Annual Benefits Enrollment

Transcription

Annual Benefits Enrollment
Employee Benefit Options
2013
The Benefits Enrollment period is from November 12th through December 14th. During this time
you have the opportunity to review your benefit choices and add, delete, or change coverage.
Any benefit changes made during this time will become effective January 1st and will remain in
effect until the next Benefit Enrollment period. Your premium for each benefit will be divided
and deducted from your paycheck(s) each month, according to your specified pay period. Keep
in mind that all employees are eligible as long as you are considered a full time employee,
working 30+ hours a week, and as long as you have met your 90 day probationary period.
Per IRS guidelines, changes to your benefits after December 14th cannot be made unless there is
a “family status change”, which is referred to as a Qualifying Event. Please see them listed
below.
1.
2.
3.
4.
5.
6.
7.
8.
90-day waiting period for new hires
Birth
Death
Marriage
Divorce
Adoption
Loss of coverage under spouse’s employment
Change of employment status from part-time to full-time or change in position.
Should you wish to add, delete or change coverage during one of these qualifying events, please
complete the appropriate enrollment forms and return to the Benefits Department.
If you have any questions, Jessica Rodriguez or Janie Saucedo are ready to assist you. You can
use the following resources to reach them:
Office (210) 344-2088
Fax (210) 344-2777
Email: [email protected]
[email protected]
Kind Regards,
The Benefits Department
EMPLOYEE BENEFITS
Table of Contents:
Page
1. Major Medical Benefits
1
2. Starbridge Limited Medical Benefit
5
3. Patient Plus Discount Card
9
4. Gap Plan Reimbursement Benefit
10
5. United Concordia Dental
12
6. Cigna Dental
13
7. Aetna Dental
14
8. VSP Vision Benefit
15
9. UNUM Life Benefit
16
10. Principal Short Term Disability
18
11. Aflac
19
12. Retirement Plan Options – Call for details (the plan is customized for each client)
$2000 Deductible 100/70 Co-Pay Plan
Your Benefits Summary – Buy-Up Plan
PLAN FEATURES
Deductible (per calendar year)
NETWORK BENEFITS
$ 2,000
$ 6,000
NON-NETWORK
BENEFITS
Individual
Family
$ 4,000 Individual
$ 12,000 Family
Member Co-payments do not accumulate towards the Deductible. All individual Deductible amounts will count toward the family Deductible, but an individual will
not have to pay more than the individual Deductible amount. This benefit plan contains a Per Occurrence Deductible that applies to certain Covered Health Services.
This Per Occurrence Deductible must be met prior to and in addition to the Annual Deductible.
Out-of-Pocket Maximum-Individual
Out-of-Pocket Maximum-Family
No Out-of-Pocket Maximum
$ 8,000 per year
$ 24,000 per year
Member Co-payments do not accumulate towards the Out-of-Pocket Maximum. All individual Out-of-Pocket Maximum amounts will count toward the family Out-ofPocket Maximum, but an individual will not have to pay more than the individual Out-of-Pocket Maximum amount. The Out-of-Pocket Maximum does not include the
Annual and Per Occurrence Deductibles.
Benefit Plan Co-Insurance
100% after Deductible has been met
Lifetime Maximum Policy Benefit
Combined Network and Non-Network Maximum of $5,000,000 per Covered
Person.
Physician’s Office Services –Sickness & Injury
Primary Physician Office Visit
Specialist Physician Office Visit
100% after $25 Co-Payment
In addition to the visit Co-Payment, the applicable Co-Payment or Deductible/Co-Insurance applies when these services are done: CT, PET, MRI, Nuclear Medicine:
Pharmaceutical Products; Scopic Procedures; Surgery; Therapeutic Treatments.
Preventative Care Services
Lab, X-Ray or other preventive tests
100%; Deductible does not apply
Urgent Care Center Services
In addition to the visit Co-Payment, the applicable Co-Payment or Deductible/Co-Insurance applies when these services are done: CT, PET, MRI, Nuclear Medicine;
Pharmaceutical Products; Scopic Procedures; surgery; Therapeutic Treatments.
Emergency Health Services-Outpatient
Request for Pre-authorization of Services required if results in an Inpatient Stay for Preferred and Non-Preferred care.
Hospital-Inpatient Stay
Ambulance Service –Emergency & Non-Emergency
Ground Ambulance
Air Ambulance
70% after Per Occurrence
Deductible of $500 and Annual
Deductible have been met.
Request for Pre-authorization
of Services is required.
100% after Network
Deductible has been met
100% after Network
Request for Pre-authorization of Services required for Non-Emergency Ambulance for both Network and Non-Network.
Page 1
Your Benefits Summary – Buy-Up Plan
PLAN FEATURES
NETWORK BENEFITS
NON-NETWORK
BENEFITS
Lab, X-Ray and Diagnostics-Outpatient
100% Deductible does not apply
Preventative Lab, X-ray and Diagnostics, refer to the Preventative Care Services category. Major Diagnostics-Outpatient pays 100%
after Deductible has been met.
Prescriptions
No Deductible
No Deductible
Out-of-Pocket Maximum
$3,000 Individual / $9,000 Family
Tier Levels:
Retail $15 / Mail Order $45
Retail $15
Retail $35
Retail $70
Tier 1
Tier 2
Tier 3
All Prescription Drug Products on the List provided by the Prescription Drug List Management Committee are assigned to Tier 1, Tier 2 or Tier 3. Only certain
Prescription Drug Products are available through mail order.
Maternity Services
Depending upon where the Covered Health Service is provided, Benefits will be the
same as those stated under each Covered Health Service category in this Summary.
For services provided in Physician’s Office,
a Co-Payment will only apply to the initial
office visit.
Request for Pre-authorization of
Services required if Inpatient Stay
exceeds 48 hours following a
normal vaginal delivery or 96 hours
following a cesarean delivery.
Surgery-Outpatient
Deductible have been met
Vision Examinations
(1 exam every 2 years)
Please review plan documents for exclusions and limitations.
Enrollment in United Healthcare is subject to pre-approval by Pinnacle and is not available in all areas.
Medical Monthly Rates
Employee Only
Employee & Spouse
Employee & Child(ren)
Family
$ 498.50
$ 1,046.84
$ 947.15
$ 1,495.49
Page 2
Your Benefits Summary – Base Plan
PLAN FEATURES
Deductible (per calendar year)
NETWORK BENEFITS
NON-NETWORK
BENEFITS
$ 4,000 Individual
$ 12,000 Family
$ 8,000 Individual
$ 24,000 Family
Member Co-payments do not accumulate towards the Deductible. All individual Deductible amounts will count toward the family Deductible, but an individual will
not have to pay more than the individual Deductible amount. This benefit plan contains a Per Occurrence Deductible that applies to certain Covered Health Services.
This Per Occurrence Deductible must be met prior to and in addition to the Annual Deductible.
Out-of-Pocket Maximum-Individual
Out-of-Pocket Maximum-Family
$ 8,000 per year
$ 24,000 per year
Member Co-payments do not accumulate towards the Out-of-Pocket Maximum. All individual Out-of-Pocket Maximum amounts will count toward the family Out-ofPocket Maximum, but an individual will not have to pay more than the individual Out-of-Pocket Maximum amount. The Out-of-Pocket Maximum does not include the
Annual and Per Occurrence Deductibles.
Benefit Plan Co-Insurance
Lifetime Maximum Policy Benefit
Combined Network and Non-Network Maximum of $5,000,000 per Covered
Person.
Physician’s Office Services –Sickness & Injury
70% after Deductible has been
met
In addition to the visit Co-Payment, the applicable Co-Payment or Deductible/Co-Insurance applies when these services are done: CT, PET, MRI, Nuclear Medicine:
Pharmaceutical Products; Scopic Procedures; Surgery; Therapeutic Treatments.
Preventative Care Services
Lab, X-Ray or other preventive tests
100%; Deductible does not apply
Urgent Care Center Services
In addition to the visit Co-Payment, the applicable Co-Payment or Deductible/Co-Insurance applies when these services are done: CT, PET, MRI, Nuclear Medicine;
Pharmaceutical Products; Scopic Procedures; surgery; Therapeutic Treatments.
Emergency Health Services-Outpatient
Request for Pre-authorization of Services required if results in an Inpatient Stay for Preferred and Non-Preferred care.
Hospital-Inpatient Stay
Ambulance Service –Emergency & Non-Emergency
Ground Ambulance
Air Ambulance
Deductible have been met.
Request for Pre-authorization
of Services is required.
100% after Network
100% after Network
Request for Pre-authorization of Services required for Non-Emergency Ambulance for both Network and Non-Network.
Page 3
Your Benefits Summary – Base Plan
PLAN FEATURES
NETWORK BENEFITS
Lab, X-Ray and Diagnostics-Outpatient
100% Deductible does not apply
NON-NETWORK
BENEFITS
Preventative Lab, X-ray and Diagnostics, refer to the Preventative Care Services category. Major Diagnostics-Outpatient pays 100% after Deductible has been met.
Prescription Drugs
No Deductible
No Deductible
Out-of-Pocket Maximum
Tier Levels:
Retail $15
Retail $35
Retail $70
Tier 1
Tier 2
Tier 3
All Prescription Drug Products on the List provided by the Prescription Drug List Management Committee are assigned to Tier 1, Tier 2 or Tier 3. Only certain
Prescription Drug Products are available through mail order.
Maternity Services
Depending upon where the Covered Health Service is provided, Benefits will be the
same as those stated under each Covered Health Service category in this Summary.
For services provided in Physician’s Office,
a Co-Payment will only apply to the initial
office visit.
Request for Pre-authorization of
Services required if Inpatient Stay
exceeds 48 hours following a
normal vaginal delivery or 96 hours
following a cesarean delivery.
Surgery-Outpatient
Deductible have been met
Vision Examinations
(1 exam every 2 years)
Please review plan documents for exclusions and limitations.
Enrollment in United Healthcare is subject to pre-approval by Pinnacle and is not available in all areas.
Medical Monthly Rates
Employee Only
Employee & Spouse
Family
$ 440.37
$ 924.77
$ 836.69
$ 1,321.10
Page 4
Annual Limit Waiver Notice
Please read the special notice below that explains the annual limits for coverage options
The Affordable Care Act prohibits health plans from applying dollar limits below a specific amount on coverage
for certain benefits. This year, if a plan applies a dollar limit on the coverage it provides for certain benefits in a
year, that limit must be at least $1.25 million.
Your health coverage, offered by Connecticut General Life Insurance Company, does not meet the minimum
standrads required by the Affordable Care Act described above.
Your coverage has an annual limit of:
Covered Services
Level 1
Level 2
Level 3
Outpatient Care
up to $1,000
per coverage year
up to $1,500
per coverage year
up to $3,000
per coverage year
up to $1,500
per surgery
up to $1,500
per occurrence
up to $300
per coverage year
up to $2,500
per accident,
2 accidents per
coverage year
up to $2,000
per coverage year
up to $5,000
per coverage year
up to $2,500
per surgery
up to $2,500
per occurance
up to $600
per coverage year
up to $5,000
per accident,
2 accidents per
coverage year
Inpatient Care
Supplemental In-hospital Surgery
up to $2,000
per coverage year
Supplemental Maternity-related
Illness
Prescription Coverage
Not included
Accident Medical Coverage
up to $1,000
per accident,
2 accidents per
coverage year
This means that your health coverage might not pay for all of the health care expenses you incur.
For example, a stay in the hospital
Level 1
Level 2
Level 3
costs around $1,853 per day.
At this cost, your insurance would
1.07 days
1.61 days
2.69 days
only pay for:
Note: If you seek care at a network hospital, additional time may be covered because the
network discount may result in a lower cost per day. If you are hospitalized for surgery or
maternity care, your coverage may also pay for additional hospital services as described in your
benefit booklet.
Your health plan has requested that the U.S. Department of Health and Human Services waive the
requirement to provide coverage for certain key benefits of at least $1.25 million this year. Your
health plan has stated that meeting this minimum dollar limit this year would result in a significant
increase in your premiums or a significant decrease in your access to benefits. Based on this
representation, this U.S. Department of Health and Human Services has waived the requirement for
your plan until December 31, 2013.
GF101_1210
Page 5
If you are concerned about your plans lower dollar limits on key benefits, you and your
family may have other options for health care coverage. For more information, go to:
www.HealthCare.gov.
If you have any questions or concerns about this notice, contact CIGNA at 1-800-420-6308.
In addition, you can contact your state's Consumer Assistance Program.
State
Primary #
State
Primary #
State
Primary #
State
Primary #
AL
(334) 241-4141
IL
(877) 527-9431
MT
(800) 322-6148
RI
(401) 462-9520
AK
(800) 467-8725
IN
(800) 622-4461
NE
(877) 564-7323
SC
(800) 768-3467
AZ
(800) 325-2548
IA
(877) 955-1212
NV
(888) 333-1597
SD
(605) 773-3563
AR
(855) 332-2227
KS
(800) 432-2484
NH
(800) 852-3416
TN
(615) 741-4737
CA
(800) 927-4357
KY
(877) 587-7222
NJ
(800) 446-7467
TX
(855) 839-2427
CO
(800) 930-3745
LA
(800) 259-5301
NM
(888) 427-5772
UT
(801) 528-3077
CT
(866) 466-4446
ME
(800) 965-7476
NY
(888) 614-5400
VT
(800) 917-7787
DE
(800) 282-8611
MD
(877) 261-8807
NC
(800) 546-5664
VI
(340) 773-6459
DC
(877) 685-6391
MA
(800) 272-4232
ND
(800) 247-0560
VA
(877) 310-6560
FL
(877) 693-5236
MI
(877) 999-6442
OH
(800) 686-1526
WA
(800) 562-6900
GA
(800) 656-2298
MN
(800) 657-3602
OK
(800) 522-0071
WV
(888) 879-9842
HI
(808) 586-2799
MS
(877) 314-3843
OR
(855) 999-3210
WI
(800) 236-8517
ID
(800) 721-3272
MO
(800) 726-7390
PA
(877) 881-6388
WY
(800) 438-5768
GF 101_1210
Page 6
ww.aetna.com
Cigna Starbridge Limited Medical Plan
Doctor’s Office Visit*
copay
plan pays
Wellness Benefit
copay
plan pays
number of occurrences
maximum amount paid by plan
Non ER Care in ER Room*
deductible
plan pays
Outpatient Care
deductible
plan pays
maximum amount paid plan
Prescription Benefit
copay
plan pays
Inpatient Care (Illness)
deductible
plan pays
In-Hospital Surgery
deductible
plan pays
Maternity Benefit
deductible
plan pays
Accident Coverage
deductible
plan pays
number of occurrences
maximum per occurrence
Accident Death Benefit
plan pays
CIGNA 24-Hour EAP℠
(Included on all plan designs)
Healthy Rewards®
Online Tools
Level 3
Level 2
Level 1
$10
100%
$10
100%
$15
100%
$20
100%
1/year
$100/visit
$20
100%
1/year
$100/visit
$100/occurrence
50%
$500/year
$100/occurrence
50%
$500/year
$100/occurrence
50%
$500/year
$150/year
80%
$2,000/year
discount program included§
$15/generic, $30/brand
100%
$600/year
$100/year
80%
$1,500/year
discount program included§
$15/generic, $30/brand
100%
$300/year
$50/year
80%
$1,000/year
$0
100%
$5,000/year
$0
100%
$3,000/year
$0
100%
$2,000/year
$0
100%
$2,500/occurrence
$0
100%
$1,500/occurrence
Covered under
Inpatient Care
$0
100%
$2,500/occurrence
$0
100%
$1,500/occurrence
Covered under
Inpatient Care
$100/occurrence
80%
2/year
$5,000
$10,000/year
$50/occurrence
80%
2/year
$2,500
$5,000/year
$50/occurrence
80%
2/year
$1,000
$2,000/year
$25,000
$15,000
$10,000
not included
discount program
included§
The CIGNA 24-Hour Employee Assistance ProgramSM is available day or night for helpful
information on a range of health topics. The EAP program includes access to: 24-hour nurse line,
mental health assistance (includes 3 in-person consultations per year per condition), and a health
information library.
Healthy Rewards offers discounts on health products and services such as: weight loss
programs, vitamins, vision and dental products. Members will also receive discounts of up
to 60% on brand names like Weight Watchers, Jenny Craig, and much more.
CIGNA provides a variety of online tools available only to our members. They’ll be able
to locate network doctors or pharmacies that provide discounts. Members can also track
the status of claims that have been submitted.
Page 7
PLEASE NOTE: If visiting the ER for a true emergency, your benefits will come out of Outpatient, Inpatient, and/or Accident
Coverage. If you receive non-emergency treatment in the Emergency Room (care you could receive in a doctor’s office), your
coverage is reduced to: $100/deductible per occurrence, the plan pays 50% of total bill with a $500 maximum per year. You will be
responsible for the remaining balance.
Please refer to limitations and exclusions for other restrictions.
*Healthy Rewards is not available in all states and is not insurance.
* The total amount Starbridge pays will count toward your Outpatient Care Maximum. *The prescription discount program is not
insurance. *Provision varies by state.
*Work related injuries are not covered.
CIGNA STARBRIDGE MONTHLY RATES
LEVEL 1
Employee Only
Employee + 1
Family
$79.22
$194.42
$293.79
LEVEL 2
Employee Only
Employee + 1
Family
$168.81
$416.60
$625.49
LEVEL 3
Employee Only
Employee + 1
Family
$258.94
$634.86
$958.87
**These rates are good through December 31, 2013**
As a reminder, we continue to include in each level of the medical plans CIGNA’s Behavioral Health programs including face to face
counselor visits, 24/7 access to registered nurse, unlimited telephonic consultation and an audio health information library. Employees
enrolled with any of the three Starbridge medical plans continue to have access to participating doctors in the CIGNA National PPO
Network. There are no out-of-network penalties with Starbridge benefit plans however, employees who use a participating network
doctor can take advantage of discounts we have already negotiated and can help their benefit dollars last longer.
We also continue to make available CIGNA’s Healthy Rewards Program as a discount program to further manage our member’s
healthcare costs for all of our medical members. This discount program further demonstrates our commitment to supporting wellness
and consumer empowerment by providing our members access to a range of health and wellness discount programs/services often not
covered by many benefit plans. Healthy Rewards targets high concern areas like weight management, tobacco cessation, fitness and
mind/body connection.
Please contact Customer Service at 1-800-308-5948 and reference Group # 8005 with any questions.
www.cignavoluntary.com
Page 8
PatientPlus Card – Highlights of Coverage
PatientPlus Card is a healthcare savings program featuring DoctorNavigator.com. The online price transparency tool is
designed to empower individuals with cost comparison information for physician services and prescriptions. The
program can help save on out-of-pocket medical expenses for uninsured individuals. The PatientPlus Card is not
insurance.
For employees that feel that the limited-benefit medical plan offerings are too expensive.
PatientPlus offers these valuable features:
•
Know physician and prescription prices before you go
•
Receive 10-40% discounts on:
1. Galaxy Health Network
400,000 Physicians and Specialists
50,000 Hospitals and Facilities
2. ScriptSave
53,000 Pharmacies
3. Coast to Coast Vision
12,000 Vision Care Providers
4. Aetna Dental Access
71,000 Dentists
•
Review patient satisfaction ratings by DrScore
•
Physicians and Hospital quality information
•
Medical condition research
•
Patient advocacy resources
PatientPlus Card – Monthly Rates
All Employee/Family Levels
$8.95
Page 9
THE GAP PLAN REIMBURSEMENT PROCEDURES
What is the Gap Plan?
The Gap Plan is a first dollar benefit program that reimburses the insured for charges
accruing towards their annual deductible and coinsurance.
Base Plan
In-Patient Benefit
Up to $1,000 (per calendar year)
Out-Patient Benefit
Up to $1,000 (per condition: 4 / family per calendar year)
Buy Up Plan
In-Patient Benefit
Up to $2,000 (per calendar year)
Out-Patient Benefit
Up to $2,000 (per condition: 4 / family per calendar year)
What does an insured need to submit a claim for reimbursement?
1. Claim Form- A completed claim form is required one time per year. If your
address or phone number has changed since your last claim you will need to send
in a new claim form with the updated information. Sign and date the
authorization section (the insured must sign and date the claim form for dependent
children).
2. Explanation of Benefits ( EOB ) from your primary insurance company. This
is the statement from the primary carrier that lists what charges they are paying,
denying or applying to deductibles, etc. This is sent to your home address
following activity on your health insurance account.
3. Itemized Provider Bill- Attach copies of the original bills showing the
diagnosis and procedure codes, date of service, name and address of the provider
and the provider tax identification number.
(REGULAR BILLING STATEMENTS NOT ACCEPTED)
What should I know about claim payment?
1. If you submit all of the information necessary to process your claim it will
take 5-10 days to issue payment.
2. Payment will be made directly to the provider if there is a balance due on the
claim form. Special Insurance Services will reimburse you directly if the
documentation you submitted shows that you have already paid the account in
full and the account balance is $0.
What is not reimbursed by the Gap Plan?
1. Copays for doctor visits or Prescriptions
2. Durable Medical equipment
3. Outpatient mental health
4. Wellness / Annual Exams (usually covered by office visit copay)
Where do I submit my paperwork?
Special Insurance Services, PO Box 250349, Plano, TX 75025-0349
For claim status please contact customer service at 1-800-767-6811.
You may fax your paperwork directly to Special Insurance Services at 1-972-960-0377.
Please make sure your name, social security number, group name and policy number is
on all correspondence.
Page 10
PINNACLE CORPORATION
First Dollar Reimbursement Plan - NEXSTEP - Special Insurance Services & Fidelity
Plan:
In-Patient Benefit:
Out-Patient Benefit:
Maximum # of Occurrences
Pre-Existing Conditions Clause:
Type of Coverage
Under 40 - Insured Only
Under 40 - Insured plus Children
Under 40 - Insured plus Spouse
Under 40 - Insured plus Family
1/1 Plan
2/2 Plan
$1,000
$2,000
$1,000
$2,000
4 per family per year 4 per family per year
No
No
Monthly
Monthly
$21.54
$30.96
$52.11
$73.02
$38.78
$55.75
$69.31
$97.75
40-49 - Insured Only
40-49 - Insured plus Children
40-49 - Insured plus Spouse
40-49 - Insured plus Family
$27.32
$54.27
$49.12
$76.10
$39.19
$87.82
$70.56
$115.92
50 and Older - Insured Only
50 and Older - Insured plus Children
50 and Older - Insured plus Spouse
50 and Older - Insured plus Family
$57.85
$98.94
$104.13
$145.17
$80.31
$136.82
$144.51
$200.96
Page 11
Schedule of Benefits
Concordia Flex Dental Plan
Plan Pays
Class I Services
•
Exams, All X-Rays, Cleanings & Fluoride Treatments, Sealants, Palliative
Treatment
Class II Services
•
•
•
Space Maintainers, Basic Restorative (Fillings, etc.), Endodontics
Non-surgical Periodontics, Repairs of Crowns, Inlays, or Onlays
Repairs of Bridges, Denture Repair, Simple Extractions
Class III Services
•
•
Surgical Periodontics, Complex Oral Surgery
Inlays, Onlays, Crowns, Prosthetics (Bridges, Dentures)
Orthodontics
•
•
Diagnostic, Active, Retention Treatment
Limited to Dependent children under the age of 18
100%
80%
80%
80%
50%
50%
50%
Deductibles & Maximums
•
•
•
$50 per Calendar Year Deductible per Member (excluding Class I & Orthodontics) not to
exceed $150 per family
$1,000 per Calendar Year Maximum per Member
$1,000 lifetime Maximum per Member for Orthodontics
All services on this Schedule of Benefits are subject to the Schedule of Exclusions and Limitations. Consult Your
Certificate for more details on the services listed.
Eligible members have the option to receive services from a dental provider of their choice. UC will pay charges in
accordance with the above benefit summary. Fees are based on reasonable and customary charges normally
charged in your area. Any amount above reasonable and customary will be the responsibility of the employee. UC
has a list of providers that have agreed to accept the reasonable and customary amount without billing the
participant the difference. Access the Provider Directory list at www.ucci.com.
Membership toll free #: 1-800-332-0366.
UNITED CONCORDIA DENTAL MONTHLY RATES
Employee Only
Employee + 1
$40.80
$78.06
Employee + Family $136.05
Page 12
CIGNA DENTAL DHMO
Diagnostic/Preventive
All covered by plan 100%
•
•
•
•
Consultation
Office Visit for Observation
Periodic and Limited Oral Evaluation
All X-Rays
Cleanings covered every 6 months
Call Cigna or Pinnacle for a Charge Schedule on the following:
•
Restorative (Fillings)
•
Crown and Bridge (All charges for crown and bridge are per unit) (Each replacement or supporting tooth equals
one unit – replacement limit 1 every 5 years)
•
Endodontics (Root canal treatment, excluding final restorations)
•
Periodontics (Treatment of supporting tissues [gum and bone] of the teeth)
•
Prosthetics (Removable tooth replacement – dentures) (Includes up to 4 adjustments within first 6 months after
insertion – replacement limit 1 every 5 years)
•
Repair to Prosthetics
•
Denture Relining (Limit 1 every 36 months)
•
Interim Dentures (Limit 1 every 5 years)
•
Oral Surgery (Includes routine post-operative treatment)
•
Orthodontics (Tooth movement)
•
General Anesthesia/I.V. Sedation
•
Emergency Services
In- network benefits only
No deductibles
No annual dollar maximum
Select a dentist from a list of network providers on www.cigna.com.
Customer Service toll free #: 1-800-244-6224
NOTE: A dentist must be selected on application. Please log on or call
customer service for a list of providers.
CIGNA DENTAL MONTHLY RATES
Employee Only
$18.69
Employee & Spouse
$49.92
$49.92
Family
$49.92
Page 13
Dental Benefits Summary
DMO
Annual Deductible *
Individual
Family
Preventive Services
Basic Services
Major Services
Annual Benefit Maximum
Office Visit Co-pay
Orthodontic Services (Adult and Child)**
Orthodontic Deductible
Orthodontic Lifetime Maximum
None
None
100%
100%
60%
None
$5
$2,300 co-pay
None
***
Passive PDN
$50
$150
100%
80%
50%
$1,500
N/A
50%
None
$1,500
*The deductible applies to: Basic & Major services only
**PDN Orthodontia is covered only for children (appliance must be placed prior to age 20)
***24 months of comprehensive orthodontic treatment plus 24 months of retention
Partial List of Plan Provisions
Preventive
DMO
Passive PDN
Oral examinations, Fluoride (a)
Cleanings, including scaling and polishing, (a) Adult/Child
Sealants (permanent Molars only) (a), Space maintainers
Bitewing X-rays (a), Full mouth Series X-rays
Basic
Root canal therapy, with X-rays and cultures
Anterior teeth/Bicuspid teeth
Amalgam (silver) fillings, Composite fillings (anterior teeth only)
Stainless steel crowns, Gingivectomy, Scaling and root planning (a)
Incision and drainage of abscess, Uncomplicated extractions
Surgical removal of erupted tooth, Surgical removal of impacted tooth (soft tissue)
Root canal therapy, molar teeth, with X-rays and cultures, Osseous surgery (a)
Surgical removal of impacted tooth (partial bony/full bony), Crown Lengthening
Major
Root canal therapy, molar teeth, X-rays and cultures
Osseous surgery (a), Surgical removal of impacted tooth (partial bony/full bony)
General anesthesia/intravenous sedation
Inlay, Onlays, Crowns, Full & partial dentures, Pontics
Denture repairs, Core buildups, including any pins
Implants
Crown Lengthening
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
See Below
See Below
80%
80%
80%
80%
80%
80%
80%
60%
60%
60%
60%
60%
Not Covered
60%
See Above
See Above
50%
50%
50%
50%
See Above
(a)Frequency and/or age limitations may apply to these services. These limits are described in the booklet/certificate or evidence of coverage.
AETNA DENTAL MONTHLY RATES
Employee Only
$53.18
Employee & Spouse
$103.45
$121.08
Family
$173.94
www.aetna.com
Page 14
PINNACLE CORPORATION and VSP provide you an
affordable eyecare plan. Sign up today.
Doctor Network..................................... VSP Signature
Your Coverage with a VSP Doctor
®
WellVision Exam focuses on your eye health and overall
wellness
• $10.00 copay......................................every 12 months
Prescription Glasses
• $25.00 copay
Lenses..................................................every 12 months
• Single vision, lined bifocal and lined trifocal lenses
• Polycarbonate lenses for dependent children
Frame................................................... every 24 months
• $120 allowance for a wide selection of frames
• 20% off amount over your allowance
~OR~
Contact Lens Care
No copay applies.................................. every 12 months
$120.00 allowance for contacts and the contact lens exam
(fitting and evaluation)
Current soft contact lens wearers may qualify for a special
program that includes a contact lens exam and initial supply
of lenses.
Extra Discounts and Savings
Glasses and Sunglasses
•Average 35 - 40% savings on all non-covered lens options
•30% off additional glasses and sunglasses, including lens
options, from the same VSP doctor on the same day as
your WellVision Exam. Or get 20% off from any VSP doctor
within 12 months of your last WellVision Exam
Contacts
•15% off cost of contact lens exam (fitting and evaluation)
Laser Vision Correction
•Average 15% off the regular price or 5% off the promotional
price. Discounts only available from contracted facilities.
•After surgery, use your frame allowance (if eligible) for
sunglasses from any VSP doctor.
VSP guarantees service from VSP doctors only. In the event
of a conflict between this information and your organization's
contract with VSP, the terms of the contract will prevail.
VSP VISION MONTHLY RATES
Employee Only
Employee & Spouse
Family
$11.19
$17.90
$18.27
$29.46
Page 15
0699562 - 11/18/11
UNUM PROVIDENT LIFE INSURANCE
Plan Description: Basic Life & AD&D Insurance
Employee Life Benefit Amount
Overall Maximum
1 X annual earnings rounded to the next higher $1,000
$100,000
Employee Life Benefit Reduction Formula
Life Benefit Reduces to:
65% at age 65; and
50% at age 70
One Time Basic Annual Earnings (BAE)
Calculate: 1x BAE is .53 per 1,000
Example: $30,000 x .53 = $15.90 per month
Important: Premiums are adjusted throughout the year according to current base salary changes. Maximum of 100,000.
Plan Description: Optional Term Life Insurance
Employee Life Benefit Amount
Overall Maximum
Amounts in $10,000 benefit units as applied for
by the employee and approved by UnumProvident
The lesser of 5 X annual earnings
or $500,000
Employee Life Benefit Reduction Formula
Life Benefit Reduces to:
- 65% at age 65; and
- 50% at age 70
Dependent Life Benefit Amount
Overall Maximum
Spouse: Amounts in $5,000 benefit units
The lesser of 100% of the employee life amount
not to exceed 50% of the employee’s
or $250,000 coverage amount
Child: - Live birth to 14 days: $1,000
The lesser of 100% of the employee life amount
- 14 days to 6 months: $1,000
or $10,000
- 6 months to 19 years (26 years if
full-time student): $10,000
Amounts in $2,000 benefit units
Child(ren): Available in increments of $2,000 up to 10,000, cost is $0.76 up to $3.80 per month whether
it’s one child or five children.
SEE NEXT PAGE FOR RATE CHART
Page 16
UNUM PROVIDENT OPTIONAL LIFE
EMPLOYEE RATES-MONTHLY COST PER COVERAGE AMOUNT
AGE
15-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
10,000
$1.47
$1.49
$1.83
$2.37
$3.54
$5.21
$8.24
$12.91
$22.36
$40.02
$80.62
20,000
$2.94
$2.98
$3.66
$4.74
$7.08
$10.42
$16.48
$25.82
$44.72
$80.04
$161.24
30,000
$4.41
$4.47
$5.49
$7.11
$10.62
$15.63
$24.72
$38.73
$67.08
$120.06
$241.86
40,000
$5.88
$5.96
$7.32
$9.48
$14.16
$20.84
$32.96
$51.64
$89.44
$160.08
$322.48
50,000
$7.35
$7.45
$9.15
$11.85
$17.70
$26.05
$41.20
$64.55
$111.80
$200.10
$403.10
60,000
$8.82
$8.94
$10.98
$14.22
$21.24
$31.26
$49.44
$77.46
$134.16
$240.12
$483.72
70,000
$10.29
$10.43
$12.81
$16.59
$24.78
$36.47
$57.68
$90.37
$156.52
$280.14
$564.34
80,000
$11.76
$11.92
$14.64
$18.96
$28.32
$41.68
$65.92
$103.28
$178.88
$320.16
$644.96
90,000
$8.82
$13.41
$16.47
$21.33
$31.86
$46.89
$74.16
$116.19
$201.24
$360.18
$725.58
100,000
$14.70
$14.90
$18.30
$23.70
$35.40
$52.10
$82.40
$129.10
$223.60
$400.20
$806.20
200,000
$29.40
$29.80
$36.60
$47.40
$70.80
$104.20
$164.80
$258.20
$447.20
$800.40
$1,612.40
300,000
$44.10
$44.70
$54.90
$71.10
$106.20
$156.30
$247.20
$387.30
$670.80
$1,200.60
$2,418.60
400,000
$58.80
$59.60
$73.20
$94.80
$141.60
$208.40
$329.60
$516.40
$894.40
$1,600.80
$3,224.80
500,000
$73.50
$74.50
$91.50
$118.50
$177.00
$260.50
$412.00
$645.50
$1,118.00
$2,001.00
$4,031.00
100,000
$14.60
$15.00
$19.00
$25.40
$37.20
$55.60
$83.00
$138.60
$233.60
$412.80
$822.40
150,000
$21.90
$22.50
$28.50
$38.10
$55.80
$83.40
$124.50
$207.90
$350.40
$619.20
$1,233.60
200,000
$29.20
$30.00
$38.00
$50.80
$74.40
$111.20
$166.00
$277.20
$467.20
$825.60
$1,644.80
250,000
$36.50
$37.50
$47.50
$63.50
$93.00
$139.00
$207.50
$346.50
$584.00
$1,032.00
$2,056.00
SPOUSE RATES-MONTHLY COST PER COVERAGE AMOUNT
AGE
15-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
5,000
$0.73
$0.75
$0.95
$1.27
$1.86
$2.78
$4.15
$6.93
$11.68
$20.64
$41.12
10,000
$1.46
$1.50
$1.90
$2.54
$3.72
$5.56
$8.30
$13.86
$23.36
$41.28
$82.24
15,000
$2.19
$2.25
$2.85
$3.81
$5.58
$8.34
$12.45
$20.79
$35.04
$61.92
$123.36
20,000
$2.92
$3.00
$3.80
$5.08
$7.44
$11.12
$16.60
$27.72
$46.72
$82.56
$164.48
25,000
$3.65
$3.75
$4.75
$6.35
$9.30
$13.90
$20.75
$34.65
$58.40
$103.20
$205.60
30,000
$4.38
$4.50
$5.70
$7.62
$11.16
$16.68
$24.90
$41.58
$70.08
$123.84
$246.72
35,000
$5.11
$5.25
$6.65
$8.89
$13.02
$19.46
$29.05
$48.51
$81.76
$144.48
$287.84
40,000
$5.84
$6.00
$7.60
$10.16
$14.88
$22.24
$33.20
$55.44
$93.44
$165.12
$328.96
45,000
$6.57
$6.75
$8.55
$11.43
$16.74
$25.02
$37.35
$62.37
$105.12
$185.76
$370.08
50,000
$7.30
$7.50
$9.50
$12.70
$18.60
$27.80
$41.50
$69.30
$116.80
$206.40
$411.20
CHILD RATES-MONTHLY COST PER COVERAGE AMOUNT
2,000
$0.76
4,000
$1.52
6,000
$2.28
8,000
$3.04
10,000
$3.80
Page 17
PRINCIPAL DISABILITY PLAN
Your group
short term disability benefits
All Members
Eligible Employees
All active, full-time employees (except part-time, seasonal,
temporary or contract employees) who work at least 30 hours per
week
BENEFIT QUALIFICATION
Definition of Disability
Income Loss Requirement
Elimination Period
Zero day residual disability
20%
Benefits begin on:
The 1st day for disability due to injury
The 8th day for disability due to sickness
BENEFITS PAYABLE
Benefit Percentage
Definition of Earnings
Maximum Weekly Benefit
Minimum Weekly Benefit
Coordination of Benefits
Social Security Integration
Benefit Duration
60% of predisability earnings
Weekly average of W-2 earnings for the prior 2 calendar year(s)
$1,500
$15
Direct integration
Primary and family
13 weeks
REHABILITATION BENEFITS
Reasonable Accommodation Benefit
$500
ADDITIONAL FEATURES
Coverage for non work-related disabilities
Mandatory rehabilitation
The policy does not provide state mandated disability benefits in CA, NY, NJ, RI or HI.
RATE SHEET (EXAMPLES)
ANNUAL SALARY
WEEKLY BENEFIT
APPROXIMATED
MONTHLY COST
$10,000.00
$115.38
$13.23
$15,000.00
$173.08
$19.85
$20,000.00
$230.77
$26.47
$25,000.00
$288.46
$33.09
$30,000.00
$346.15
$39.70
$40,000.00
$461.54
$52.94
$50,000.00
$576.92
$66.17
$60,000.00
$692.31
$79.41
$100,000.00
$1,153.85
$132.35
Page 18
AFLAC
NOTICE TO EMPLOYEES
AFLAC is the leading provider of Guaranteed Renewable insurance programs in the world. Their programs provide
CASH benefits to the plan holder, and coverage is available for spouses and children. Some of the plans being offered
through Payroll Deduction are: Accident Indemnity, Cancer Indemnity, Short Term Disability (2 year maximum
coverage), Personal recovery Plus (Heart Attacks, strokes, comas, etc) and a Hospital Indemnity Plan. A brief
description of each is as follows:
PERSONAL ACCIDENT INDEMNITY PLAN AFLAC’s newest and most innovative policy is our Personal
Accident Indemnity Plan and offers a full range of benefits.
Some important features of the insurance policy are:
•
•
•
•
Accident Emergency Treatment Benefit
Initial Accident Hospitalization Benefit
Intensive Care Unit Confinement Benefit
Major Diagnostic Exams, Physical Therapy
Benefit, Appliances Benefit, Prosthesis Benefit
•
•
•
•
Accidental-Death and Dismemberment Benefits
Accident Hospital Confinement Benefit
Wellness Benefit
Blood/Plasma/Platelets Benefit, Ambulance
Benefit, Transportation Benefit & Family
Lodging Benefit
PERSONAL CANCER INDEMNITY PLAN Our Cancer Expense Policy provides benefits to assist you in
meeting the high cost of cancer treatment.
•
•
•
First Occurrence Benefit
Hospital Confinement Benefit
Outpatient Hospital Surgical Benefit
•
•
•
Transportation and Lodging Benefit
Hospice Benefit
Any many more…..
PERSONAL SHORT-TERM DISABILITY AFLAC’s Personal Short-Term Disability insurance is your personal
income protection plan; it is designed to help close the financial gap that can be created by your being disabled.
Some of the Important features of the insurance policy are:
•
•
Different benefit periods are available.
Guaranteed-renewable to age 70, subject to the
company’s right to change premium by class.
•
•
14-day waiting period.
Short-Term Disability insurance stays with you
regardless of job or occupation change.
•
•
Hospital Confinement Benefit
Stroke, Coma & Paralysis
•
Transportation Benefit
PERSONAL RECOVERY PLUS
•
•
•
First Occurrence Benefit
Continuing Care Benefits for Heart Attack &
Coronary Artery Bypass Surgery
Ambulance Benefit
HOSPITAL INDEMNITY Hospital Indemnity Insurance Policy (H.I.P.) was designed to help cover the rising costs
of hospital confinement.
•
•
Annual Hospitalization Confinement Benefit
Invasive Diagnostic Exams
•
•
Surgical Benefit
Plus…more
If interested in any of the policies listed above, or for further information please
contact the Benefits Dept. at 210-344-2088 to request for the AFLAC representative
to contact you for an on-site presentation.
Page 19
Pinnacle PEO Corporation
9311 San Pedro Ave. STE 700 San Antonio TX, 78216
(210) 344-2088 Phone (210) 344-2777 Fax
www.pinnaclepeo.com
0113UH2A

Annual Benefits Enrollment

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