biopsy Miscellaneous – Bone marrow aspiration/biopsy Renal – biopsy Respiratory – Biopsy – Bronchoscopy – Pulmonary function test (PFT) Skin – Biopsy – Excision of lesion Thyroid – biopsy Urologic – Cystoscopy
Tier 2 diagnostic procedures Cardiac – Angiogram – Arteriogram – Thallium stress test – Transesophageal echocardiogram (TEE)
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Diagnostic radiology – Computerized tomography scan (CT scan) – Electroencephalogram (EEG) – Magnetic resonance imaging (MRI) – Myelogram – Positron emission tomography scan (PET scan) IMB7000 – PLAN 3
The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.
Tier 1 outpatient surgical procedures Breast
Gynecological
Cardiac
Liver
Digestive
Musculoskeletal system
– Axillary node dissection – Breast capsulotomy – Lumpectomy
– Dilation and curettage (D&C) – Endometrial ablation – Lysis of adhesions
– Pacemaker insertion
– Paracentesis
– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions
– Carpal/cubital repair or release – Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair) – Removal of orthopedic hardware – Removal of tendon lesion
Skin
– Laparoscopic hernia repair – Skin grafting
Ear, nose, throat, mouth – Adenoidectomy – Removal of oral lesions – Myringotomy – Tonsillectomy – Tracheostomy – Tympanotomy
Tier 2 outpatient surgical procedures Breast
Gynecological
Cardiac
Musculoskeletal system
– Breast reconstruction – Breast reduction
– Hysterectomy – Myomectomy
– Angioplasty – Cardiac catheterization
Digestive
– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy
Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty
Thyroid
– Excision of a mass
Eye
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, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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1-16 | 101581-1
Hospital Confinement Indemnity Insurance Health Screening Individual Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.
Health screening .............................................................................. $_____________ Maximum of one health screening test per covered person per calendar year; subject to a 30-day waiting period
Blood test for triglycerides Bone marrow testing Breast ultrasound CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) CEA (blood test for colon cancer) Carotid Doppler
Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy
Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy
For more information, talk with your benefits counselor.
Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels
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. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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IMB7000 – HEALTH SCREENING BENEFIT | 5-16 | 101579-1
Hospital Confinement Indemnity Insurance Medical Treatment Package
The medical treatment package for Individual Medical BridgeSM coverage can help pay for deductibles, co-payments and other out-of-pocket expenses related to a covered accident or covered sickness. The medical treatment package cannot be paired with Plan 1. Air ambulance ............................................................................................. $1,000 Maximum of one benefit per covered person per calendar year
Ambulance .................................................................................................... $100 Maximum of one benefit per covered person per calendar year
Appliance ...................................................................................................... $100 Maximum of one benefit per covered person per calendar year
Doctor’s office visit ................................................................................... $25 per visit Maximum of three visits per calendar year for named insured coverage or maximum of five visits per calendar year for all covered persons combined
Emergency room visit ............................................................................. $100 per visit
For more information, talk with your benefits counselor.
Maximum of two visits per covered person per calendar year
X-ray ................................................................................................ $25 per benefit Maximum of two benefits per covered person per calendar year
THIS POLICY PROVIDES LIMITED BENEFITS.
ColonialLife.com
EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-VA. This is not an insurance contract and only the actual policy provisions will control.
©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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IMB7000 – MEDICAL TREATMENT PACKAGE | 9-16 | 101596-VA
Hospital Confinement Indemnity Insurance Optional Riders Individual Medical BridgeSM offers two optional benefit riders – the daily hospital confinement rider and the enhanced intensive care unit confinement rider. For an additional cost, these riders can help provide extra financial protection to help with out-of-pocket medical expenses.
Daily hospital confinement rider ................................................................. $100 per day Per covered person per day of hospital confinement Maximum of 365 days per covered person per confinement
Enhanced intensive care unit confinement rider .............................................. $500 per day Per covered person per day of intensive care unit confinement Maximum of 30 days per covered person per confinement
Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.
For more information, talk with your benefits counselor.
EXCLUSIONS
ColonialLife.com
We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the rider. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000 and R-EIC7000 (including state abbreviations where used, for example: R-DHC7000-TX and R-EIC7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy or rider provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 6-16 | 101582-1
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MEDICAL BRIDGE BENEFIT PREMIUMS INDIVIDUAL MEDICAL BRIDGE Plan 1 Named Insured
Hospital Confinement $100 Health Screening
Ages 17-49 Ages 50-59 Ages 60-64 Ages 65-75
12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium
$1,000.00
$1,500.00
$18.20 $23.20 $29.25 $36.85
$23.65 $30.75 $39.60 $50.65
INDIVIDUAL MEDICAL BRIDGE Plan 3 Named Insured Hospital Confinement Medical Treatment Pkg $100 Health Screening
$1,000.00
$1,500.00
Outpatient Surgical Procedure
Option 1 Tier 1 $500 Tier 2 $1,000 CY Max $1,500
Option 1 Tier 1 $500 Tier 2 $1,000 CY Max $1,500
$37.80 $47.50 $58.20 $71.60
$43.25 $55.05 $68.55 $85.40
Ages 17-49 Ages 50-59 Ages 60-64 Ages 65-75
12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium
Sample rates only. Multiple choices and options available and rates may vary.
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Click on the video below to learn more about Term Life Insurance!
TERM LIFE INSURANCE
Term Life Insurance Life insurance protection when you need it most Life insurance needs change as life circumstances change. You may need different coverage if you’re getting married, buying a home or having a child. Term life insurance from Colonial Life provides protection for a specified period of time, typically offering the greatest amount of coverage for the lowest initial premium. This fact makes term life insurance a good choice for supplementing cash value coverage during life stages when obligations are higher, such as while children are younger. It’s also a good option for families on a tight budget — especially since you can convert it to a permanent cash value plan later.
With this coverage: n A beneficiary can receive a benefit that is typically free from income tax. n The policy’s accelerated death benefit can pay a percentage of the death benefit if the covered person is diagnosed with a terminal illness. n You can convert it to a Colonial Life cash value insurance plan, with no proof of good health, to age 75. n Coverage is guaranteed renewable up to age 95 as long as premiums are paid when due. n Portability allows you to take it with you if you change jobs or retire.
Talk with your Colonial Life benefits counselor to learn more.
ColonialLife.com
Spouse coverage options
Dependent coverage options
Two options are available for spouse coverage at an additional cost:
You may add a Children’s Term Life Rider to cover all of your eligible dependent children with up to $20,000 in coverage each for one premium.
1. Spouse Term Life Policy: Offers guaranteed premiums and level death benefits equivalent to those available to you –whether or not you buy a policy for yourself. 2. Spouse Term Life Rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).
The Children’s Term Life Rider may be added to either the primary or spouse policy, not both.
If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 7-19 | NS-16570-1
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How much coverage do you need? £ YOU $ ___________________ Select the term period: £ 10-year £ 15-year £ 20-year £ 30-year £ SPOUSE $ ___________________ Select the term period: £ 10-year £ 15-year £ 20-year £ 30-year
Select any optional riders: £ Spouse term life rider $ _____________ face amount for ________-year term period £ Children’s term life rider $ _____________ face amount £ Accidental death benefit rider £ Chronic care accelerated death benefit rider
Optional riders At an additional cost, you can purchase the following riders for even more financial protection.
Spouse term life rider Your spouse may receive a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.
Children’s term life rider You can purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.
Accidental death benefit rider The beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.
Chronic care accelerated death benefit rider If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.1 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living.2 Premiums are waived during the benefit period.
Critical illness accelerated death benefit rider
£ Critical illness accelerated death benefit rider
If you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.1 A subsequent diagnosis benefit is included.
£ Waiver of premium benefit rider
Waiver of premium benefit rider Premiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period.3
To learn more, talk with your Colonial Life benefits counselor.
1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits. 2 Activities of daily living are bathing, continence, dressing, eating, toileting and transferring. 3 You must resume premium payments once you are no longer disabled.
EXCLUSIONS AND LIMITATIONS If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you.
ColonialLife.com
This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC18-ITL5000/ITL5000 and rider forms ICC18-R-ITL5000-STR/RITL5000- STR, ICC18-R-ITL5000-CTR/R-ITL5000-CTR, ICC18-R-ITL5000-WP/R-ITL5000-WP, ICC18-R-ITL5000-ACCD/RITL5000- ACCD, ICC18-R-ITL5000-CI/R-ITL5000-CI, ICC18-R-ITL5000-CC/R-ITL5000-CC. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
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9-21 | 101895-2
TERM LIFE INSURANCE PREMIUMS 10-Year Term Base Plan Monthly Non-Tobacco Rates Issue Age 25 30 35 40 45 50 55 60
Pay Premium
$10,000.00
$25,000.00
$50,000.00
$100,000.00
12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium
$6.64 $7.06 $7.57 $7.98 $9.17 $11.72 $16.17 $23.36
$10.60 $11.65 $12.94 $13.96 $16.92 $23.29 $34.44 $52.39
$10.21 $10.21 $11.25 $14.04 $18.62 $25.58 $36.37 $53.96
$16.42 $16.42 $18.50 $24.08 $33.25 $47.16 $68.75 $103.91
20-Year Term Base Plan Monthly Non-Tobacco Rates Issue Age 25 30 35 40 45 50 55 60
Pay Premium
$10,000.00
$25,000.00
$50,000.00
$100,000.00
12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium
$6.71 $7.12 $7.69 $8.23 $9.68 $12.67 $18.06 $26.84
$10.77 $11.81 $13.23 $14.58 $18.21 $25.69 $39.14 $61.10
$10.54 $10.54 $11.58 $15.42 $21.79 $31.58 $46.33 $72.00
$17.08 $17.08 $19.17 $26.83 $39.58 $59.16 $88.66 $139.99
Sample rates only. Multiple choices and options available and rates may vary.
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Click on the video below to learn more about Whole Life Insurance!
WHOLE LIFE INSURANCE
Whole Life Plus Insurance*
You can’t predict your family’s future, but you can prepare for it.
Advantages of Whole Life Plus insurance
Help give your family more peace of mind and coverage for final expenses with Colonial Life Individual Whole Life Plus insurance.
• Permanent life insurance coverage that stays the same through the life of the policy
Benefits and features Choose the age when your premium payments end — Paid-Up at Age 70 or Paid-Up at Age 100 Stand-alone spouse policy available even without buying a policy for yourself
• Premiums will not increase due to changes in health or age.
Ability to keep the policy if you change jobs or retire
• Accumulates cash value based on a nonforfeiture interest rate of 3.75%2
Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness1
• Policy loans available, which can be used for emergencies
Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses
• Benefit for the beneficiary that is typically tax-free
Provides cash surrender value at age 100 (when the policy endows)
Additional coverage options Spouse term rider Cover your spouse with a death benefit up to $50,000, for 10 or 20 years.
Juvenile Whole Life Plus policy Purchase a policy (Paid-Up at Age 70) while children are young and premiums are low — whether or not you buy a policy for yourself. You may also increase the coverage when the child is 18, 21 and 24 without proof of good health.
Children’s term rider
Your cost will vary based on the amount of coverage you select.
You may purchase up to $20,000 in term life insurance coverage for all of your eligible dependent children and pay one premium. The children’s term rider may be added to either your policy or your spouse’s policy — not both. 90
WHOLE LIFE PLUS (IWL5000)
Benefits worksheet
Additional coverage options (Continued)
For use with your benefits counselor
Accelerated death benefit for long term care services rider3
How much coverage do you need?
Talk with your benefits counselor for more details.
YOU $_______________________
Accidental death benefit rider
Select the option:
Paid-Up at Age 70 Paid-Up at Age 100 SPOUSE $ __________________ Select the option:
Paid-Up at Age 70 Paid-Up at Age 100 DEPENDENT STUDENT
$ ____________________________ Select the option:
Paid-Up at Age 70 Paid-Up at Age 100 Select any optional riders:
Spouse term rider
$ _____________face amount for _________-year term period
Children’s term rider
$ ______________ face amount
Accelerated death benefit for long term care services rider
Accidental death benefit rider Chronic care accelerated death benefit rider
Critical illness accelerated death benefit rider
Guaranteed purchase option rider
Waiver of premium benefit rider
To learn more, talk with your benefits counselor.
An additional benefit may be payable if the covered person dies as a result of an accident before age 70, and doubles if the injury occurs while riding as a fare-paying passenger using public transportation. An additional 25% is payable if the injury occurs while driving or riding in a private passenger vehicle and wearing a seatbelt.
Chronic care accelerated death benefit rider If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.1 Talk with your benefits counselor for more details.
Critical illness accelerated death benefit rider If you suffer a heart attack, stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.1 A subsequent diagnosis benefit is included.
Guaranteed purchase option rider This rider allows you to purchase additional whole life coverage — without having to answer health questions — at three different points in the future. The rider may only be added if you are age 50 or younger when you purchase the policy. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.
Waiver of premium benefit rider Policy and rider premiums are waived if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premiums will resume.
* Whole Life Plus is a marketing name of the insurance policy filed as “Whole Life Insurance” in most states. 1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits. 2 Accessing the accumulated cash value reduces the death benefit by the amount accessed, unless the loan is repaid. Cash value will be reduced by any outstanding loans against the policy. 3 The rider is not available in all states. This life insurance does not specifically cover funeral goods or services and may not cover the entire cost of your funeral at the time of your death. The beneficiary of this life insurance may use the proceeds for any purpose, unless otherwise directed. EXCLUSIONS AND LIMITATIONS: If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC19-IWL5000-70/ IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC23IWL5000-LTC/IWL5000-LTC, ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/RIWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000GPO/R-IWL5000-GPO (including state abbreviations where applicable). For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
ColonialLife.com
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FOR EMPLOYEES
8-23 | 642298-2
WHOLE LIFE INSURANCE PREMIUMS Adult Base Plan Paid-up to Age 70 Non-Tobacco Rates Issue Age 25 30 35 40 45 50
Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium
$10,000.00 $9.87 $11.92 $14.96 $19.35 $25.57 $34.87
$25,000.00 $24.69 $29.79 $37.39 $48.37 $63.93 $87.18
$50,000.00 $49.37 $59.58 $74.79 $96.75 $127.87 $174.37
$100,000.00 $98.75 $119.16 $149.58 $193.49 $255.74 $348.74
$200,000.00 $197.49 $238.32 $299.15 $386.98 $511.48 $697.47
$100,000.00 $92.00 $104.58 $125.16 $155.08 $198.83 $250.99 $324.49 $429.57
$200,000.00 $183.99 $209.16 $250.32 $310.15 $397.65 $501.98 $648.97 $859.13
Adult Base Plan Paid-up to Age 100 Non-Tobacco Rates Issue Age 25 30 35 40 45 50 55 60
Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium 12-Pay Premium
$10,000.00 $9.20 $10.46 $12.52 $15.51 $19.88 $25.10 $32.45 $42.96
$25,000.00 $23.00 $26.14 $31.29 $38.77 $49.71 $62.75 $81.12 $107.39
$50,000.00 $46.00 $52.29 $62.58 $77.54 $99.41 $125.49 $162.24 $214.78
Sample rates only. Multiple choices and options available and rates may vary.
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Click on the video below to learn more about Legal Benefits!
LEGAL BENEFITS
PLAN INTRODUCTION
COVERED SERVICES
PROTECT YOURSELF AND YOUR FAMILY FOR ONLY $19/MONTH The Legal Resources Legal Plan provides 100% coverage on a broad range of legal services. Whether it's an every day legal need or unexpected life event, you can relax...you’re covered.
JOIN DURING YOUR
The annual cost is less than what you would pay for just one hour of attorney’s time!
LEGAL LIFE EVENTS
AGE
ENROLLMENT PERIOD!
20s 30s 40s 50s 60s Renting an apartment
Getting married
Teenage drivers
Estate planning
Revision or review of will
Traffic violations
Buying a home
Home refinance
Family issues
Advance medical directive
Courtroom representation
Preparing a will
Power of attorney for parents
Landlord disputes
Estate advice
Auto purchase agreement
Power of attorney for spouse
Elder Law advice
Insurance claims
Home sale or purchase
Advice and consultation
Contractor disputes
Property disputes
HOA hearings
Warranty disputes
FAQs
CONTACT US
OVERVIEW & MEMBER STORIES
FIND A LAW FIRM 94
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EASY DOCUMENT NAVIGATION
COVERED SERVICES
PLAN INTRODUCTION
FULLY COVERED SERVICES LEGAL RESOURCES COVERS 100% OF THE ATTORNEY FEES FOR FULLY COVERED LEGAL SERVICES General Advice and Consultation
Wills and Estate Planning
• Unlimited in-person or telephone advice and consultation for fully covered services
• Will preparation and periodic updates • Advance medical directive • Financial powers of attorney • Contingent trust for minor children
Family Law • Uncontested domestic adoption • Uncontested divorce • Uncontested name change
Elder Law • Estate advice • Powers of attorney for members’ parents
Traffic Violations • Traffic infractions and misdemeanors • Speeding • Reckless driving • Driving under the influence
Preparation and Review of Routine Legal Documents • Unlimited pages and occurrences
Real Estate • Purchase, sale, or refinance of primary residence • Deed preparation • Tenant-Landlord matters • Landlord-Tenant consultation
Consumer Relations and Credit Protection • Warranty disputes • Billing disputes • Collection agency harassment
1st Offense
Criminal Matters3
Civil Actions
• Defense of misdemeanor • Misdemeanor defense of juveniles
• Representation as defendant • Representation as plaintiff • Insurance matters • Initial administrative hearing • Small Claims Court advice
Fully covered for first offense involving alcohol or illegal drugs
2
Identity Theft • Prevention assistance • Education services • Identity recovery assistance
This SUMMARY OF COVERAGE is intended to provide a broad general overview of plan coverage and is not a contract. Coverage may vary by organization. For specific coverage questions, please call Member Services at 800.728.5768. Member is responsible for all non-attorney costs such as filing fees, court costs, fines, etc.
Don’t see your legal need listed? The Legal Resources Plan offers a 25% discount4 on all other legal needs, including pre-existing legal matters.
HOW THE PLAN WORKS 1
2
Choose a law firm that best suits your needs from our highly rated law firm network. Use our Law Firm Finder at LegalResources.com to find a firm near you.5 If you need to transfer to another Plan Law Firm, call Member Services.
Certified paralegals in our Member Services Department provide you with dedicated, ongoing support and assist you with any coverage or attorney-related concerns.
2 Member is responsible for all non-attorney costs such as filing fees, fines, court costs etc. The Plan covers the individual, spouse and qualifying dependents. 12 month commitment required. Courtroom representation, when necessary, is fully covered through General District Court for claims in excess of $400. The definition of General District Court may vary by state.
4 Since your employer is the participating sponsor, you may not use the Plan in a dispute with your employer.
3 Offenses involving illegal drugs, alcohol (except 1st offense DUI) and firearms are covered at a 25% discount.
Legal Benefits Inc., Virginia Beach, VA. Legal Resources® is Legal Benefits Inc. and all its subsidiaries.
5 Timing of selection may vary based on your location or your employer’s enrollment procedures. ©2017
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Colonial Life for Policyholders Portal A faster, simpler way to manage your benefits
THE PORTAL OFFERS YOU: Faster service than calling/emailing Confirmation when a claim has been submitted
Colonial Life for Policyholders is an online portal created with you in mind. It’s the most convenient and efficient way to file a claim and manage your benefits.
Here’s what you can do on Colonial Life for Policyholders:
Simplified bill payment and management Answers to frequently asked questions and live chat assistance if you don’t see what you are looking for.
LEARN MORE Find out how simple your claims and benefits experience can be by learning more about the Colonial Life for Policyholders portal. Just visit ColonialLife.com to see what this online account administration platform can do for you.
File claims with a simple, guided form
Set up direct deposit for approved payments
View claim status or policy details anytime
Opt for instant alerts by email or text
Update your personal info & preferences
BECOME A MEMBER TODAY: 1
Go to ColonialLife.com/access to register.
2
Click “create an account”, fill out the required information and click Submit.
3
Enjoy faster service and improved benefits awareness.
NEED TO FILE A CLAIM? Filing online means never waiting for mail or dealing with fax machines and complex paper forms . Our guided question wizard walks you through the process and checks for missing information that could cause delays. Opting for direct deposit can also get approved payments to you up to a week faster than paper check.
AFTER YOU FILE: Check your claim status by logging into your account at ColonialLife.com/access. You can also sign up for text or email alerts so you know instantly if status changes or more information is needed. For your convenience, you can login anytime with a mobile device to photograph and upload documents with your camera.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2022 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
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43233-41
Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives. Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments. Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not re- disclose the information unless permitted or required by those laws. Re-disclosed information may no longer be protected by federal privacy laws. This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P. O. Box 1365, Columbia, SC 29202. You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that person's legal Guardian, Power of Attorney Designee, or Conservator. _________________________ ___________________ _______________ ___________ (Printed name of individual (Social Security (Signature) (Date Signed) subject to this disclosure) Number) If applicable, I signed on behalf of the proposed insured as ____________________(indicate relationship). If legal Guardian, Power of Attorney Designee, or Conservator. ______________________________ (Printed name of legal representative)
____________________________ (Signature of legal representative)
UW Authorization
____________ (Date Signed) 62891-1
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REQUIRED HEALTH CARE NOTICES Newborn and Mothers’ Health Protection Act Group health plans and health insurance issuers generally may not, under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Women’s Health and Cancer Rights Act In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully. As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits: 1. All stages of reconstruction of the breast on which the mastectomy has been performed: 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prostheses and treatment of physical complications of the mastectomy , including lymphedemas. Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan.
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Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
REQUIRED HEALTH CARE NOTICES GEORGIA - MEDICAID
ALABAMA - MEDICAID Website: myalhipp.com Phone: 1-855-692-5447
Website: medicaid.georgia.gov/health-insurance premium-payment-program-hipp Phone: 678-564-1162, ext. 2131
ALASKA - MEDICAID
INDIANA - MEDICAID
The AK Health Insurance Premium Payment Program Website: myakhipp.com Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: dhss.alaska.gov/dpa/Pages/ medicaid/default.aspx
Healthy Indiana Plan for Low-Income Adults 19-64 Website: www.in.gov/fssa/hip Phone: 1-877-438-4479 All other Medicaid Website: www.in.gov/medicaid Phone: 1-800-457-4584
ARKANSAS - MEDICAID
IOWA - MEDICAID AND CHIP (HAWKI)
Website: myarhipp.com Phone: 1-855-MyARHIPP (855-692-7447)
Medicaid Website: dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563
CALIFORNIA - MEDICAID
KANSAS - MEDICAID
Website: www.dhcs.ca.gov/services/Pages/ TPLRD_CAU_cont.aspx Phone: 916-440-5676
Website: www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884
COLORADO - HEALTH FIRST COLORADO (MEDICAID) & CHILD HEALTH PLAN PLUS (CHP+)
KENTUCKY - MEDICAID
Health First Colorado Website: www.healthfirstcolorado.com Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711 CHP+: www.colorado.gov/pacific/hcpf/childhealth-plan-plus CHP+ Customer Service: 1-800-359-1991/State Relay 711 Health Insurance Buy-In Program (HIBI): www.colorado.gov/pacific/hcpf/health-insurancebuy-program HIBI Customer Service: 1-855-692-6442
Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: chfs.ky.gov
FLORIDA - MEDICAID
Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)
LOUISIANA - MEDICAID
Website: www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html Phone: 1-877-357-3268 99
REQUIRED HEALTH CARE NOTICES MAINE - MEDICAID
NEVADA - MEDICAID
Website: www.maine.gov/dhhs/ofi/public assistance/index.html Phone: 1-800-442-6003 TTY: Maine Relay 711
Medicaid Website: dhcfp.nv.gov Medicaid Phone: 1-800-992-0900
NEW HAMPSHIRE - MEDICAID
MASSACHUSETTS - MEDICAID AND CHIP
Website: www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext. 5218
Website: www.mass.gov/eohhs/gov/departments/ masshealth Phone: 1-800-862-4840
NEW JERSEY - MEDICAID AND CHIP
MINNESOTA - MEDICAID
Medicaid Website: www.state.nj.us/humanservices/dmahs/clients/medicaid Medicaid Phone: 609-631-2392 CHIP Website: www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710
Website: mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/medical-assistance.jsp [Under ELIGIBILITY tab, see “What if I have other health insurance?”] Phone: 1-800-657-3739
NEW YORK - MEDICAID
KANSAS - MEDICAID
Website: www.health.ny.gov/health_care/ medicaid Phone: 1-800-541-2831
Website: www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884
NORTH CAROLINA - MEDICAID
MISSOURI - MEDICAID
Website: medicaid.ncdhhs.gov Phone: 919-855-4100
Website: www.dss.mo.gov/mhd/participants/ pages/hipp.htm Phone: 573-751-2005
NORTH DAKOTA - MEDICAID Website: www.nd.gov/dhs/services/medicalserv/medicaid Phone: 1-844-854-4825
MONTANA - MEDICAID Website: dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084
OKLAHOMA - MEDICAID & CHIP Website: www.insureoklahoma.org Phone: 1-888-365-3742
NEBRASKA - MEDICAID Website: www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178
OREGON - MEDICAID & CHIP Website: healthcare.oregon.gov/Pages/index.aspx Phone: 1-800-699-9075
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REQUIRED HEALTH CARE NOTICES PENNSYLVANIA - MEDICAID
VERMONT - MEDICAID
Website: www.dhs.pa.gov/providers/Providers/ Pages/Medical/HIPP-Program.aspx Phone: 1-800-692-7462
Website: www.greenmountaincare.org Phone: 1-800-250-8427
VIRGINIA - MEDICAID AND CHIP
RHODE ISLAND - MEDICAID AND CHIP
Website: www.coverva.org/hipp Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282
Website: www.eohhs.ri.gov Phone: 1-855-697-4347 or 401-462-0311 (Direct RIte Share Line)
WASHINGTON - MEDICAID
SOUTH CAROLINA - MEDICAID
Website: www.hca.wa.gov Phone: 1-800-562-3022
Website: www.scdhhs.gov Phone: 1-888-549-0820
WEST VIRGINIA - MEDICAID
SOUTH DAKOTA - MEDICAID
Website: mywvhipp.com Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
Website: dss.sd.gov Phone: 1-888-828-0059
TEXAS - MEDICAID
WISCONSIN - MEDICAID AND CHIP
Website: gethipptexas.com Phone: 1-800-440-0493
Website: www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002
UTAH - MEDICAID
WYOMING - MEDICAID
Medicaid Website: medicaid.utah.gov CHIP Website: health.utah.gov/chip Phone: 1-877-543-7669
Website: wyequalitycare.acs-inc.com Phone: 307-777-7531
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REQUIRED HEALTH CARE NOTICES To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
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COBRA CONTINUATION OF COVERAGE INTRODUCTION: You’re getting this notice because you recently gained coverage under a group plan. This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.
A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.”
You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to King and Queen County Public Schools and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.
What Is Cobra Continuation Coverage?: COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage [choose and enter appropriate information: must pay or aren’t required to pay] for COBRA continuation coverage.
When is COBRA continuation coverage available?
If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. • If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Jennifer Jackson at King and Queen County Public Schools. Applicable documentation will be required i.e. court order, certificate of coverage etc. How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events,
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COBRA CONTINUATION OF COVERAGE or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.
the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.
There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.
Disability extension of 18-month period of COBRA continuation coverage: If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage: If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage?: Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?: In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period to sign up for Medicare Part A or B, beginning on the earlier of • The month after your employment ends; or
For more information visit https://www.medicare.gov/medicare-and-you. If you have questions: Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare. gov. Keep your Plan informed of address changes: To protect your family’s rights, let the Plan Administrator knowabout any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan Contact Information King and Queen County Public Schools Jennifer Jackson, Finance Director jejackson@kqps.net Ashley Edwards, Human Resources Director aeedwards@kqps.net 242 Allen’s Circle King and Queen Courthouse, VA 23085
FSA COBRA Administrator: Ameriflex 2508 Highlander Way, Suite 200 Carrollton, Texas 75006 Fax: 609-257-0136
• The month after group health plan coverage based on current employment ends. If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of
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PRIVACY NOTICES Non Public Information (NPI) We collect Non Public Information (NPI) about our customers to provide them with insurance products and services. This may include telephone number, address, date of birth, occupation, income and health history. We may receive NPI from your applications and forms. medical providers, other insurers, employers, insurance support organizations, and service providers. We share the types of NPI described above primarily with people who perform insurance, business, and professional services for us, such as helping us pay claims and detect fraud. We may share NPI with medical providers for insurance and treatment purposes. We may share NPI with an insurance support organization. The organization may retain the NPI and disclose it to others for whom it performs services. In certain cases, we may share NPI with group policy holders for reporting and auditing purposes. We may share NPI with parties to a proposed or final sale of insurance business or for study purposes. We may also share NPI when otherwise required or permitted by law, such as sharing with governmental or other legal authorities. When legal necessary, we ask your permission before sharing NPI about you our practices apply to our former, current and future customers. Please be assured we do not share your health NPI to market any product or service. We also do not share any NPI to market non financial products and services. For example, we do not sell your name to catalog companies. The law allows us to share NPI as described above (except health information) will affiliates to market financial products and services. The law does not allow you to restrict these disclosures. We may also share with companies that help us market our insurance products and services, such as vendors that provide mailing services to us. We may share with other financial institution to jointly market financial products and services. When required by law, we ask your permission before we share NPI for marketing purposes. When other companies help us conduct business, we expect them to follow applicable privacy laws. We do not authorize them to use or share NPI except when necessary to conduct the work they are performing for us or to meet regulatory or other governmental requirements.
Our affiliated companies, including insurers and insurance service providers, may share NPI about you with each other. The NPI might not be directly related to our transaction or experience with you. It may include financial or other personal information such as employment history. Consistent with the Fair Credit Reporting Act, we ask your permission before sharing NPI that is not directly related to our transaction or experience with you. We have physical, electronic and procedural safeguards that protect the confidentiality and security of NPI. We give access only to employees who need to know the NPI to provide insurance products or services to you. You may request access to certain NPI we collect to provide you with insurance products and services, You must make your request in writing and send it to the address, telephone number and policy number if we have issued a policy. If you request, we will send copies of the NPI to you. If the NPI includes health information, we may provide the health information to you through a health care provider you designate. We will also send you information related to disclosures. We may charge a reasonable fee to cover our copying costs. This section applies to NPI we collect tor provide you with coverage. It does not apply to NPI we collect in anticipation of a claim or civil or criminal proceeding.
in our files. We will file your statement with the disputed NPI. We will include your statement any time we disclose the disputed NPI. We will also give the statement to any person designated by your if we may have disclosed the disputed NPI to that person int he past two years.
Disclosure Notice Concerning The Medical Information Bureau Information regarding your insurability will be treated as confidential. Colonial or its reinsure(s) may, however, make a brief report thereon to the Medical Information Bureau, a nonprofit membership organization of life insurance companies which operates an information exchange on behalf of its members. If you apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such company, the Bureau, upon request, will supply such company with the information in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with the procedure set forth in the federal Fair If you believe NPI we have about you Credit Reporting Act. The address of is incorrect, please write us. Your letter the Bureau’s information office is: 50 should include your full name, address, Braintree Hill Park, Suite 400, Braintree, telephone number and policy number if we have issued a policy. Your letter should MA 02184-8734, telephone (617) 4263660. also explain why you believe the NPI is inaccurate. If we agree with you, we will Colonial or its reinsure may also correct the NPI and notify you of the release information in its file to other correction. We will also notify any person who may have received the incorrect NPI life insurance companies to whom you from us in the past two years if you ask us may apply for life or health insurance or to whom a claim for benefits may be to contact that person. submitted. If we disagree with you, we will tell you we are not going to make the correction, We will give the reason(s) for our refusal. We will also tell you that you may submit a statement to us. Your statement should include the NPI you believe is correct. It should also include the reasons(s) why you disagree with our decision not to correct the NPI 105
CONTINUATION OF COVERAGE We are committed to being there for you and your family at every stage of life. Pierce Group Benefits makes it easy to stay protected! The following benefits can be self-enrolled online or by contacting PGB Employee Services, with Individual and Family coverage options available for most plans. You are eligible to sign-up the first day after the end date of your employer-sponsored plan.
DENTAL BENEFITS
VISION BENEFITS
TELEMEDICINE BENEFITS
SUPPLEMENTAL/VOLUNTARY POLICIES Your individual supplemental/voluntary policies through Colonial Life are portable! To transfer your benefits from payroll deduction to direct billing or automatic bank draft, please call Employee Services at 800-387-5955 within 30 days of becoming unemployed, switching careers, or retiring.
TRANSFERRING EMPLOYERS? If you are transferring from a current PGB client to another, some benefits may be eligible for transfer. Please call Employee Services at 800-387-5955 for assistance.
Please visit www.piercegroupbenefits.com/individualcoverage or call 800-387-5955 for more information on these policies, as well as to enroll/continue your benefits.
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ABOUT PIERCE GROUP BENEFITS Pierce Group Benefits is a leading full-service employee benefits administration and consulting agency serving employer groups across the Southeast. By leveraging market strength, exclusive partnerships, and industry expertise, we deliver trusted advice, products, and solutions that benefit employers and employees alike; delivered by one team and driven by one purpose — together we can do more.
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