Employee Benefits Plan
Arranged by Pierce Group Benefits
WESTMORELAND COUNTY PUBLIC SCHOOLS PLAN YEAR: October 1, 2018 - September 30, 2019
What’s Inside Benefits Plan Overview..................................................................
Westmoreland County Public Schools Plan Year October 1, 2018 through September 30, 2019
Health Insurance The Local Choice Benefits-At-A-Glance……….…………...………
Dental Benefits The Local Choice Benefits-At-A-Glance……….…………….………
Vision Benefits The Local Choice Benefits-At-A-Glance……….…………….………
Westmoreland County Public 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
Pierce Group Benefits Rev. 08/08/2018
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Contribution Schedule for The Local Choice Coverage……
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Flexible Spending Accounts………………………………
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Medical Bridge Indemnity Benefits………………………..
18
Disability Benefits…………………………………………
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Cancer Benefits…………………………………………...
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Group Critical Care Benefits………………………………
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Accident Benefits…………………………………………
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Life Insurance Term Life Insurance……..…………………………….………………..… Whole Life Insurance…………………………………..………………….
Vision Benefits
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Superior Vision Benefits-At-A-Glance………….…………….………
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Mobile Apps – View Benefits On-the-Go………………………….……
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COBRA Continuation of Coverage Rights……..………………………
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Authorization Form……………………………………………………
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Notice of Insurance Information Practices…………………………….
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Supplemental Continuation of Coverage Form………………………..
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WESTMORELAND COUNTY PUBLIC SCHOOLS EMPLOYEE BENEFITS PROGRAM Provided by Pierce Group Benefits
Pre-Tax Benefits Health Insurance
Anthem –The Local Choice*
Dental Insurance
Delta Dental – The Local Choice*
Vision Insurance
Anthem – The Local Choice* Superior Vision**
Flexible Spending Accounts*** o Medical Reimbursement Maximum $2,650/year o Dependent Care Reimbursement Maximum $5,000/year Cancer Benefits
Colonial Life
Medical Bridge Indemnity Benefits
Colonial Life
Accident Benefits
Colonial Life
*The Local Choice benefits are included in this booklet for information purposes only. **Westmoreland County Public Schools will pay the Employee Only portion for each tier of Superior Vision benefits for employees that waive medical coverage and provide proof of coverage elsewhere. ***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 September 30, 2018.
Post-Tax Benefits Disability Benefits
Colonial Life
Group Critical Care Benefits
Colonial Life
Life Insurance o Term Life Insurance o Whole Life Insurance
Colonial Life Colonial Life
Enrollment Period
August 13, 2018 through September 7, 2018 Effective Dates
October 1, 2018 through September 30, 2019
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Qualifications • You must work 20 hours or more per week and be in a contract. Important Facts:
The plan year for Flexible Spending Accounts, Colonial Insurance products and Superior Vision lasts from October 1, 2018 through September 30, 2019. Deductions for Flexible Spending Accounts, Colonial Insurance products and Superior Vision will begin October 2018. 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 Pierce Group Benefits Service Center at 1-800-387-5955 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 Medical Bridge plan have a 30day waiting period for new enrollees. Coverage, therefore, will not begin until October 31, 2018.
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 Benefits Program until the next plan year. Please contact your Westmoreland County Public Schools Benefit Administrator for more information.
To enroll or make changes to your Benefits Plan, please see the representative while he/she is at your location.
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HEALTH INSURANCE Provided by Anthem – The Local Choice The Local Choice Health Benefits are listed in this benefit booklet for Informational Purposes Only
Westmoreland County Public School 10/1/2018 - 9/30/2019 Key Advantage 500
Plan Year Deductible (applies as indicated) One Person Family (two or more people)
Plan Year Out-of-Pocket Expense Limit Individual Out of Pocket Maximum Family Out of Pocket Maximum
Lifetime Maximum
Key Advantage Expanded
In-Network
Out-of-Network
In-Network
Out-of-Network
$500
$1,000
$100
$200
$1,000
$2,000
$200
$400
In-Network
Out-of-Network
In-Network
Out-of-Network
$4,000 $8,000
$7,000 $14,000
$2,000 $4,000
$3,000 $6,000
Unlimited for all plans
Unlimited for all plans
Primary Care Physician Visits
$25 copayment
$15 copayment
Specialist
$40 copayment
$25 copayment
20% coinsurance after deductible
$250 copayment (waived if admitted)
$25 copayment
$15 copayment
Covered Services Doctor's Visits (outpatient or in-office)
Emergency Room Chiropractic, Spinal Manipulations (30 visit limit) - PCP
Hospital and Other Covered Services Pre-certification may be required
Inpatient Hospital Services Ambulance Services Outpatient Hospital Services Outpatient Diagnostic Services Outpatient Therapy - Occupational, Speech, Physical, Cardiac, Chemotherapy, Radiation, Infusion, and Respiratory
Diabetic Equipment
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
$300 copayment/stay 20% coinsurance after deductible $100 copayment 20% coinsurance, no deductible 20% coinsurance after deductible 20% coinsurance after deductible
Maternity Prenatal & Provider Services- Primary Care Physician
$25 copayment
$15 copayment
Prenatal & Provider Services- Specialty Care Physician
$40 copayment
$25 copayment
Hospital Services for Delivery Diagnostic tests, labs, and x-rays
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20% coinsurance after deductible 20% coinsurance after deductible
$300 copayment per stay** 20% coinsurance, no deductible
Health Insurance
Westmoreland School Anthem BlueCrossCounty BlueShieldPublic – The Local Choice 10/1/2018 - 9/30/2019 Key Advantage 500
Health Behavioral Plan Year Deductible (applies as indicated) Inpatient Treatment/Residential Treatment
One Person Partial Hospitalization (Day Program)
Family (two or more people) Outpatient Professional Provider Visits
Plan Year Out-of-Pocket Expense Limit Drug Benefit* Prescription Individual Out of Pocket Maximum Family Out of Pocket Maximum Tier 1
Lifetime Maximum
In-Network
Out-of-Network
20% coinsurance after deductible $500 $1,000 after 20% coinsurance deductible
Key Advantage Expanded In-Network
Out-of-Network
$300 copayment per stay
$100
$200
$100 copayment per stay
$1,000
$2,000
$200
In-Network
Out-of-Network
In-Network
Out-of-Network
$4,000 $8,000
$7,000 $14,000
$2,000 $4,000
$3,000 $6,000
$25 copayment
$10 Copayment
$400
$15 copayment
$10 Copayment
Unlimited for all plans
Unlimited for all plans
$30 Copayment
$30 Copayment
$45 Copayment
$45 Copayment
Primary 4 Care Physician Visits Tier
Copayment $55 $25 copayment
$55 $15 Copayment copayment
Home Delivery Services (Mail Order) Specialist
$40 copayment copay 2 x retail
$25 copayment copay x retail 2
Tier 2 3 Tier Doctor's
Covered Services Visits (outpatient or in-office)
Emergency Room
Diabetic Supplies
20% coinsurance after
$250 copayment (waived if
no deductible 20% Coinsurance, deductible
no deductible 20% Coinsurance, admitted)
Chiropractic, Manipulations visit limit) - PCP $25 copayment you may get the drug, no generic equivalent for the$15 is copayment However, if there program. drug generic (30 mandatory *You have a Spinal brand and pay only the applicable benefit level. If there is a generic equivalent available, you may opt to use the brand level-plus the difference between the brand and generic allowable charge. applicable Services pay the Covered but you'll brand Hospital and Other Pre-certification may be required
Inpatient Hospital Services Ambulance Services Outpatient Hospital Services Outpatient Diagnostic Services Outpatient Therapy - Occupational, Speech, Physical, Cardiac, Chemotherapy, Radiation, Infusion, and Respiratory
Diabetic Equipment
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
$300 copayment/stay 20% coinsurance after deductible $100 copayment 20% coinsurance, no deductible 20% coinsurance after deductible 20% coinsurance after deductible
Maternity Prenatal & Provider Services- Primary Care Physician
$25 copayment
$15 copayment
Prenatal & Provider Services- Specialty Care Physician
$40 copayment
$25 copayment
Hospital Services for Delivery Diagnostic tests, labs, and x-rays
20% coinsurance after deductible 20% coinsurance after deductible
$300 copayment per stay** 20% coinsurance, no deductible
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DENTAL INSURANCE Provided by Delta Dental – The Local Choice The Local Choice Dental Benefits are listed in this benefit booklet for Informational Purposes Only
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Dental Insurance Delta Dental – The Local Choice
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VISION INSURANCE Provided by Anthem – The Local Choice The Local Choice Vision Benefits are listed in this benefit booklet for Informational Purposes Only
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!
Go to www.anthem.com/tlc to find a Blue View Vision provider near you
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.
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.
BLUE VIEW VISION PLAN AT-A-GLANCE
IN-NETWORK
OUT-OF-NETWORK
High Deductible Health Plan
$15 copayment
$50 allowance
Key Advantage 1000
$40 copayment
$50 allowance
Key Advantage 500
$40 copayment
$50 allowance
Key Advantage 250
$35 copayment
$50 allowance
Key Advantage Expanded
$25 copayment
$50 allowance
$100 allowance then 20% off remaining balance
$80 allowance
Routine Eye Exam (once per year)
Eyeglass frames Once per plan year you may select any eyeglass frame* and receive the following allowance toward the purchase price:
Standard Eyeglass Lenses Polycarb onate lenses included for children under 19 years old. Once per plan year you may receive any one of the following lens options: · Standard plastic single vision lenses (1 pair)
$20 copay; then covered in full
$50 allowance
· Standard plastic bifocal lenses (1 pair)
$20 copay; then covered in full
$75 allowance
· Standard plastic trifocal lenses (1 pair) Upgrade Eyeglass Lenses (available for additional cost)
$20 copay; then covered in full $100 allowance 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. Lens Options Member cost for upgrades
UV Coating
$15
Tint (Solid and Gradient)
$15
Standard Scratch-Resistance
$15
Standard Polycarbonate
$40
Standard Progressive (add-on to b ifocal) Standard Anti-Reflective Coating
$65 $45
Other Add-ons and Services
Discounts on lens upgrades are not available out-of-network
20% off retail price
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 per plan year. $100 allowance then 15% off the · Elective Conventional Lenses** $80 allowance remaining balance $100 allowance (no additional · Elective Disposable Lenses** $80 allowance discount) · Non-Elective Contact Lenses**
$250 allowance
$80 allowance
*Discount is not available on certain frame brands in which the manufacturer imposes a no discount policy. **Elective contact lenses are in lieu of eyeglass lenses. Non-elective lenses are medically necessary when glasses are not an option for visio correction such as after cataract surgery.
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Vision Insurance Anthem Blue View Vision – The Local Choice
ROUTINE VISION CARE SERVICES (continued) BLUE VIEW VISION PLAN AT-A-GLANCE
IN-NETWORK
OUT-OF-NETWORK
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
You pay up to $55
Discount not available
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.
Premium contact lens fitting
10% off retail price
Discount not available
A premium contact lens fitting includes all lens designs, materials and speciality fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal.
Additional Savings on Eyewear & Assessories 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 (as many pairs as you like)
Conventional Contact Lenses (Materials Only)
LASIK VISION CORRECTION
40% discount off retail
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.
15% off retail price
NON-ROUTINE VISION SERVICES
Additional Eyewear & Accessories Includes eyeglass frames and eyeglass lenses purchased separately, some non-prescription sunglasses, eye glasses cases, lens cleaning supplies, contact lens solutions, etc.
20% off retail price
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.
The additional savings program is subject to change without notice
If you choose an out-of-network provider, you must complete the Blue View out-of-network 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-of-pocket limit is reached.
Questions? Contact Anthem member services at 1-800-552-2682
This benefit overview insert is only one piec 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 judgement. They are not agents or employees of Anthem. Anthem Blue Cross and Blue Shield is the trade name of Antehm 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 Blue Shield Association.
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WESTMORELAND COUNTY PUBLIC SCHOOLS CONTRIBUTION SCHEDULE
The Local Choice Health Benefits Program Insurance Premiums October 1, 2018 – September 30, 2019 Key Advantage Expanded with Comprehensive Dental Monthly Premium
Employee Only
Employer Share
Employee Share
with Preventive Dental Only Monthly Premium
Employer Share
Employee Share
$769.00
$600.95
$168.05
$753.00
$600.95
$152.05
Employee + One (Child or Spouse)
$1,423.00
$721.15
$701.85
$1,393.00
$721.15
$671.85
Family
$2,076.00
$841.35
$1,234.65
$2,033.00
$841.35
$1,191.65
Key Advantage 500 with Comprehensive Dental Monthly Premium
Employee Only
Employer Share
Employee Share
with Preventive Dental Only Monthly Premium
Employer Share
Employee Share
$645.00
$600.95
$44.05
$629.00
$600.95
$28.05
Employee + One (Child or Spouse)
$1,193.00
$721.15
$471.85
$1,164.00
$721.15
$442.85
Family
$1,742.00
$841.35
$900.65
$1,698.00
$841.35
$856.65
Advantage 65 with Dental and Vision Retirees Eligible for Medicare
Monthly Premium
Employee Only
$201.00
NOTE: The School Board share of the monthly premium is deducted for each employee. This could be a savings for some employees. Employee couples and employee couples with children may want to take this into consideration when choosing which plan and option to enroll in.
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FLEXIBLE SPENDING ACCOUNTS
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Flexible Spending Accounts
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Flexible Spending Accounts
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Flexible Spending Accounts
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Flexible Spending Accounts
Employer: Westmoreland County Public Schools Plan Year: October 1, 2018 through September 30, 2019
FREQUENTLY ASKED QUESTIONS What are my Maximum Annual Contributions? The maximum you may contribute to the Healthcare Flexible Spending Account is $2,650 /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 20 hours per week and in a contract are eligible to participate. Eligible employees must sign a new enrollment form before the start of each plan year. New employees must sign an enrollment form within 30 days of their hire date in order to participate for the remainder of the year. 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.
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Flexible Spending Accounts
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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!
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MEDICAL BRIDGE INDEMNITY 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 1-800-387-5955 for any assistance.
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Medical Bridge Indemnity Benefit
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Medical Bridge Indemnity Benefit
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Medical Bridge Indemnity Benefit
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Medical Bridge Indemnity Benefit
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Medical Bridge Indemnity Benefit
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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 1-800-387-5955 for any assistance.
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Disability Benefit
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Disability Benefit
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Disability Benefit
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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 1-800-387-5955 for any assistance.
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Cancer Benefit
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Cancer Benefit
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Cancer Benefit
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Cancer Benefit Level 4 Benefits
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Cancer Benefit Level 4 Benefits
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Cancer Benefit Wellness Benefit
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Cancer Benefit Cancer Rates – Levels 1-4
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
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GROUP CRITICAL CARE BENEFIT Provided by Colonial Life The following information highlights the benefits of the current Group 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 1-800-387-5955 for any assistance.
GROUP CRITICAL CARE – PLAN 1 – CANCER AND SPECIFIED DISEASE
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Group Critical Care Benefit Plan 1 – Cancer & Specified Disease
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Group Critical Care Benefit Plan 3 – Specified Disease GROUP CRITICAL CARE – PLAN 3 – SPECIFIED DISEASE
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Group Critical Care Benefit Plan 3 – Specified Disease
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Group Critical Care Benefit Health Screening Benefit
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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 1-800-387-5955 for any assistance.
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Accident Benefit
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Accident Benefit
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Accident Benefit
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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 1-800-387-5955 for any assistance.
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Term Life Insurance
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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 1-800-387-5955 for any assistance.
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Whole Life Insurance
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Whole Life Insurance Long-Term Care Benefit Rider
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Whole Life Insurance Long-Term Care Benefit Rider
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Juvenile Whole Life Insurance
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Juvenile Whole Life Insurance
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VISION INSURANCE Provided by Superior
Westmoreland County Public Schools will pay the Employee Only portion for each tier of Superior Vision benefits for employees that waive medical coverage and provide proof of coverage elsewhere.
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MOBILE APPS – VIEW BENEFITS ON-THE-GO
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General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction You are receiving this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct. If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: Your spouse dies; Your spouse’s hours of employment are reduced; Your spouse’s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: The parent-employee dies; The parent-employee’s hours of employment are reduced; The parent-employee’s employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a “dependent child.” Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Westmoreland 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. When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: The end of employment or reduction of hours of employment; Death of the employee; Commencement of a proceeding in bankruptcy with respect to the employer; or The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Constance Allen at Westmoreland County Public Schools. Applicable documentation will be required i.e. court order, certificate of coverage etc.
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General Notice of COBRA Continuation Coverage Rights (continued)
How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov. Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan contact information Westmoreland County Public Schools Attn: Constance Allen 141 Opal Lane Montross, Virginia Phone: 804-493-8018 Fax: 804-493-9323 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
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Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives. Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments. Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by those laws. This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202. You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, or Conservator.
________________________ (Printed name of individual subject to this disclosure)
_____________ (Social Security Number)
___________________ (Signature)
________________ (Date Signed)
If applicable, I signed on behalf of the proposed insured as __________________________ (indicate relationship). If legal Guardian, Power or Attorney Designee, or Conservator.
________________________________ (Printed name of legal representative)
_____________________________ (Signature of legal representative)
___________ (Date Signed)
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THE LOCAL CHOICE (TLC)
AMERIFLEX
HEALTH, DENTAL & VISION
FLEXIBLE SPENDING ACCOUNTS
Medical, Pharmacy, Vision/Hearing
Mailing Address…..7 Carnegie Plaza Ste. 200, Cherry Hill, NJ 08003 Internet Address for Ameriflex………………www.myameriflex.com
1-800-552-2682 1-855-223-9277
For questions, duplicate cards and other service questions contact: 1-888-868-3539
ID Card Order Line
Please fax claims to the number printed on your form
1-866-587-6713
For Directions on checking your account balance and history online (cardholders only) and accessing manual claim forms, please visit www.myameriflex.com.
Behavioral Health and Employee Assistance Program (EAP)
Coverage While Traveling (BlueCard Program) 1-800-810-2583
24/7 NurseLine
See page 16 of your Benefit Booklet for information on Managing your Flexible Spending Accounts!
1-800-337-4770
Delta Dental
Superior - Vision Insurance
1-888-335-8296
www.thelocalchoice.virginia.gov
Customer Service.........................................................1-800-507-3800 Internet Address….........................................www.superiorvision.com
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 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 1-800880-9325 or MAIL to PO Box 100195, Columbia, SC 29202 If your Wellness/Cancer Screening test was more than one year 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 Westmoreland County Public 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.
To view your benefits online visit
www.piercegroupbenefits.com/westmorelandcountypublicschools or for additional information concerning plans offered to employees of Westmoreland County Public Schools, please contact our Pierce Group Benefits Service Center at 1-800-387-5955.