MONTGOMERY COUNTY SCHOOLS PLAN YEAR: March 1, 2019 - February 29, 2020
What’s Inside
Benefits Plan Overview………………………………………………..
2
Online Enrollment Instructions …………….……………...
4
Flexible Spending Accounts………………….……………
6
Montgomery County Schools
Cancer Benefits…………………………………………...
13
Plan Year March 1, 2019 through February 29, 2020
State of North Carolina Disability BENEFITS AT A GLANCE**………………………………..
24
Disability Benefits…………………………………………
25
Accident Benefits…………………………….……………
34
State of North Carolina Teachers’ and State Employees’ Health Plan – Plan Comparison**…………...……………
38
Medical Bridge Benefits………………………….………..
40
Critical Care Benefits……………...………………………
47
Life Insurance……………………………………………..
54
Dental Benefits……………………………………………
67
Vision Benefits……………………………….……………
71
Tax-Sheltered Annuity……………………….…………….
72
Pet Insurance…………..…………………..……………..
74
Identity Theft Shield & Life Events Legal Plan ……………..
76
Mobile Apps – View Benefits On-the-Go………………………….……
77
COBRA Continuation of Coverage Rights ……..……….………………
78
Authorization Form……………………………………………………
79
Notice of Insurance Information Practices…………………………….
80
Supplemental Continuation of Coverage Form ………….……………..
81
Montgomery County Schools is offering all eligible employees a comprehensive Benefits Program. This booklet highlights the benefits offered through your employer for the current plan year. Benefits described in this booklet are voluntary, employee-paid benefits unless otherwise noted. You have the opportunity to select the benefits in which you wish to participate. Please see the Benefits Plan Overview section of the booklet for more details. This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail. All information in this booklet including premiums quoted is subject to change. All policy descriptions are for information purposes only. Your actual policies may be different than those in this booklet.
Arranged & Enrolled by
Rev. 03/07/2019
**The State of North Carolina Disability and State of North Carolina Teachers’ and State Employees’ Health Plan pages are included in this booklet for informational purposes only.
Montgomery County Schools | 1
MONTGOMERY COUNTY SCHOOLS EMPLOYEE BENEFITS PROGRAM Provided by Pierce Group Benefits
Pre-Tax Benefits Flexible Spending Accounts* o Medical Reimbursement Maximum $2,700/year o Dependent Care Reimbursement Maximum $5,000/year
Ameriflex
Cancer Benefits
Colonial Life
Medical Bridge Benefits
Colonial Life
Dental Insurance
Sun Life
Vision Insurance
Superior
Tax-Sheltered Annuity
Voya
*You will need to re-sign for the Spending Accounts if you want them to continue next year. IF YOU DO NOT RE-SIGN, YOUR CONTRIBUTION WILL STOP EFFECTIVE February 28, 2019.
Post-Tax Benefits Disability Benefits
Colonial Life
Accident Benefits
Colonial Life
Critical Care Benefits
Colonial Life
Life Insurance o Term Life Insurance o Whole Life Insurance o Group Term Life Insurance
Colonial Life Colonial Life Colonial Life
Pet Insurance
Nationwide
Identity Theft Shield & Life Events Legal Plan
Legal Shield
Insurance Products will remain in effect unless you see a representative to change them.
ENROLLMENT PERIOD January 2, 2019 through February 1, 2019 EFFECTIVE DATES March 1, 2019 through February 29, 2020 (FSAs, Colonial, Group Term Life, TSAs & Legal Plan) April 1, 2019 through March 31, 2020 (Dental & Vision) 2 | Montgomery County Schools
Qualifications • You must work 30 hours or more per week. Important Facts:
The plan year for Colonial Insurance products, Spending Accounts, Voya Tax-Sheltered Annuities, Colonial Group Term Life and Legal Shield Identity Theft Shield & Life Events Legal Plan lasts from March 1, 2019 through February 29, 2020. The plan year for Sun Life Dental and Superior Vision lasts from April 1, 2019 through March 31, 2020. Please Note: Dental benefits are based on the Calendar Year, running from January 1st through December 31st. Dental benefits and deductibles will reset every January 1st.
Deductions for Colonial Insurance products, Spending Accounts, Voya Tax-Sheltered Annuities, Sun Life Dental, Colonial Group Term Life, Superior Vision and Legal Shield Identity Theft Shield & Life Events Legal Plan will begin March 2019.
If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when meeting with the Benefits Representative.
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, available from your Benefits Representative during the open enrollment period. Please note that your debit card is good through the expiration date printed on the card.
Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as defined by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time or vice-versa.
Once a family status change has occurred, an employee has 30 days to notify the North Carolina Service Center at 1-888-662-7500 to request a change in elections.
Medical Reimbursement and Dependent Care Reimbursement expenses must be incurred during the Plan Year in order to be eligible for reimbursement.
An employee has 90 days after the plan year ends to submit claims for medical reimbursement and/or dependent care expenses that were incurred during the plan year. Please note that if employment terminates during the plan year, that employee's plan year ends the day employment ends. The employee has 90 days after the termination date to submit claims.
Unlike Medical Reimbursement Accounts, with Dependent Care Flexible Spending Accounts the maximum reimbursement you can get is equal to the current account balance in your Dependent Care account.
The Colonial Cancer plan and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until March 31, 2019.
Additionally, some policies may include a pre-existing condition clause. Please read your policy carefully for full details.
Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution.
An employee taking a leave of absence, other than under the Family & Medical Leave Act, may not be eligible to re-enter the Flexible Benefits Program until the next plan year. Please contact your Montgomery County Schools Benefit Administrator for more information.
To enroll or make changes to your Flexible Benefits Plan, please see the representative while he/she is at your location.
Montgomery County Schools | 3
ONLINE ENROLLMENT INSTRUCTIONS FOR YOUR ANNUAL ENROLLMENT PERIOD You can make the following benefit elections online from January 2, 2019 through February 1, 2019: Sign up/re-enroll in the Flexible Spending Accounts (Medical Reimbursement and Dependent Care). Enroll, change or cancel your Vision insurance. Enroll, change or cancel your Dental insurance. Enroll, change or cancel your Pre-Paid Legal. Enroll, change or cancel your Pet Insurance (see pages 77-78 for enrollment instructions) Enroll, change or cancel your Colonial products (please see further details below) The following benefit elections must be made with your Benefits Representative during the enrollment period and are not available for online enrollment. Enroll, change or cancel your Group Term Life insurance. Enroll, change or cancel your Tax-Sheltered Annuities. Enroll or change Colonial products (please see further details below)
HARMONY ONLINE ASSISTANCE 1.
Complete the following steps to begin the online enrollment process.
Go to https://harmonyenroll.coloniallife.com
Enter your User Name: MON6K9W- and then your Social Security Number (ex. MON6K9W-123456789)
Enter your Password: First 4 letters of your last name and then last 4 numbers of your Social Security Number (ex. SMIT6789)
Helpful Tips: If you are a new employee and unable to log into the online system, please see the Benefits Representative while he/she is at your school or location or at the scheduled make-up day. If you are an existing employee and unable to log into the online system, please contact the Harmony Help Desk at 866-8754772 between 8:30am and 6:00pm or speak with your Benefits Representative while he/she is at your school or location or at the scheduled make-up day. 2. 3. 4. 5. 6. 7. 8.
The screen prompts you to create a NEW password [____________________________]. Choose a security question and enter answer [______________________________________]. Click on ‘I Agree’ and then “Enter My Enrollment”. The screen shows ‘Me & My Family’. Verify that the information is correct and enter the additional required information (title, marital status, work phone, e-mail address). Click ‘Save & Continue’ twice. The screen allows you to add family members. It is only necessary to enter family member information if adding or including family members in your coverage. Click ‘Continue’. The screen shows updated personal information. Verify that the information is correct and make changes if necessary. Click ‘Continue’. The screen shows ‘My Benefits’. Review your current benefits and make changes/selections for the upcoming plan year.
Dental (Choose one of the options and click ‘Save & Continue’): 1. If you have existing coverage and would like to keep it without making changes, click ‘Keep This Benefit’; 2. If you would like to enroll in coverage, or change existing coverage, choose your plan in the Enroll section; 3. If you would like to decline coverage, click ‘Decline/Cancel Coverage’ Select family members that you wish to cover with your dental insurance by clicking ‘Add a Family Member’.
Vision (Choose one of the options and click ‘Save & Continue’): 1. If you have existing coverage and would like to keep it without making changes, click ‘Keep This Benefit’; 2. If you would like to enroll in coverage, or change existing coverage, choose your plan in the Enroll section; 3. If you would like to decline coverage, click ‘Decline/Cancel Coverage’ Select family members that you wish to cover with your vision insurance by clicking ‘Add a Family Member’. Note: If you cancel your vision coverage, please be aware that you will not be allowed back into the plan for two years since the benefits are based on a 24-month plan design.
Pre-Paid Legal (Choose one of the options and click ‘Save & Continue’): 1. 2.
If you would like to enroll in coverage, choose your plan in the Enroll section; If you would like to decline coverage, click ‘Decline/Cancel Coverage’
Instructions continued on next page
4 | Montgomery County Schools
Online Enrollment Instructions
Health Care FSA (Choose one of the options and click ‘Save & Continue’): 1. Enter annual amount. MAX $2,700/year Dependent Care FSA (Choose one of the options and click ‘Save & Continue’): 1. Enter annual amount. MAX $5,000/year Cancer Assist You may enroll online in Cancer Assist coverage.
Disability – NCK1000 You may enroll online in NCK1000 – the North Carolina Educator Disability Plan.
Accident 1.0 You may enroll online in Accident 1.0; however persons over age 64 applying for coverage and employees wishing to purchase an individual policy for their spouse must meet with the Benefits Representative.
Medical Bridge You may enroll online in Medical Bridge coverage.
Critical Care You may enroll online in Critical Care coverage.
Term Life 1000 You may enroll online in Term Life 1000; however, employees wishing to purchase an individual policy for their spouse should meet with the Benefits Representative.
Whole Life 1000 You may enroll online in Whole Life 1000; however, employees wishing to purchase an individual policy for their spouse should meet with the Benefits Representative.
9. 10. 11. 12.
Click ‘Finish’. Click ‘I Agree’ to electronically sign the authorization for your benefit elections. Click ‘Print a copy of your Elections’ to print a copy of your elections. Please do not forget this important step!!! Click ‘Log out & close your browser window’ and click ‘Log Out’.
Please Note: When using the Harmony online enrollment system, Internet Explorer should be utilized for best results. Harmony is not compatible with other browsers (such as Google Chrome and Firefox), and web pages may not display properly when using browsers other than Internet Explorer.
Montgomery County Schools | 5
FLEXIBLE SPENDING ACCOUNTS
6 | Montgomery County Schools
Flexible Spending Accounts
Montgomery County Schools | 7
Flexible Spending Accounts
8 | Montgomery County Schools
Flexible Spending Accounts
Montgomery County Schools | 9
Flexible Spending Accounts
Employer: Montgomery County Schools Plan Year: March 1, 2019 through February 29, 2020
FREQUENTLY ASKED QUESTIONS What are my Maximum Annual Contributions? The maximum you may contribute to the Healthcare Flexible Spending Account is $2,700 /year. The maximum you may contribute to the Dependent Care Account is $5,000 /year. What happens if I don’t use all the money in my FSA by the end of the plan year? By law, employers are not allowed to return leftover money to participants. When can I start using the money in my FSA account? You can access your annual contribution at the start of your plan year. Will I get paid less every pay period if I enroll in an FSA? Your gross, or pre-tax, pay will remain the same. But your “net” pay will be lower because a portion of it will go into your FSA account. The advantage is that this money gets put into your FSA account before taxes, which lowers your “taxable” income. You have complete access to these funds for any qualified medical expense for you and your family. When do I choose my contribution amount and can I change it anytime? You choose your FSA contribution amount during your annual enrollment; this is the time of year you can elect and/or change your benefits such as medical, dental, etc. Once your contribution election becomes effective, you won’t be able to change it until the next enrollment period, unless there is a change in your eligibility status, which the IRS refers to as a “qualifying event.” Some qualifying events include, but are not limited to (please refer to your Summary Plan Description for an exhaustive list): Change in provider (Dependent Care only) Change in cost of day care (Dependent Care only) Change in legal marital status Change in number of legal dependents The election change must be consistent with the qualifying event. A change is considered consistent with the qualifying event for healthcare FSAs if the following occurs: The employee, spouse, or dependent is gaining or losing eligibility for health coverage. The election change corresponds with the gain or loss of coverage. Instead of enrolling in an FSA, why shouldn’t I just make these deductions on my income tax? Claiming a tax return deduction is only beneficial for people with substantial uninsured medical expenses. According to the IRS, only medical/dental expenses that exceed 10% of your “adjusted gross income” and are not covered by insurance can be deducted from your income taxes. Most people do not have uninsured medical expenses high enough to qualify for this deduction. Who is eligible to participate? Employees who work at least 30 hours per week are eligible to participate. Eligible employees must sign a new enrollment form before the start of each plan year. New employees must wait until the annual enrollment in order to enroll in Flexible Spending Accounts. Eligible employees can claim expenses incurred by their dependents as defined under section 125 of the Internal Revenue Code. What happens to my FSA contributions if I leave or am terminated from my job? If you leave or are terminated from your job and have a positive balance in your FSA account, you do have COBRA rights. If you do not exercise those rights, the balance remaining in your FSA will be forfeited. Ameriflex will deactivate the terminated employee’s MyAmeriflex Card on the date they are notified of the termination. Any eligible expenses incurred, and not yet submitted for reimbursement prior to or on the date of termination, must be filed using a manual claim form and must be received by Ameriflex within the run-out period described in the Summary Plan Description. How may I access my account information? You may log in to your FSA account anytime to view your account balance, account activity and transaction history. Access your account at www.myameriflex.com. You may also call Ameriflex directly at 888-868-3539 to speak to a representative or to access the 24/7 Interactive Voice Response System.
10 | Montgomery County Schools
Flexible Spending Accounts Managing Your Account
Montgomery County Schools | 11
Flexible Spending Accounts The FSA Store
The FSAStore – One Convenient Location for All Your FSA Purchases Pierce Group Benefits recently partnered with the FSAStore to provide one convenient location for all your FSA eligible purchases. Through our partnership, Pierce Group Benefits and the FSAStore can help you shop for FSA eligible items, search for local and eligible physicians, and answer the many questions that come along with having a Flexible Spending Account. COMPONENTS The FSAstore focuses on three main channels to help you better understand your benefits and eligible services and products as an FSA participant:
Products – Shop for more than 4,000 FSA eligible products Services – Find FSA eligible services and providers in your area Learning Center – Learn more about your FSA and get answers to your questions BENEFITS
By utilizing FSAStore, you get the following benefits:
Easily understand which products require a prescription and which do not Get access to FSA eligible services and providers in your area Find answers to commonly and not-so-commonly asked FSA questions Enjoy free shipping on orders over $50 with a short 1-2 day turnaround time Have access to 24/7 customer support Get your favorite brands at discounted prices ACCESSING FSASTORE Accessing the FSAStore is easy. Simply visit www.FSAStore.com!
12 | Montgomery County Schools
CANCER BENEFIT Provided by Colonial Life The following information highlights the benefits of the current Cancer policy available through your benefits package. If you enrolled in a Cancer Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.
Montgomery County Schools | 13
Cancer Benefit
14 | Montgomery County Schools
Cancer Benefit
Montgomery County Schools | 15
Cancer Benefit
16 | Montgomery County Schools
Cancer Benefit
Montgomery County Schools | 17
Cancer Benefit
18 | Montgomery County Schools
Cancer Benefit
Montgomery County Schools | 19
Cancer Benefit
20 | Montgomery County Schools
Cancer Benefit
Montgomery County Schools | 21
Cancer Benefit
22 | Montgomery County Schools
Cancer Benefit
Individual Cancer Rates LEVEL 1 – Monthly Premiums - Composite Rates Employee
Employee /Spouse
One-Parent Family
Two-Parent Family
$18.25
$28.75
Level 1 with $100 Cancer Wellness/Health Screening Premium
$18.10
$28.60
LEVEL 2 – Monthly Premiums - Composite Rates Employee
Employee /Spouse
One-Parent Family
Two-Parent Family
$21.95
$34.15
Level 2 with $100 Cancer Wellness/Health Screening Premium
$21.65
$33.85
LEVEL 3 – Monthly Premiums - Composite Rates Employee
Employee /Spouse
One-Parent Family
Two-Parent Family
$27.10
$44.85
Level 3 with $100 Cancer Wellness/Health Screening Premium
$26.65
$44.40
LEVEL 4 – Monthly Premiums - Composite Rates Employee
Employee /Spouse
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 4 with $100 Cancer Wellness/Health Screening Premium
$35.60
$59.40
OPTIONAL RIDERS Employee
Employee /Spouse
Specified Disease Hospital Confinement Rider Premium
$1.25
Initial Diagnosis of Cancer Rider (per $1,000) Premium
$1.50
Initial Diagnosis of Cancer Progressive Payment Rider Premium
$7.80
$17.05
Montgomery County Schools | 23
STATE OF NORTH CAROLINA DISABILITY BENEFITS AT A GLANCE To be eligible for Short-Term Disability benefits you must have at least one year of contributing membership service in the Retirement System earned within the 36 calendar months preceding your disability. To be eligible for Long-Term Disability benefits you must have at least five years of contributing membership service in the Retirement System earned within the 96 calendar months prior to becoming disabled or upon cessation of continuous salary continuation payments, whichever is later.
THE STATE OF NORTH CAROLINA PROVIDES A DISABILITY INCOME PLAN FOR ITS PERMANENT, FULL-TIME TEACHERS AND STATE EMPLOYEES – AT NO COST TO THE INDIVIDUAL. The State Plan is designed to provide for the continuation of a portion of your salary should you suffer the misfortune of an accident or sickness which disables you for longer than 60 days. HERE’S HOW IT WORKS… 1.
WHEN YOU ARE DISABLED: First 12 Months of Disability
Thereafter**
Percentage of Your Total Monthly Salary the State Pays You*
50%
65%
Maximum Total Benefit
$3,000
$3,900
Workers’ Compensation
Workers’ Compensation Social Security
Reduced By
Not Reduced By Social Security ---------------------* 1/12 of your total pay during the 12 months prior to your disability. ** you must have at least five years of contributing membership service in the Retirement System earned within the 96 calendar months prior to the end of the short-term disability period. 2.
Benefits under the State Plan are payable, for “Disability,” which means that you are mentally or physically incapable of performing the duties of your usual occupation.
3. You become a member of the plan when you become a full-time, permanent employee of the State, and you are eligible to receive benefits from the Plan if you become disabled after you have completed one year’s service. Your coverage under the Plan ends when your employment with the State terminates. 4.
Benefits of the Plan are payable beginning 60 DAYS AFTER THE DATE OF YOUR DISABILITY (60-day waiting period).
5.
The Plan coordinates with other benefits related to your employment, so that after the amounts you are eligible to receive from Social Security (for the first six months only), Workers’ Compensation, or State retirement plans, etc., the State pays you enough, in addition, to total a) 50% the first twelve months and b) 65% thereafter of your total salary, as explained in the chart above. HOWEVER, ANY BENEFIT FROM A PLAN FOR WHICH YOU PAY THE ENTIRE COST YOURSELF DOES NOT AFFECT THE STATE PLAN IN ANY WAY. BENEFITS ARE SUBJECT TO NC STATE LAW
This information provided by Colonial Life Columbia, South Carolina 29202 www.coloniallife.com 24 | Montgomery County Schools
DISABILITY BENEFIT Short-Term Disability Benefit Provided by Colonial Life The following information highlights the benefits of the current Disability policy available through your benefits package. If you enrolled in a Disability Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.
Montgomery County Schools | 25
Disability Benefit Short-Term Disability
26 | Montgomery County Schools
Disability Benefit Short-Term Disability
Montgomery County Schools | 27
Disability Benefit Short-Term Disability
28 | Montgomery County Schools
Disability Benefit Short-Term Disability
Montgomery County Schools | 29
Disability Benefit Short-Term Disability
30 | Montgomery County Schools
Disability Benefit Short-Term Disability
Montgomery County Schools | 31
Disability Benefit Short-Term Disability
32 | Montgomery County Schools
Disability Benefit Short-Term Disability
Montgomery County Schools | 33
ACCIDENT BENEFIT Provided by Colonial Life The following information highlights the benefits of the current Accident policy available through your benefits package. If you enrolled in an Accident Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.
34 | Montgomery County Schools
Accident Benefit
Montgomery County Schools | 35
Accident Benefit
36 | Montgomery County Schools
Accident Benefit
Accident 1.0 – Preferred with Health Screening Monthly Premiums Named Insured Employee & Spouse One-Parent Family Two-Parent Family
$21.15 $28.97 $32.67 $40.48
Montgomery County Schools | 37
STATE OF NORTH CAROLINA TEACHERS’ AND STATE EMPLOYEES’ HEALTH PLAN The following summary is included in this benefit booklet for informational purposes only. Open enrollment for the State of North Carolina Teachers’ and State Employees’ Health Plan is not part of this Flexible Benefits Plan Open Enrollment Period.
38 | Montgomery County Schools
State of North Carolina Teachers’ and State Employees’ Health Plan
Montgomery County Schools | 39
MEDICAL BRIDGE BENEFIT Provided by Colonial Life The following information highlights the benefits of the current Medical Bridge policy available through your benefits package. If you enrolled in a Medical Bridge Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.
40 | Montgomery County Schools
Medical Bridge Benefit Plan 2
Montgomery County Schools | 41
Medical Bridge Benefit Plan 3
42 | Montgomery County Schools
Medical Bridge Benefit Plan 3
Montgomery County Schools | 43
Medical Bridge Benefit Health Screening
44 | Montgomery County Schools
Medical Bridge Benefit Medical Treatment Package
Montgomery County Schools | 45
Medical Bridge Benefit Optional Riders
46 | Montgomery County Schools
CRITICAL CARE BENEFIT Provided by Colonial Life The following information highlights the benefits of the current Critical Care policy available through your benefits package. If you enrolled in a Critical Care Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.
Montgomery County Schools | 47
Critical Care Benefit Plan 1 – Cancer & Specified Disease
48 | Montgomery County Schools
Critical Care Benefit First Diagnosis Building Benefit Rider – Specified Disease & Cancer (Plan 1)
Montgomery County Schools | 49
Critical Care Benefit Plan 3 – Specified Disease
50 | Montgomery County Schools
Critical Care Benefit Plan 3 – Specified Disease
Montgomery County Schools | 51
Critical Care Benefit First Diagnosis Building Benefit Rider – Specified Disease (Plan 3)
52 | Montgomery County Schools
Critical Care Benefit Health Screening Benefit
Montgomery County Schools | 53
TERM LIFE INSURANCE Provided by Colonial Life The following information highlights the benefits of the current Term Life policy available through your benefits package. If you enrolled in a Term Life Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.
54 | Montgomery County Schools
Term Life Insurance
Montgomery County Schools | 55
WHOLE LIFE INSURANCE Provided by Colonial Life The following information highlights the benefits of the current Whole Life policy available through your benefits package. If you enrolled in a Whole Life Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.
56 | Montgomery County Schools
Whole Life Insurance
Montgomery County Schools | 57
Whole Life Insurance Long-Term Care Benefit Rider
58 | Montgomery County Schools
Whole Life Insurance Long-Term Care Benefit Rider
Montgomery County Schools | 59
Juvenile Whole Life Insurance
60 | Montgomery County Schools
Juvenile Whole Life Insurance
Montgomery County Schools | 61
GROUP TERM LIFE INSURANCE Provided by Colonial
62 | Montgomery County Schools
Group Term Life Insurance
Montgomery County Schools | 63
Group Term Life Insurance
64 | Montgomery County Schools
Group Term Life Insurance
Montgomery County Schools | 65
Group Term Life Insurance
Employee Supplemental Life Increments of $10,000 to a maximum of $500,000 or the lesser of 5x salary
10-month $0.216 per $1,000
Spouse Supplemental Life Increments of $5,000 to a maximum $0.216 per $1,000 of $500,000 not to exceed 100% of the Employee Supplemental Life amount Child(ren) Supplemental Life Increments of $5,000 to a maximum of $10,000
66 | Montgomery County Schools
$0.18 per $1,000
12-month $0.18 per $1,000
$0.18 per $1,000
$0.15 per $1,000
DENTAL INSURANCE Provided by Sun Life
Montgomery County Schools | 67
Dental Insurance
68 | Montgomery County Schools
Dental Insurance
Montgomery County Schools | 69
Dental Insurance
70 | Montgomery County Schools
VISION INSURANCE Provided by Superior
Outline of Benefits Copayments:
Materials Discount SVP8-20
$10.00 Comprehensive Eye Exam $10.00 Materials $25.00 Contact Lens Fitting
In-network co-pays are paid directly to the provider Out-of-network co-pays will be deducted from the out-of-network reimbursement. Materials co-pay applies to lenses and/or frames, not contact lenses
In-Network1
Out-ofNetwork1
Covered in Full Covered in Full
Up to $44 Up to $39
Covered in Full Covered in Full Covered in Full Covered in Full Covered to providers retail trifocal amount
Up to $34 Up to $48 Up to $64 Up to $88 Up to $64
Contact Lenses(Per Pair):2 Medically Necessary Elective3
Covered in Full Up to $150
Up to $210 Up to $100
Contact Lens Fitting4 Standard Specialty
Covered in Full Up to $50
Not Covered Not Covered
Frames – Standard3
Up to $150
Up to $77
Comprehensive Eye Exam:
Ophthalmologist (MD) Optometrist (OD) Standard Lenses (Per Pair): Single Vision Bifocal Trifocal Lenticular Progressives
These discounts apply to upgrades on the covered frame and lenses only. For discounts on additional pairs, please refer to the Discounts on Additional Purchases.
Frames 20% off the difference between the covered frame allowance and the retail price of the selected frame. Note: Discounts do not apply when prohibited by the manufacturer.
Add-ons to the covered pair of lenses Lens Options and Member pays 20% off Upgrades retail up to: Scratch coat (factory) Ultraviolet coat
1
All in-network and out-of-network allowances are at the retail value. 2 Contact lenses are in lieu of eyeglass lenses and frames benefit. 3 The insured is responsible for paying any charges in excess of this allowance. 4 Standard contact lens fitting applies to an existing contact lens user who wears disposable, daily wear, or extended wear lenses only. The specialty contact lens fitting applies to new contact lens wearers and/or a member who wears toric, gas permeable or multi-focal lenses.
Plan Frequency Comprehensive Exam Contact Lens Fitting Exam Lenses Frames Contact Lenses
12 Months 12 Months 12 Months 24 Months 12 Months
Standard anti-reflective coat High Index 1.6 Polycarbonate Standard photochromic Plastic tints solid or gradient Glass coloring Power over 4.00 Sphere, 2.00D Cylinder & 5.00D Prism Cosmetic finishing, beveling, edging & mounting All other lens options/upgrades
$13 (single vision & standard lined multifocal lenses) $15 (single vision & standard lined multifocal lenses) $50 (single vision & standard lined multifocal lenses) $55 (single vision lenses only) $40 (single vision lenses only) $80 (single vision lenses only) $25 (any type lenses) $35 (any type lenses) Member pays: 20% discount off retail 20% discount off retail 20% discount off retail
Higher end or brand name lens upgrades are at an additional expense to you. These upgrades will be available at a 20% discount off retail. Progressive Power Lens Benefit (no-line): The member pays the difference between the provider’s price for Standard Trifocal lenses and the price of the progressive power lenses selected, less 20%.
For assistance with using your plan, please contact Customer Service at (800) 507-3800. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance Coverage for your vision plan. Please check with your Benefits Administrator or Human Resources department if you have any questions.
Monthly Rates Employee Only Employee + One Dependent Employee + Family
10-Month $11.64 $22.56 $33.12
12-Month $9.70 $18.80 $27.60
Materials Discounts on Additional Purchases: Prescription eyeglass lenses Add-on charges to basic lenses Contact lenses, standard hard or soft Disposable contact lenses
30% off retail 20% off retail 20% off retail 10% off retail
All other prescription materials Eyeglass frames Everyday “frame and lens” package pricing
20% off retail 30% off retail 20% off retail
Discounts are provided by Superior Vision contracted providers identified in the provider directory.
Refractive Surgery Discount Superior Vision Services has a nationwide network of refractive surgeons. These providers offer Superior Vision Plan members a discounted rate off the usual and customary prices for LASIK surgery. These discounts vary depending on the provider but are the best possible discounts available to Superior Vision.
Superior Vision Services, Inc. PO Box 967 Rancho Cordova, CA 95741, 800-507-3800 www.superiorvision.com The Superior Vision Plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life
Montgomery County Schools | 71
TAX-SHELTERED ANNUITY Benefits Provided by Voya
72 | Montgomery County Schools
Tax-Sheltered Annuity
Montgomery County Schools | 73
PET INSURANCE Provided by Nationwide
74 | Montgomery County Schools
Pet Insurance
Montgomery County Schools | 75
IDENTITY THEFT SHIELD & LIFE EVENTS LEGAL PLAN Provided by Legal Shield
76 | Montgomery County Schools
MOBILE APPS – VIEW BENEFITS ON-THE-GO
Montgomery County Schools | 77
General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction - You are receiving this notice because you have recently become covered under a group health plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. 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 when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional 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. What is COBRA Continuation Coverage? - COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens:
Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens:
Your spouse dies; Your spouse’s hours of employment are reduced; Your spouse’s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens:
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.”
When is COBRA Coverage Available? - The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, commencement of a proceeding in bankruptcy with respect to the employer, or the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event. You Must Give Notice of Some Qualifying Events - For the 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. How is COBRA 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. When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended. Disability extension of 18-month period of continuation coverage - If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total 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 continuation coverage. Second qualifying event extension of 18-month period of continuation coverage - If your family experiences another qualifying event while receiving 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 notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. 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 ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), 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 the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) Keep Your Plan Informed of Address Changes - In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. COBRA Administrator for Dental Coverage Interactive Medical Systems, PO Box 1349, Wake Forest, NC 27588 COBRA Administrator for Vision Coverage Superior Vision, Attn: COBRA, 11101 White Rock Road, Rancho Cordova, CA 95670 COBRA Administrator for FSA Coverage Ameriflex, 2508 Highlander Way, Suite 200, Carrollton, TX 75006, Fax: 609-257-0136
78 | Montgomery County Schools
Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives. Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments. Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by those laws. This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202. You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, or Conservator.
________________________ (Printed name of individual subject to this disclosure)
_____________ (Social Security Number)
___________________ (Signature)
________________ (Date Signed)
If applicable, I signed on behalf of the proposed insured as __________________________ (indicate relationship). If legal Guardian, Power or Attorney Designee, or Conservator.
________________________________ (Printed name of legal representative)
_____________________________ (Signature of legal representative)
___________ (Date Signed)
Montgomery County Schools | 79
80 | Montgomery County Schools
Montgomery County Schools | 81
Flexible Spending Accounts – AMERIFLEX
Voya – Tax-Sheltered Annuity
Mailing Address…..7 Carnegie Plaza Ste. 200, Cherry Hill, NJ 08003 Internet Address for Ameriflex………………www.myameriflex.com
Customer Service.........................................................1-877-884-5050
For questions, duplicate cards and other service questions contact:
Customer Service.........................................................1-800-442-7742 Fax Claims …………………………………………..1-563-242-0184 Internet Address……………………………....…www.sunlife.com/us
Medical or Dependent Care Customer Service……....1-888-868-3539 Please fax claims to the number printed on your form
For Directions on checking your Flexible Spending Account balance and history online (cardholders only) and accessing manual claim forms, please visit www.myameriflex.com. See page 11 of your Benefit Booklet for information on Managing your Flexible Spending Accounts!
Sun Life - Dental Insurance
Superior - Vision Insurance Customer Service.........................................................1-800-507-3800 Internet Address….........................................www.superiorvision.com
Nationwide – Pet Insurance Customer Service………………………….…………1-877-738-7874 Internet Address………………………..…www.PetsNationwide.com
North Carolina State Health Plan
To view your benefits online visit
Customer Service.........................................................1-888-234-2416 Internet Address…........................................................http://shpnc.org
Harmony Online Enrollment See pages 4-5 for online enrollment instructions Technical Help Desk ...................................................1-866-875-4772
www.piercegroupbenefits.com/ montgomerycountyschools or for additional information concerning plans offered to employees of Montgomery County Schools, please contact our North Carolina Service Center at 1-888-662-7500, ext. 100
Colonial Life Visit ColonialLife.com to set up your personal account. Download the free My Colonial Life app available at the Apple iTunes store to access claims and policy information! Customer Service & Wellness Screenings 1-800-325-4368 TDD for hearing impaired customers call 1-800-798-4040
Internet Address www.coloniallife.com
Claims Fax 1-800-880-9325
If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 18 months, you need the name and date of the test performed as well as your doctor’s name and phone number. Colonial also needs to know if this is for you or another covered individual and their name and social security number. You may: FILE BY PHONE! Call 1-800-325-4368 and provide the information requested by Colonial’s Automated Voice Response System, 24 hours per day, 7 days a week, or SUBMIT ON THE INTERNET using the Wellness Claim Form at www.coloniallife.com, or Write your name, address, social security number and/or policy/certificate number on your bill and indicate “Wellness Test.” Fax this to Colonial at 1-800-880-9325 or MAIL to PO Box 100195, Columbia, SC 29202 If your Wellness/Cancer Screening test was more than 18 months ago, you must fax or mail Colonial a copy of the bill or statement from your doctor indicating the type of procedure performed, the charge incurred and the date of service. Please write your full name, social security number, and current address on the bill. Please Note: If your cancer policy includes a second part to the screening benefit, bills for tests covered and a copy of the diagnostic report (reflecting the abnormal reading of your first test) must be mailed or faxed to us for benefits to be provided.
When you terminate employment with Montgomery County Schools, you have the opportunity to continue your Colonial coverage either through direct billing or automatic payment through your bank account. Please contact Colonial at 1-800-325-4368 to request the continuation of benefits form.