KOONCE PFEFFER BETTIS

Transcription

KOONCE PFEFFER BETTIS - Aleutians East Borough School District

2013 Employee
Benefits Handbook
Prepared by
1.888.533.9669 (in ak) • 1.907.522.2229
ALEUTIANS EAST BOROUGH SCHOOL
DISTRICT
BENEFITS SUMMARIES
TABLE OF CONTENTS
Health Reimbursement Arrangement Summary
Flexible Spending Account Summary
Flex Plan Services
Aleutians East Borough is identifier
1.866.897.1996
Medical Benefits Summary
Premera Blue Cross Blue Shield of Alaska
Group #9000092
1.800.508.4722
Dental Benefits Summary
Group #9000092
1.800.508.4722
Vision Benefits Summary
Group #9000092
1.800.508.4722
Life and AD&D Benefits Summary
USAble Life
Group #50018466
1.800.370.5856
Voluntary Life and AD&D Benefits Summary
USAble Life
Group #50018466
Employee Assistance Program
CompPsych – GuidanceResources
Group #: AKPSEAP
august 2013 - prepared by
907.522.2229 - 1.888.533.9669
1.800.370.5856
1.866.681.3416
DISTRICT
SUMMARY OF
HEALTH REIMBURSEMENT ARRANGEMENT
AND FLEXIBLE SPENDING ACCOUNT (HRA & FSA)
FLEX PLAN SERVICES
Purpose of Plan
Uses
Out of Network
HRA Balance
FSA
Contact
Telephone
Fax (for claims)
E-mail (for claims)
Health Reimbursement Arrangement (HRA)
AEBSD funds up to $3,705 for you, $7,410 for you and 1
dependent, $11,115 for you and 2 or more dependents
plus all co-pays (office visit and Rx) into your HRA
accounts each year to reimburse you and your family
members’ deductible expenses beyond $100!!!
After the 1st $100 is paid by you and/or your family
members, any expenses that go toward the
deductibles will be paid by AEBSD at 90% via your HRA
until you and/or your covered family members have
paid $195 in 10% for a total annual out of pocket
maximum of $295 (assuming you see a preferred
provider).
AEBS/Premera will pay 100% of remaining eligible
claims for the remainder of the calendar year.
If you do see a provider out of the Premera network,
Premera will pay 50% of reasonable vs 80% of
negotiated fees, however, AEBSD will pay 10% of those
out of network charges via the HRA.
Every January 1, AEBSD will add funds to you and your
family members’ HRA accounts up to $3,705 each plus
co-pays, even if you have used every penny!
Flexible Spending Account (FSA)
A flexible spending account allows you to put your own
pre-tax money into an account to pay for out of pocket
eligible expenses. Please see Carl Warner for detailed
information regarding your Flexible Spending Account
options. Also, see following page listing eligible
expenses under the medical portion of the FSA. If you
have children, you can also put your own pre-tax
money into a dependent care FSA. Pre-taxing your
money saves you approximately 30%!
www.flex-plan.com
1.866.897.1996
1.425.709.7125
[email protected]
907.522.2229 - 1.888.533.9669
KNOWLEDGEABLE
INNOVATIVE
ESTABLISHED
Health Reimbursement Arrangement (HRA)
Flex-Plan Services, Inc. is proud to be the claims administrator for your Health Reimbursement Arrangement. This
plan has been established by Aleutians East Borough School District to reimburse you and your family for medical
expenses.
Plan Information
Plan Year: January 1, 2013 – December 31, 2013
Benefit: The HRA will reimburse eligible expenses as indicated below:
Deductible Benefit:
Coinsurance Benefit:
 0% of the first $100
 90% of the next $1,400
 50% of the first $110
 100% of the next $2,390
Medical & Rx Copay Benefit:
Out-of-Network Benefit:
 10% of out-of-network charges
 100% of all medical and Rx copays
Maximum HRA Reimbursement
Employee only: $3,705*
Employee plus one: $7,410*
Employee plus family: $11,115*
*Plus all copays and 10% of out-of-network charges
Eligible Expenses: Deductible, coinsurance, out-of-network, and office visit and Rx drug copay expenses associated
with the employer sponsored group medical plan.
How it Works: Get treatment from a provider. The provider will bill your medical insurance. You will receive an
Explanation of Benefits (EOB) from the insurance carrier. Submit the EOB and a completed claim form to Flex-Plan
Services for reimbursement. It is then your responsibility to pay the provider.
FSA or HRA: If you also maintain a Health Care FSA, HRA eligible claims will first be reimbursed from your HRA, any
residual amount will then be reimbursed from the FSA.
HRA Claims Submission
1) Fill out a claim form, make sure to write legibly and sign the bottom.
2) Include an Explanation of Benefits (EOB) from your insurance carrier.
• If you have dual coverage, also include the EOB from the secondary insurance carrier.
3) Claims can be submitted using one of the following methods – fax, email, mail, online or through the
Flexi app for Android or iPhone. Please use only one method per submission.
4) Your reimbursement will be distributed by your employer.
5) You will have 90 days to turn in claims at the end of the plan year.
6) In the event that your employment is terminated, you will have 90 days to submit claims for expenses
incurred prior to your reported termination date.
•
You may have the ability to continue coverage under COBRA see your employer for details.
Phone: 425-452-3421 or 866-897-1996
Flex-Plan Services, Inc.
Email: [email protected]
Website: www.flex-plan.com
Participant Portal
Flex-Plan Services provides online account access for participants as a customary service. The online
portal gives participants the ability to empower themselves by managing their benefits online.
Plan participants have access to their online account through the
participant portal where they can update their personal information, view
claims history, submit claims, check balances and access plan forms and
documents.
Once you are registered, you can also submit claims via the new Flexi App
for Android or iPhone!
Our Website will allow you to create your own login and password.
Step 1: Visit www.flex-plan.com, choose the “Participant” tab and select
the link “Manage My Benefits”.
*If you are not already registered for online account access you will need
to complete registration. Go to Step 2.
*If you are registered for online account access just log in as normal.
Forgot your username and/or password? Click on ‘Forgot Password’.
Your User Name and temporary password will be emailed to you.
Step 2: Registering your Account:
First time users will select the “Register With Flex-Plan.com” link.
You will need the following information to register your account:
•
•
•
•
•
Last Name, First Initial
E-mail Address: (E-mail address are required to access your
account on-line, if you have not provided an e-mail address to
Flex-Plan you must do so in writing prior to registering for
account access.)
Company Code: AEB
Choose a User Name
Date of Birth
Do not forget to review and accept the ‘Terms and Conditions’. Shortly
after registering for online access you will receive an e-mail confirmation
with a temporary password.
Step 3: To change your account password, log into your account:
• Click on ‘Update My Information’
• Click on ‘Change My Password’
You will be sent a confirmation email stating that you have recently
changed your password in your online profile.
If information is incomplete, or Flex-Plan does not have all the
information for your record, please contact us so we can update the
record.
Contact Customer Service
Customer service is available Monday through Friday from 7:00 am to 5:00 pm, PT.
You can reach customer service toll-free at (866) 897-1996 or email at [email protected].
AEB
ALEUTIANS EAST BOROUGH SCHOOL DISTRICT
HEALTH REIMBURSEMENT & FLEXIBLE SPENDING ARRANGEMENT
CLAIM FORM
FOR PLAN YEAR JANUARY 1, 2013 through DECEMBER 31, 2013
Section I – Employee Information
Last Name, First Name
MI
Day Phone
__________-__________-__________
Employee SSN
Address
City
St
Email * SEE INFORMATION BELOW
Zip
 Address Change
Submit paperless claims online or via the new Flexi App for iPhone and Android! Just take a picture and submit!
Instructions
1.
Complete Section I – Employee Information.
2.
Do not staple any documentation to claim form, please tape to separate sheet or include loosely in envelope. Do not send originals (all claims are stored electronically and paper
copies will be shredded).
3.
Complete Section II – Day Care Claims. Attach proper documentation showing the date(s) of service, cost of service, dependent’s name, and provider’s name and tax ID or social security number
(No cancelled checks, balance forwards, or bank card receipts).
4.
Complete Section III – Health Care Claims. Attach proper documentation showing the date(s) of service, type(s) of service and cost (No cancelled checks, balance forwards, or bank card receipts).
Itemize all expenses to prevent delays in reimbursement.
5.
Complete Section IV - Signing the claim form. Claims can be submitted using one of the following methods – fax, email, mail or online. Online claim status is available at www.flex-plan.com.
Claims must be submitted at least three (3) full business days prior to the scheduled reimbursement date.
Section II – Day Care FSA
Start Date
End Date
Provider’s Name, Tax ID/or SSN
See IRC Section 129 for qualifying Day Care expenses or consult your tax advisor for
more information.
Name of Dependent
Age
Total Day Care FSA Request
Cost
$
HRA Eligible Expenses: Deductible, coinsurance, office visit and Rx drug copays and out-of-network expenses associated
with the employer sponsored group medical plan. An Explanation of Benefits (EOB) is required for reimbursement. *If claimant
has secondary coverage, provide EOB’s from both carriers.
FSA Eligible Expenses: All section 213 expenses. Visit our website for more information: www.flex-plan.com
Section III – Health Reimbursement Arrangement and Health Care FSA
Service Dates
Type of Service
Name of Provider
For Whom
Total Request
Does the claimant have secondary coverage?
 No
Net Cost
$
 Yes
If yes, please provide an Explanation of Benefits (EOB) from both carriers.
If you maintain a Health Care FSA, any residual claim amount not covered by the HRA will automatically be entered into the FSA. If you do
not wish to have the residual amount entered into your Health Care FSA, please indicate below.
 No, please do not enter residual amount into my Health Care FSA
Section IV – Signature
To the best of my knowledge my statements on this claim form are complete and true. I understand that I am solely responsible for the sufficiency, accuracy, and veracity of claims and all information
related to these claims submitted to my HRA, Health Care (“HCFSA”) or Day Care Flexible Spending Arrangement (“DCFSA”), and that unless an expense for which payment or reimbursement is claimed
is a proper expense under the HRA, HCFSA or DCFSA, I may be liable for the payment of all related taxes including federal, state or city income tax on amounts paid from the HRA, HCFSA or DCFSA
which relate to such expense. I further understand that no day care tax credit is permitted for amounts for which reimbursement is made. I am claiming health care reimbursement for eligible medical care
expenses incurred by myself, spouse and/or dependents. Note: The IRS does not recognize Domestic Partners for purposes of receiving tax-favored health benefits. For further information please contact
your employer. I certify that these expenses have not been reimbursed under this plan or by any other source and that they will not be reimbursed by any other source or insurance. By providing an
email address, I consent to receive all possible communications from Flex-Plan, agents, and subcontractors regarding the Plan via email. I may withdraw consent at anytime without
charge by contacting Flex-Plan by phone, email, or mail. To update your email address contact Flex-Plan by phone, email, or mail. You have the right to receive paper version of an electronic document
free of charge. Software requirements will be provided with each electronic document. I hereby authorize my HRA, HCFSA and/or DCFSA to be reduced by the amount(s) shown above.
Participant’s Signature X
Date
Fax completed forms and documentation to:
(425) 709-7125 or Toll-free (866) 831-6222
Customer Service:
Email forms and documentation to:
[email protected]
email: [email protected]
Website: www.flex-plan.com
Mail forms and documentation to:
Flex-Plan Services
PO Box 53250 Bellevue, WA 98015-3250
Phone: 425-452-3421 or 866-897-1996
WHAT’S ELIGIBLE?
A Health Care FSA can cover a wide variety of expenses. We’ve assembled a list of common expenses that are eligible for
reimbursement. Not all eligible items are on this list. For a more exhaustive list, visit our website at www.flex-plan.com.
ELIGIBLE HEALTH CARE EXPENSES
Items marked with an asterisk (*) are considered over-the-counter (OTC) medicines or drugs and require a prescription for reimbursement.
Acne treatment*
Acupuncture
Allergy & Sinus medication*
Antacids*
Antibiotic ointment*
Anti-diarrheal*
Antifungal foot cream*
Anti-gas medication*
Anti-itch cream/gel*
Antiseptic*
Asthma treatment*
Bandages/gauze
Birthing classes or Lamaze
Blood pressure monitor
Braces (knee, ankle, wrist)
Breast pump
Burn cream*
Chiropractic services
Coinsurance
Cold / hot pack
Cold sore treatment*
Cold/cough medication*
Compression stockings
Contacts & solutions
Contraceptives
Copays
CPAP machine
Crutches
Deductibles
Dental services
Diabetic supplies
Diaper rash ointment*
Digestive Aids*
Drug addiction treatment
Ear wax removal kits
Eye drops
Feminine Anti-Fungal/Anti-Itch*
Fertility monitor
Fertility treatment
Flu shots
Hearing aids & supplies
Hemorrhoid medication*
Hormone therapy
Hospital fees
Immunizations
Incontinence supplies
Individual counseling
Insect bite treatment*
Lab work
Lactation Consultant
Lactose intolerance pills*
Laser eye surgery
Laxative*
Lice treatment products*
Medical records
Motion sickness relief*
Nasal strips
Naturopathic visits
Orthodontia
Orthotics
Oxygen and equipment
Pain relievers*
Parasitic treatment*
Physical exams
Physical therapy
Pregnancy test
Prenatal vitamins
Prescription drugs
Prescription glasses
Reading glasses
Respiratory Treatments*
Saline nasal spray
Sleep Aids & Sedatives*
Sleep deprivation treatment
Smoking cessation products*
Smoking cessation programs
Speech therapy
Sterilization procedures
Stool softener*
Thermometer
Throat lozenges*
Vision care
Walker
Wart treatment*
Wheelchair & repair
X-rays
ADDITIONAL DOCUMENTATION REQUIRED
Certain medical expenses are not reimbursable under a Health Care FSA unless a licensed health care practitioner states that the service or
product is medically necessary. Flex-Plan will need a Letter of Medical Necessity (LMN) for these items to be reimbursed. The LMN is
available on our website. Please note that certain expenses may require additional documentation to be reimbursed.
Air conditioner
Air purifier
Automobile modifications
Braille books
Breast augmentation
Breast reduction
Cosmetic procedures
Genetic testing
Home medical equipment
Humidifiers
Learning disability fees
Lumbar support
Massage therapy
Mole removal
Motorized scooter
Nutritionist expenses
Vitamins and supplements
Weight loss programs
INELIGIBLE HEALTH CARE EXPENSES
The following expenses are not eligible under a Health Care FSA. Under no circumstances will the following items be reimbursed. Please do
not submit claims for these items.
Airborne
Books
Boutique practice fees
COBRA premiums
College insurance
CPR classes
Electrolysis/laser hair removal
Face lift
Finance charges
Funeral expenses
Gym membership
Hair transplant
Household help
Hygiene products
Illegal operations/substances
Imported OTC items
Imported prescriptions
Late fees
Liposuction
Marijuana
Marriage counseling
Massage chair
Mattress
Missed appointment fee
Hair growth products
Electric toothbrush/picks
Teeth whitening
Toiletries
Veneers
Warranties
DISTRICT
SUMMARY OF MEDICAL INSURANCE BENEFITS
PREMERA BLUE CROSS BLUE SHIELD OF ALASKA
Group #9000092
Deductible
Office Visit Co-pay
(6/calendar year, then to deductible)
Acupuncture (12/calendar yr)
Spinal Manipulations (12/cal. yr)
Rehab (PT, Massage, etc. – 45/cal.yr)
Preventive Office Visit
Preventive Care (including lab & pathology, PAP
smears, mammograms, PSA, etc.)
Lab work if not preventive
Prescription Drugs Co-pay
1 month supply, retail pharmacy
Prescription Drugs Co-pay
Mail order, 3 month supply
Coinsurance Maximum
(point at which YFSD/Premera begins paying
100% for remainder of calendar year)
$1,500* you only pay $100
$25**
$25**
$25**
$25**
No Cost to You!
No Cost to You!
Deductible then coinsurance
$10/$20/$40**
$20/$40/$80**
You pay $295 in 10% plus your
deductible expenses,
YFSD/Premera pay 100% of all
other eligible charges
Additional Hospital Deductible
None
ER Co-Pay (waived if admitted)
$100
Annual Maximum
$2,000,000
Website
www.premera.com
Contact
1-800-508-4722
1-866-224-8550
*Aleutians East Borough SD, via the HRA, will pay 90% of remainder of $1,500 deductible
after you have paid your $100 portion
**Co-pays are reimbursed 100% to you by Aleutians East Borough SD
A highlight of your plan follows. For specifics, please go to website or your booklet
Based on using preferred providers
907.522.2229 - 1.888.533.9669
Highlights of your Health Care Coverage
ALEUTIANS EAST BOROUGH SD-APS
GROUP ID-9000092
Effective Date: 07/01/2013
*Premera Blue Cross Blue Shield of Alaska believes this plan is a “grandfathered health plan” under the Affordable Care Act. For more information, please refer to
your Benefit Booklet.
Any deductibles, copays, and coinsurance percentages shown are amounts for which you’re responsible.
Medical Benefits apply after the calendar-year deductible is met unless otherwise noted, or if the cost share is a copay.
MEDICAL PLAN
*GRANDFATHERED
2013 APS - HSE $1500
IN-NETWORK
OUT-OF-NETWORK
$1,500 PCY
Shared with In-Network
20%
Hospital and Hospital-Based CD
Programs: 50% Other Facilities and
Professionals: Same as In-Network
$4,000 PCY
Not Applicable
First 6 visits $25 Copay; then Deductible,
20% (all other office visits such as
therapy, are subject to the $25 copay but
do not apply to the 6 visit limit)
Same as Office Visit In-Network Cost
Share (highest benefit level)
Preventive Office Visit (Unlimited)
Covered In Full1
Covered In Full1
Immunizations (Unlimited)
Covered In Full1
Professionals: Same as In-Network3
Health Education (HE) (Unlimited)
Covered in Full
Covered In Full1
Diabetes Health Education (DE) (Unlimited)
Covered in Full1
Covered In Full1
First 6 visits $25 Copay; then Deductible,
20% (all other office visits such as
therapy, are subject to the $25 copay but
do not apply to the 6 visit limit)
Deductible, then 20%
Deductible, then Hospital and
Hospital-Based CD Programs: 50%
Other Facilities and Professionals: Same
as In-Network
MEDICAL COST SHARE OPTIONS
Individual Deductible PCY (Family deductible 3X Individual)
Coinsurance (Member's percentage of costs after deductible based
on allowable charges)
Individual Out of Pocket Maximum PCY, Excludes Copay (Family
OOP max 3X Individual)
Office Visit Cost Share
PREVENTIVE CARE OPTIONS AND HEALTH EDUCATION
PROFESSIONAL CARE
Professional Office Visit Including Urgent Care
Inpatient Professional Services
DIAGNOSTIC SERVICE OPTIONS
Preventive Professional Diagnostic Imaging and Laboratory
Services - Including Mammogram and PAP/PSA
Other Professional Diagnostic Imaging
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Page 1 of 4
An Independent Licensee of the Blue Cross Blue Shield Association
GROUP ID-9000092
MEDICAL PLAN
*GRANDFATHERED
2013 APS - HSE $1500
Other Professional Diagnostic Laboratory/Pathology
IN-NETWORK
OUT-OF-NETWORK
Covered In Full1
Diagnostic Mammography
FACILITY CARE OPTIONS
Inpatient Facility
Outpatient Surgery Facility
Skilled Nursing Facility (60 days PCY)
Hospice Inpatient Facility (10 days Inpatient; within the 6 month lifetime
maximum)
Programs: 50%; Other Facilities: Same
as In-Network
as In-Network
as In-Network
EMERGENCY CARE OPTIONS
$100 Copay; then Deductible, 20%
Air Ambulance (Unlimited)
Ambulance Transportation (Unlimited)
Allergy/Therapeutic Injections
Same as In-Network Cost Share
Mental Health Inpatient Facility Care (Unlimited)
Emergency Care (Waive copay if admitted to inpatient facility)
Emergency Room Physician
Transportation - Air or Surface (High Option 3 round trips PCY for
patient (includes 3 round trips PCY for parent or guardian if pt. under 18
yrs of age))
OTHER SERVICES
$25 Copay
Mental Health Outpatient Professional Care (Unlimited)
as In-Network
Chemical Dependency Inpatient Facility Care (Office: $25 copay;
Inpatient and OP Hospital: Deductible then coinsurance)
Office: $25 copay; Inpatient and OP
Hospital: Deductible then coinsurance
Chemical Dependency Outpatient Professional Care (Office: $25
copay; Inpatient and OP Hospital: Deductible then coinsurance)
$25 copay
Office: $25 copay; Inpatient and OP
Hospital: Deductible then coinsurance
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Page 2 of 4
GROUP ID-9000092
MEDICAL PLAN
*GRANDFATHERED
2013 APS - HSE $1500
Rehab Inpatient Facility (30 days PCY)
IN-NETWORK
OUT-OF-NETWORK
as In-Network
$25 Copay
Rehab Outpatient Care, Including Physical, Occupational, Speech
and Massage Therapy; Cardiac & Pulmonary Rehab.; and Chronic
Pain (45 visits PCY)
as In-Network
as In-Network
as In-Network
as In-Network
Medical Supplies, Equipment, Prosthetics (MS: Unlimited, ME:
Unlimited, Pro: Unlimited)
Foot Orthotics, Orthopedic Shoes and Accessories ($300 PCY
(Unlimited Diabetes Related))
Home Health Visits (130 visits PCY)
Hospice Care (Home Health and Respite) (Hospice Home Visits:
Unlimited; Respite: 240 hours; within the 6 month lifetime maximum)
Transplants (Unlimited up to the member annual maximum; $75,000
donor and $7,500 travel and lodging limits)
Covered as any other service
Not Covered
Manipulations (Spinal and other) (24 visits PCY)
$25 Copay
Acupuncture (12 visits PCY)
$25 Copay
Covered In Full1
Routine Vision Exam (1 PCY)
$25 Copay
$25 Copay
Vision Hardware ($150 PCY)
Covered In Full1
Covered In Full1
Routine Hearing Exam (Exam: 1 every 3 years, combined with HW to a
combined $400 limit every 3 consecutive years)
Waive Deductible, constant 20%
Hearing Hardware (Exam: 1 every 3 years, combined with HW to a
combined $400 limit every 3 consecutive years)
ALTERNATIVE CARE
Nutritional Therapy (Unlimited)
SUPPLEMENTAL BENEFITS
ANNUAL PLAN MAXIMUM
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Page 3 of 4
GROUP ID-9000092
Pharmacy Benefits
Tier 1 = Generic
Tier 2 = Preferred Brand Name
Tier 3 = Non Preferred Brand Name
Below is a brief overview of what you can expect to pay for a prescription drug, depending on which "tier" category it falls under in the Preferred Drug List for
your plan when using an In-Network Pharmacy. For more information on your pharmacy benefits, including Out-of-Network benefits, see your benefit
booklet. To find out what tier applies to a specific medication, see out Preferred Drug List in your pharmacy packet or at www.premera.com.
PHARMACY PLAN
2013 APS - 3-TIER RX 10/20/40
Cost Share Category
Tier1/Tier2/Tier3
PRESCRIPTION DRUGS
Retail Cost Shares
$10/$20/$40
Mail Cost Shares
$20/$40/$80
Retail: 90 Days; Mail: 90 Days; Specialty: 30 Days
Day Supply
$0
Individual Deductible PCY
Same as in-network
Out of Network (Non-participating retail pharmacies)
Out of Pocket Maximum
Unlimited
Annual Benefit Maximum
Unlimited
Drug List
Preferred
Specialty Pharmacy
Mandatory
¹Benefits provided at 100% of allowable charges; not subject to deductible or coinsurance.
³Seasonal immunizations provided at a pharmacy will be covered in full up to maximum allowable amount.
PCY = Per Calendar Year. Balance billing may apply if a provider is not contracted with Premera Blue Cross Blue Shield of Alaska. Members are responsible for amounts in
excess of the allowable charge.
This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highlight
is not a contract For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service.
1-1NFJ48 Rev #1 Q
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Page 4 of 4
Using Your Preventive Benefits
For Grandfathered Plans*
Your Premera Blue Cross Blue Shield of Alaska plan covers in-network preventive care in full. So, go
ahead and use your preventive benefits. They’re a good way to maintain and even improve your health.
When the listed screenings, tests and services are billed by your doctor as routine preventive services,
your plan covers them in full. You’ll get the most value from these benefits by choosing an in-network
doctor. It is also a good idea to bring this list to your exam so your doctor is aware of your coverage.
Adults
Suggested preventive care services
Age 19 – 64
• Blood pressure testing
• Breast cancer screening (mammography)
• Clinical breast exam
• Lipid panel (cholesterol, lipoprotein, triglycerides)
• Diabetes screening (type 2)
• Colon cancer screening (fecal occult blood)
• Colon cancer screening (colonosopy, sigmoidoscopy, barium
enema. Not a core preventive benefit, refer to your benefit
booklet cost sharing information.)
• Cervical cancer screening (Pap smear and HPV testing)
preventive services
for adults
• Osteoporosis (DEXA bone density) study
• Prostate cancer (PSA blood) test
• Flu (Influenza)
• Diphtheria, tetanus, pertussis
IMMUNIZATIONs
• Shingles
Recommended age and frequency varies. Talk with your provider about tests, screenings and immunizations that
are right for you. * In general, a plan may be “grandfathered” if it was in effect prior to March 23, 2010 and
it has not changed significantly since that date. Some individual plans may not cover these
services. Log in to premera.com to check your benefits.
005468 (05-2013)
Children | Teens
Suggested Preventive care services
For children under age 18, routine exams, immunizations and screenings listed below are covered when
received from a doctor within your plan’s network.
• Well baby exam—ages 0 to 3
• Well child exam—ages 4 to 18
Well Child
and Teens
• Cervical cancer screening
(PAP Smear and HPV testing)
• Flu (Influenza)
• Diptheria, tetanus, pertussis
• Hepatitis A
• Hepatitis B
• Measles, mumps, rubella (MMR)
• Varicella (chicken pox)
• Inactivated polio virus
• Pneumonia (PCV or PPV)
Immunizations
• HPV (human papillomavirus)
Helpful Tips
When tests or screenings are not preventive
Your preventive benefits offer full coverage for many tests, screenings and immunizations. During
your preventive exam, your doctor may find an issue or problem that requires further testing or
screening for a proper diagnosis to be made. Also, if you have a chronic disease, your doctor may
check your condition with tests. These types of screenings and tests help to diagnose or monitor
your illness. These diagnostic tests are not covered by your preventive benefits and often require you
to pay a greater share of the costs.
About facility fees
Some medical clinics charge a separate facility fee for all doctor visits, including preventive service
visits. These facility fees are not covered by your preventive benefits. So, they may result in an added
out-of-pocket cost to you—even if the doctor is in our network. When making an appointment,
always ask if your doctor’s office charges a facility fee. You can get the most value from your medical
benefits if you choose an in-network doctor who practices at a medical center that does not charge
a facility fee.
Anesthesia for preventive colonoscopies
If you are ready to schedule a preventive colonoscopy, you should know how your anesthesia for this
screening will be covered. Conscious sedation, a type of anesthesia, is covered by your health plan as
part of the colonoscopy screening. However, general anesthesia may not be covered.
This means that, if your doctor uses general anesthesia, you could receive a separate bill for your
screening. So, you should talk with your doctor before your colonoscopy to see if conscious sedation
is right for you.
Find an in-network doctor
Download Premera Mobile
DISTRICT
SUMMARY OF DENTAL INSURANCE BENEFITS
Group #9000092
Preventive Services
Cleanings, exams,
Routine x-rays …
Paid at 100%
Basic Services
Fillings, root canals …
No deductible
Paid at 80% after
deductible
Major Services
Bridges, crowns,
in/onlays …
Paid at 50% after
deductible
Calendar Year Maximum $1,500
Website
www.premera.com
Contact
1.888.508.4722
907.522.2229 - 1.888.533.9669
Highlights of your Dental Coverage
DENTAL PLAN
COVERED SERVICES
DENTAL STANDARD 1500
Individual/Family Deductible PCY
Diagnostic/Preventive
$0 PCY / $0 PCY
0%
-cleanings (limited to 2 PCY)
-emergency exams (limited to 1 PCY)
-fluoride treatments (limited to 2 applications PCY for members under age
20)
-routine oral exams (limited to 2 PCY)
-sealants (for members under age 19)
-space maintainers (for members under age 20)
-x-rays (including bitewing x-rays; complete series or panoramic X-ray once
per 36 consecutive months)
Basic
20%
-emergency palliative treatment
-endodontic (root canal) treatment (limited to 2 per arch when performed in
conjunction with overdentures)
-fillings (limited to once per tooth surface every 24 consecutive months)
-full mouth debridement (limited to once every 3 calendar years)
-general anesthesia (limited to covered dental procedures at a dental-care
provider's office when dentally necessary)
-oral surgery (including simple and surgical extractions)
-periodontal maintenance (limited to 4 visits per calendar year)
-periodontal scaling (limited to once per quadrant every 2 calendar years)
-periodontal surgery
Major
50%
-dentures, partial & fixed bridges (replacements limited to once every 5
calendar years)
-inlays, onlays & crowns (replacements limited to once per tooth every 5
years)
-recementing & repair of crowns, inlays, bridgework & dentures
Annual Maximum
$1,500 PCY
This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highlight
is not a contract For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service.
1-1NFJ48 Rev #1 Q
5/21/2013 12:23 PM
Page 1 of 1
DISTRICT
SUMMARY OF VISION INSURANCE BENEFITS
Group #9000092
Routine Eye Exams
$25 office visit co-pay*
1 time per calendar year
Materials (lenses,
contacts, frames)
Up to $150 per calendar year
Website
www.premera.com
Contact
1.888.508.4722
*paid 100% by AEBSD via HRA
907.522.2229 - 1.888.533.9669
DISTRICT
LIFE AND ACCCIDENTAL DEATH & DISABILITY INSURANCE BENEFITS
USAble Life
Group #50018466
Deductible
None
Amount of Life coverage
$30,000
Amount of AD&D coverage
$30,000
Dependent Life coverage
Spouse:
$2,000;
Children 14 days – 23 years:
$1,000;
Benefit Reduction
Full benefit to age 65 then
benefit schedules down (see
certificate for details)
Website
www.usablelife.com
Contact
1.800.370.5856
907.522.2229 - 1.888.533.9669
Alaska Political Subdivision (APS)
Life and Accidental Death & Dismemberment
Your employee benefits summary
USAble Life is proud to make the following benefits available to you:
Group Term Life/ Accidental Death &
Dismemberment
Employee Life: $30,000
AD&D: $30,000
May include depended life option:
Spouse $1,000 and children $1,000 age 14 days to 26 years
OR
Spouse $2,000 and children $1,000 age 14 days to 26 years
Benefits reduce to 65% at your age 65 and to 50% at your age 70, and to 30% at age 75, and to 20% at age 80
and terminate at retirement.
Note: Check with your HR representative to see if your plan includes Domestic Partner coverage.
Important Note: If you are not actively at work on the date your insurance or any increase in insurance is scheduled to take effect, the coverage or increase in coverage will take effect on the
day you return to active work. This benefit summary provides a very brief description of USAble Life’s insurance products. This is not an insurance policy and only the actual provisions of an
issued policy control. USAble Life’s policies set forth the rights and obligations of covered persons and USAble Life. Plea se be aware that certain limitations and exclusions may apply, and
certain coverage may reduce or terminate due to age or lack of eligibility. If you enroll and are approved for coverage, you will be furnished with a policy or certificate of insurance. Please
read your insurance documents carefully.
Group Term Life Insurance is designed to provide benefits to your designated beneficiary for loss of life.
Group Term Life coverage also includes the following benefits:
• Accelerated Death Benefit
• Conversion
• Waiver of Premium
Accidental Death and Dismemberment (AD&D) is payable, if within 365 days of a covered accident, you suffer loss of life or
dismemberment. AD&D provides protection for losses occurring on or off the job.
AD&D coverage also includes the following benefits:
• Seat Belt/ Air Bag Rider Benefit
• Coma Benefit
• Exposure & Disappearance Benefit
• Repatriation Benefit
• Paralysis Rider
• Spouse Training Benefit Rider
Additional Services with Group Term Life:
Assist America is a global emergency medical travel assistance company. Anytime you, your spouse and/or minor dependent children are
traveling 100 miles or more away from home or in another country—with or without you present, they are protected by Assist America’s vast
assistance resources. A single phone call is all it takes to put Assist America in motion on your behalf.
Online Will Prep is a will preparation service. Living will documents are also available at no cost. Go to www.estateguidance.com to create
a simple or living will and use Promotional Code USW.
PO Box 1650
Little Rock, Arkansas 72203
(800) 648-0271
DISTRICT
VOLUNTARY
(EMPLOYEE PAID)
LIFE AND ACCCIDENTAL DEATH & DISABILITY INSURANCE BENEFITS
USAble Life
Group #50018466
Deductible
None
Amount of Life coverage
$20,000 - $300,000
Amount of AD&D coverage
Same
Guarantee Issue
(no questions asked)
$60,000
Benefit Reduction
Full benefit to age 65 then
benefit schedules down (see
certificate for details)
Website
www.usablelife.com
Contact
1.800.370.5856
907.522.2229 - 1.888.533.9669
Alaska Political Subdivision (APS)
Voluntary Life and Accidental Death & Dismemberment
Your employee benefits summary
USAble Life is proud to make the following benefits available to you:
Voluntary Group Term Life/
Accidental Death & Dismemberment
Employee: If you are age 69 or younger, you may purchase coverage in units of $20,000 to maximum of
$60,000 without medical evidence of insurability. Coverage over these amounts to a maximum of $300,000 is
available with medical evidence of insurability.
Benefits reduce to 65% at your age 65 and to 50% at your age 70, and to 30% at age 75, and to 20% at age 80
and terminate at retirement.
Important Note: If you are not actively at work on the date your insurance or any increase in insurance is scheduled to take effect, the coverage or increase in coverage will take effect on the
day you return to active work. This benefit summary provides a very brief description of USAble Life’s insurance products. This is not an insurance policy and only the actual provisions of an
issued policy control. USAble Life’s policies set forth the rights and obligations of covered persons and USAble Life. Plea se be aware that certain limitations and exclusions may apply, and
certain coverage may reduce or terminate due to age or lack of eligibility. If you enroll and are approved for coverage, you will be furnished with a policy or certificate of insurance. Please
read your insurance documents carefully.
Voluntary Group Term Life (VGTL) If you need additional term life protection for you, think about USAble Life’s low cost Voluntary Group Term Life
coverage. You select the benefit amounts to suit your specific situation, and premium payments are made through payroll deduction.
VGTL coverage includes the following benefits:
• Accelerated Benefits Rider
• Conversion
• Portability
• Waiver of Premium
Voluntary Accidental Death and Dismemberment (VAD&D) is payable, if within 365 days of a covered accident, you suffer
loss of life or dismemberment. AVD&D provides protection for losses occurring on or off the job.
Voluntary AD&D coverage also includes the following benefits:
• Seat Belt/ Air Bag Rider Benefit
• Coma Benefit
• Exposure & Disappearance Benefit
• Repatriation Benefit
• Paralysis Rider
• Spouse Training Benefit Rider
PO Box 1650
Little Rock, Arkansas 72203
(800) 648-0271
Voluntary Life and AD&D Premium Cost Worksheet - Alaska Political Sub-Divisions
Voluntary Life and AD&D for Employees Only
Your
Age
Monthly Rate for
Voluntary Life and
AD&D
(per $1,000 of benefit)
<30
30-34
35-39
40-44
45-49
50-54
55-59
60-64
$0.14
$0.16
$0.20
$0.29
$0.41
$0.59
$0.90
$1.33
Monthly Premium (Based on Level Coverage) Example
$20,000
$40,000
$60,000
$80,000
$100,000
$140,000
$160,000
$200,000
$220,000
$240,000
$280,000
$300,000
$2.80
$3.20
$4.00
$5.80
$8.20
$11.80
$18.00
$26.60
$5.60
$6.40
$8.00
$11.60
$16.40
$23.60
$36.00
$53.20
$8.40
$9.60
$12.00
$17.40
$24.60
$35.40
$54.00
$79.80
$11.20
$12.80
$16.00
$23.20
$32.80
$47.20
$72.00
$106.40
$14.00
$16.00
$20.00
$29.00
$41.00
$59.00
$90.00
$133.00
$19.60
$22.40
$28.00
$40.60
$57.40
$82.60
$126.00
$186.20
$22.40
$25.60
$32.00
$46.40
$65.60
$94.40
$144.00
$212.80
$28.00
$32.00
$40.00
$58.00
$82.00
$118.00
$180.00
$266.00
$30.80
$35.20
$44.00
$63.80
$90.20
$129.80
$198.00
$292.60
$33.60
$38.40
$48.00
$69.60
$98.40
$141.60
$216.00
$319.20
$39.20
$44.80
$56.00
$81.20
$114.80
$165.20
$252.00
$372.40
$42.00
$48.00
$60.00
$87.00
$123.00
$177.00
$270.00
$399.00
Benefits are available for employees who are age 65 or greater. Please contact your Human Resources Department for rates.
Employees may elect increments of $20,000 up to a maximum of $300,000.
Voluntary Life and AD&D are packaged. One may not be purchased independent of the other.
Guarantee Issue of $60,000 is available during the initial enrollment period.
Conditions & Exclusions
About
Assist America, Inc., formed in 1990, is the nation’s largest
provider of global emergency services through employee benefit
plans. Assist America responds when any eligible member
becomes ill or injured while traveling just 100 miles or more away
from home or abroad.
Conditions
Assist America will not provide services in the following instances:
• Travel undertaken specifically for securing medical treatment
• Injuries resulting from participation in acts of war
or insurrection
• Commission of unlawful act(s)
• Attempt at suicide
• Incidents involving the use of drugs unless prescribed by
a physician
• Transfer of member from one medical facility to another
medical facility of similar capabilities and providing a similar
level of care
Assist America will not evacuate or repatriate a member:
• Without medical authorization
• With mild lesions, simple injuries such as sprains, simple
fractures, or mild sickness which can be treated by local
doctors and do not prevent the member from continuing
his/her trip or returning home
• With a pregnancy over six months
• With mental or nervous disorders unless hospitalized
Exclusions
Please detach card and carry with you at all times.
• Travel by a member’s spouse when it is for the benefit
of the spouse’s employer (spouse business travel)
• Trips exceeding 90 days from legal residence without prior
notification to Assist America (Separate purchase of Expatriate
coverage is available)
While assistance services are available worldwide, transportation
response time is directly related to the location/jurisdiction where an
event occurs. Assist America is not responsible for failing to provide
services or for delays in the delivery of services caused by strikes or
conditions beyond its control, including by way of example and not by
limitation, weather conditions, availability of airports, flight conditions,
availability of hyperbaric chambers, communications systems, or
where rendering of service is limited or prohibited by local law or edict.
All consulting physicians and attorneys are independent contractors
and not under the control of Assist America. Assist America is not
responsible or liable for any malpractice committed by professionals
rendering services to a member.
This is not a medical insurance card. Claims for reimbursement for services not provided by
Assist America will not be accepted.
ATTENTION
Le titulaire de cette carte est membre d’Assist America et a droit à
l’assistance médicale et aux services personnels d’Assist America.
El portador de esta tarjeta es miembro de Assist America y tiene derecho
a los servicios personales y de asistencia médica de Assist America.
The holder of this card is a member of Assist America and is entitled
to its medical and personal services.
or via e-mail: [email protected]
Outside the U.S.A.
Toll free inside the U.S.A.
+1-609-986-1234
800-872-1414
If you require medical assistance and are more than 100 miles from your
permanent residence or abroad, call Assist America’s Operations Center at:
For questions regarding the program, contact:
GLOBAL EMERGENCY SERVICES
Reference Number 01-AA-USA-06081
Name
USAble Life
320 West Capitol Avenue, Suite 700
Little Rock, AR 72201
Telephone: 1-800-648-0271
www.usablelife.com
202 Carnegie Center l Suite 302A l Princeton, NJ 08540
609-921-0868
www.assistamerica.com
is a registered service mark of Assist America, Inc.
05.08.300M
Global
Emergency
Services
Provided by
Global Emergency Services
Congratulations! As part of your policy with USAble Life you now have
a unique global emergency services program from Assist America. This
program immediately connects you to doctors, hospitals, pharmacies
Key Services
Medical Consultation, Evaluation & Referral
Calls to Assist America’s Operations Center are evaluated by medical
personnel and referred to English-speaking, Western-trained doctors
and/or hospitals.
Assist America’s Operations Center is
staffed 24 hours a day, 365 days a
year with trained multilingual and
medical personnel, including nurses
and doctors, to advise and assist you
quickly and professionally in a medical
emergency.
Assist America will render every possible assistance in the event of
a member’s death. This service includes arranging the preparation
of the remains for transport, procuring required documentation,
providing the necessary shipping container as well as paying
for transport.
Emergency Trauma Counseling
and other services when faced with a medical emergency while traveling
100 miles or more away from your permanent residence or abroad.
Return of Mortal Remains
Hospital Admission Guarantee
Assist America will guarantee hospital admission outside the United
States by validating a member’s health coverage or by advancing
funds to the hospital.
Assist America will provide initial telephone-based counseling and
referrals to qualified counselors as needed or requested.
Lost Luggage or Document Assistance
Assist America will help members locate lost
luggage, documents or personal belongings.
Emergency Medical Evacuation
If adequate medical facilities are not available locally, Assist America
will use whatever mode of transport, equipment and personnel
necessary to evacuate a member to the nearest facility capable
of providing a high standard of care.
Interpreter & Legal Referrals
Assist America will refer members to interpreters
and/or legal personnel, as necessary.
Pre-trip Information
One simple phone call to the number on your Assist America
identification card will connect you to:
l
l
Critical Care Monitoring
A global network of pre-qualified medical providers
Assist America’s medical personnel will maintain regular
communication with the member’s attending physician and/or
hospital and relay information to the family.
A state-of-the-art Operations Center with worldwide
response capabilities
Medical Repatriation
l
Experienced crisis management professionals
l
Air and ground ambulance service providers
If a member still requires medical assistance upon being discharged
from a hospital, Assist America will repatriate him/her home or to
a rehabilitation facility with a medical or non-medical escort,
as necessary.
Assist America offers members web-based
country profiles that include visa requirements,
immunization and inoculation recommendations, as
well as security advisories for any travel destination.
Please detach card and carry with you at all times.
CALL ASSIST AMERICA WHEN TRAVELING 100 MILES OR
MORE AWAY FROM HOME OR IN ANOTHER COUNTRY AND:
• You require medical or counseling assistance
Assist America completely arranges and pays for all of the assistance
services it provides without limits on the covered cost. This alleviates
many of the obstacles and potential expenses that can be caused by
medical emergencies away from home.
Prescription Assistance
If a member needs a replacement prescription while traveling, Assist
America will help in filling that prescription.
• You require legal assistance
• You experience local language problems
Emergency Message Transmission
It is important to keep your identification card with you at all times so
that you can call for services whenever you need them.
Assist America will receive and transmit emergency messages
for members.
Assist America is not travel or medical insurance, rather it is a provider
of global emergency services.* Assist America’s services do not replace
medical insurance during medical emergencies away from home. All
medical costs incurred should be submitted to your health plan and
are subject to the policy limits of your health coverage.
Compassionate Visit
If a member is traveling alone and will be hospitalized for more than
seven days, Assist America will provide economy, round-trip, common
carrier transportation to the place of hospitalization for a designated
family member or friend.
Care of Minor Children
*All services must be arranged and
provided by Assist America. No claims
for reimbursement will be accepted.
Assist America will arrange for the care
of children left unattended as the result
of a medical emergency and pay for
any transportation costs involved in
such arrangements.
All services must be arranged and provided
by Assist America. No claims for
reimbursement will be accepted.
PLEASE PROVIDE THE FOLLOWING INFORMATION WHEN
YOU CALL:
• Your name, telephone number and relationship to the patient
• Patient’s name, age, gender, reference number and employer
• A description of the patient’s condition
• Name, location and telephone number of hospital or treating
doctor, if applicable
An Overview of Your EstateGuidance® Program
YOUR
life
YOUR
work
YOUR
best
No Cost Will Preparedness Service
Protect Your Family, Safeguard Your Assets, Make
Sure Your Wishes Are Carried Out
Log on to EstateGuidance and Complete
EstateGuidance® is a new member benefit that offers you
the ease and simplicity of online will preparation—at no
cost! Wills are perhaps the most important legal documents
for you to have. Without them, the courts—and not you—
make important decisions regarding your assets, your
children and even whether you should receive artificial life
support. With EstateGuidance you can create two important
types of wills to ensure that all your wishes are carried out:
> Complete a customized will for your estate
> Name a guardian for your children
> Name an executor to settle your estate
> Specify funeral and burial wishes
> A will, also known as a simple will, ensures that you
control who gets your property and other financial assets,
who will be the guardian of your children, and who will
manage your estate.
Your Will:
Your Living Will:
> Specify in advance your end-of-life decisions
> Name a health care surrogate to make medical decisions
on your behalf if you become unable to do so
> Name an alternate surrogate if your first choice cannot
serve
*Certain additional features, such as printing and electronic storage, are
available at an additional cost.
> A living will makes certain that your wishes are followed
while you are alive but unable to communicate, such as
whether you want artificial life support, if you become
terminally ill or are in an irreversible coma or vegetative
state.
> Creating your will is easy. Just go to estateguidance.com,
enter your special promotional code, click on Get Started
and sign in. An intelligent online questionnaire will guide
you through the process. Both the simple will and living
will can be completed online and downloaded to your
computer. In addition, you will receive instructions about
how to execute your wills and store them.
Take This Important Step Today!
Copyright © 2009 ComPsych Corporation. All rights reserved.
Go to: estateguidance.com
To create your Will,
enter your promotional code: USW
To create your Living Will, enter your
promotional code: USLW
ComPsych®
GuidanceResources®
Y O U R S I N G L E S O U R C E F O R S U P P O R T, R E S O U R C E S & I N F O R M AT I O N
®
ComPsych
GuidanceResources
®
®
REASONS
TO CALL
YOUR EAP
Whatever the reason, we can help.
››Family matters
››Stress
››Relationships
››Grief and loss
››Substance abuse
Call anytime, 24/7, for expert guidance
and support that’s free and confidential.
Call: 866.681.3416 TDD: 800.697.0353
Online: www.guidanceresources.com
Your company Web ID: AKPSEAP
ComPsych
GuidanceResources
®
Lost? Don’t know which way to go?
Your GuidanceResources program offers confidential
support, expert information and valuable resources for
all of life’s issues. Services are available 24 hours a day,
7 days a week, at no cost to you.
®
Call: 866.681.3416 TDD: 800.697.0353
Online: www.guidanceresources.com
Your company Web ID: AKPSEAP
®

KOONCE PFEFFER BETTIS - Aleutians East Borough School District

Transcription

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