1. health and fitness

2011 - 2012 Employee Benefits
Summary Overview
Booklet compliments of
CGI Employee Benefits Group
What’s Inside
Welcome and Table of Contents
Site of Service
Medical Plan
Health Reimbursement Arrangement
Flexible Spending Account
Dental Plan
Vision Plan
Life and AD&D
Short & Long Term Disability
Long Term Care
401(k) Retirement Plan
Employee Assistance Program
Paid Time Off
Continuing Coverage through COBRA
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Your Individual Benefits Plan
Welcome to CGI Employee Benefits Group, the official sponsor of your benefits program!
As an active full-time employee you are eligible to participate in a competitive benefit
program. This summary of benefits is provided to give you a general overview of the benefit
choices you have as an employee. We have attempted to make this summary as up to date
and accurate as possible. However, if there are any discrepancies between this summary
and the plan documents, the plan documents will supersede this summary. Employee
benefit plans and policies may be changed at the sole discretion of the company at any
time. Please make sure that you read all benefits information provided to you.
Once you make benefit elections they will be effective for the plan period. The only time
you may change your benefits during the plan year is in the event of a qualified life change.
A qualified life change is defined as the birth or adoption of a dependent, death of a
dependent, marriage, divorce or loss of other coverage. In order to change your benefits
you must notify Human Resources within 30 days of the qualified event. We will have an
open enrollment period once a year for anyone who wants to change their benefits but has
not had a qualified life change.
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Site of Service Benefit
With Anthem’s Site of Service benefit you are able to save money and lower your out-ofpocket costs.
Here’s How:
When you use an independent laboratory for blood tests, urine test, Pap test or biopsy,
your share of the cost will be zero ($0) and you will not need to pay a deductible or
coinsurance.
Talk with your doctor to schedule with one of these participating Eligible Independent Labs:
Quest Diagnostics 800-377-7220
www.questdiagnostics.com
LabCorp 888-522-2677
www.labcorp.com
Converge Diagnostic Service LLC 866-616-6695
www.convergedx.com
Also by using an eligible ambulatory surgery center for outpatient surgery or an outpatient
procedure such as a colonoscopy, tonsillectomy or knee arthroscopy done at an eligible
ASC, your share of the cost will be $75 and you will not pay for any deductible or
coinsurance.
Talk with your doctor to schedule with one of these participating Eligible Ambulatory
Surgery Center:
Bedford Ambulatory Surgery Center 603- 622-3670
www.bedfordsurgical.com
Capital Orthopedic Surgery Center LLC 603-228-7211
www.concordhospital.org
Concord ASC 603-415-9460
www.concordhospital.org
Dartmouth Hitchcock Clinic 603-629-1800
www.dartmouth-hitchcock.org
Elliot One Day Surgery Center 603-663-5900
www.elliothospital.org
Salem Surgery Center 603-898-3610
www.salemsurgerycenter.com
SJH Surgicenter LLC 603-595-3673
www.sjhsurgicenter.com
For an additional list of AMS please visit Anthem on line at anthem.com/siteofservicenh
and click on eligible ambulatory surgery centers. Coverage for procedures offered at
facilities varies based on the actual procedure performed and the services covered under
you’re your health benefit plan. Contact Anthem customer service for additional information
regarding plan coverage prior to services being rendered.
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Anthem Medical Insurance
CGI offers Medical Insurance through Anthem BC/BS of New Hampshire. Employees are eligible for medical
benefits the first of the month following date of hire. Employees and their eligible dependents may choose to
enroll in the Anthem HMO Blue New England Site of Service Plan or the Lumenos with HSA Plan.
Access Blue New England
HNEVP56B
General Deductible
Preventive Care
Immunization, lead screening, PSA
Physical exams, routine hearing exams
Outpatient care
Your Cost Sharing:
$3,000 per member
$9,000 per family
*See Health Reimbursement Arrangement on Page 5
Covered in full
Medical exams, injections, office surgery &
anesthesia
$25 per visit PCP
$50 per visit Specialist or Network Walk-in-Center
Surgery and anesthesia in an independent
ambulatory surgery center
$75 per admission
Lab tests furnished by an independent
laboratory provider
Covered in full
$50 per visit
Physical, Occupational, or speech therapyup to 20 visits per therapy, per member, per CY
Lab tests furnished by a hospital facility
X-ray, CT Scan, MRI, outpatient facility fees
Surgery in outpatient dept. of hospital or in
ambulatory surgery center
Inpatient Care
Physician in-hospital care, surgery, delivery, lab, Xray, CT scan, MRI, medical supply, medication &
physical, occupational and speech therapy
Subject to deductible
Subject to deductible
Durable Medical Equipment
Subject to deductible
Mental Health & Substance Abuse Services
Outpatient- $25 per visit, unlimited visits per member, per cy
Inpatient- Subject to deductible
Emergency Room charge
Urgent Care facility charge
ER/ urgent care physician fee, CT scan, MRI,
medical supplies
Prescription Drug
$250 per visit, waived if admitted
$50 per visit
Subject to deductible
Retail 30 day supply
$10 Tier 1
$35 Tier 2
30% Tier 3 coinsurance.
Coinsurance max up to $2,500
per member, no more $7,500
per family, per calendar year.
Mail order 90 day supply
$10 Tier 1
$70 Tier 2
30% Tier 3 coinsurance.
Coinsurance max up to $2,500
per member, no more $7,500
per family, per calendar year.
Your medical plan is fully insured with: Anthem Blue Cross and Blue Shield
Note: This is a brief summary of your coverage. For more detailed information on benefits, limitations and
exclusions refer to the Summary Plan Description and Subscriber Certificate provided by the carrier.
Please contact Anthem Customer Service at 1-800-870-3122 with questions regarding coverage, claims, or to
change your Primary Care Physician.
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Plan Features
LUMENOS HSA
GHSA 286VA
Earn Health Rewards
With your Lumenos HSA plan you may earn reward dollars to redeem for gift cards to select retailers.
Complete the Health Assessment online, you may earn $50
Enroll in a Personal Health Coach Program, you may earn, $100
Graduate from a Personal Health Coach Program, you may earn $200
Complete the Smoking Cessation Program and/ or Weight Management Program, you may earn $50 each
Contributions to your HSA
$3,050 individual coverage
$6,150 family coverage
Deductible
$2,500 per Member
$6,000 per Family
Coinsurance
network providers 0% coinsurance
out-of- network 30% to $5,000 /$10,000
Office Visits/ Preventive/ OBGYN
100% covered as long as you receive care from an
network provider
Inpatient Hospital Services
Outpatient Surgery Services
Diagnostic X-rays/ lab test
Emergency Hospital Services
Inpatient & Outpatient Mental Health &
Substance Abuse Services
Maternity
Chiropractic Care
Covered at 100% for in-network provider or 70%
for out- of- network providers, after deductible has
been satisfied
Prescription Drugs
Home Health & Hospice Care
Physical, Speech & Occupational
Therapy Services
Durable Medical Equipment, limited to
$3,500 per member per cy
Your medical plan is fully insured with: Anthem Blue Cross and Blue Shield
Note: This is a brief summary of your coverage. For more detailed information on benefits, limitations and
exclusions refer to the Summary Plan Description and Subscriber Certificate provided by the carrier.
Please contact Anthem Customer Service at 1-888-224-4896 with questions regarding coverage, claims, or to
change your Primary Care Physician.
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Health Reimbursement
Arrangement
CGI offers a Health Reimbursement Arrangement (HRA) as part of your employee benefits
package. The HRA is an employer benefit plan where the employer reimburses a portion of
your plan’s annual deductible. This year the plan deductible is $3,000 per member.
Covered members are responsible for 25% of each deductible related expense up to a
maximum of $750 per member with a maximum of $2,250 per family. CGI will reimburse
75% of each deductible related expense up to $2,250 per member with a maximum of
$6,750 per family. Contact Adam Dunn for additional information.
Flexible Spending Accounts
(FSA)
Employees are eligible to enroll in the flexible spending accounts upon date of hire. FSAs
provide employees with and important tax advantage that can help you pay health care and
dependent care costs on a pre-tax basis. Your Health Care Reimbursement FSA and
Dependent Care FSA plans are administered through: CGI Employee Benefits Group.
Below are the benefit attributes:
Health Care Reimbursement FSA
Dependent Care FSA
$5,000 Annual Maximum
$5,000 Annual Maximum
Beginning January 1, 2011, OTC medications now require a doctor’s prescription to
be eligible for FSA reimbursement. Please see your FSA brochure for additional
details.
As an eligible employee participating in the employee benefit programs, you may be
required to contribute toward the cost of the benefits you have elected. Through the section
125 plan your contributions can be deducted before FICA and federal taxes.
Please direct inquiries to CGI Benefit Administration Department at 1-888-383-0088.
For more information visit: www.cgibenefitsgroup.com.
Please be advised this is a brief overview. Please refer to your Summary Plan
Description for complete benefit information.
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Dental Insurance
CGI offers Dental Insurance through Securian. Employees are eligible for dental
benefits the first of the month following date of hire. The Securian Dental program
includes all of the following coverages.
SERVICES
Calendar Year Deductible
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Deductible applies to Basic and Major Restorative Services and does
not apply to Diagnostic and Preventive Services
Calendar Year Maximum (Per Person)
•
Applies to Diagnostic and Preventive, Basic and Major Restorative Services
Diagnostic and Preventive Services
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Oral exams (twice in a 12 month interval)
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Cleanings (twice in a 12 month interval)
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X-Rays
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Fluoride treatments (through age 18, once in a 12 month interval)
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Sealants (through age 15)
Basic Services
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Space maintainers (through age 18, once per lifetime for extracted
primary posterior teeth)
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Fillings (Amalgams: Anterior Composites)
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Endodontic (root canals)
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Periodontics (diseased gum tissue or bone)
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Oral surgery & extractions
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Anesthesia in conjunction with complex surgery only
Major Restorative Services
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Fillings (Posterior Composites)
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Crowns and onlays. Fixed prosthodontics, bridges
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Removable prosthodontics, dentures and partials
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Repair of dentures, partials or bridges
LEVEL OF BENEFITS*
$25 Individual
$75 family
$1,500
100%
No Waiting Period
50%
No Waiting Period
50%
No Waiting Period
*Claim payments are based on the amount charged by the dentist or our Maximum
Allowable Fee, whichever is less. If the dentist charges more than our Maximum Allowable
Fee, the patient is responsible for the difference. Deductibles are per individual, with a
maximum of three per family. We strongly encourage you to ask your dentist to submit a
pretreatment estimate request for services anticipated to exceed $200. This information is
intended to provide you a summary of your dental coverages; in all cases the Securian
Dental Benefit Plan Summary controls the terms and conditions of your coverage. Please
refer to your Summary Plan Description for complete benefit information. Please direct
inquires to 1-800-234-9009 or www.securiandental.com.
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Anthem Vision
All employees and their eligible dependents are eligible to enroll after the first of the month
following date of hire in the Anthem Vision Plan. The Anthem Vision provides a wide
network of experienced ophthalmologists, optometrists, and opticians. Anthem Visions
network also includes convenient retail locations. You may also choose to receive care
outside of the Anthem Vision network. For more information please visit www.anthem.com.
Vision Care Services
In-Network
Out-of- Network
Annual Routine Eye Exam
$10 copay
Up to $48
Eyeglass frames
$10 copay
Up to $52
Eyeglass lenses
Standard single vision
$10 copay
Standard bifocal lenses $10 copay
Standard trifocal lenses $10 copay
Standard lenticular lenses $10 copay
Up to $32
Up to $47
Up to $66
Up to $88
You may receive any one of the
following lens options once every
12 months.
Eyeglass lens upgrade
Contact lenses
UV Coating - $16.00
Tin (solid & gradient) - $15.00
Scratch resistance - 18.00
Polycarbonate - $35.00
Progressive(add on to bifocal) n/a
Additional add-on – 20% discount
Conventional lenses
$10 copay
$105 retail allowance
Discount on lens upgrades are
not available out-of-network
Conventional lenses
Up to $84
Disposable lenses
$10 copay
$105 retail allowance
Disposable lenses
Up to $84
Non-elective Contact lenses
$10 copay
$260 retail allowance
Non-elective Contact lenses
Up to $210
Your vision plan is fully insured with: Anthem Vision
Note: For more detailed information on benefits, limitations and exclusions refer to the
Summary of Benefits and Subscriber Certificate provided by the carrier.
Please contact Anthem at 1-888-799-6290 with questions about your vision benefits or
need to locate at provider.
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Life and AD&D Insurance
CGI Employee Benefits Group provides employees with Group Life and Accidental Death and
Dismemberment (AD&D) insurance upon date of hire and pays the full cost of this benefit. Contact
Adam Dunn to update beneficiary information.
Life and AD&D Insurance
$50,000
Your Life and AD&D insurance is fully insured through Unum.
Please be advised this is a brief overview. Please refer to your Summary Plan Description for
complete benefit information.
VOLUNTARY LIFE INSURANCE
Voluntary Life Insurance benefits are available for employees to purchase the first of the
month following receipt of application.
Employees may purchase supplemental Term Life and AD&D insurance up to 5 times
salary to a maximum of $500,000. Term Life and AD&D may also be purchased for spouse
and dependents. Please see Adam Dunn for more information
Disability Insurance
SHORT TERM DISABILITY
CGI will compensate 100% of semi-monthly salary for up to 90 days at the companies’
discretion.
VOLUNTARY LONG TERM DISABILITY INCOME PROTECTION
Long Term Disability Insurance is also available on a Voluntary basis. The benefit payable
is 60% of your monthly earnings to a maximum of $5,000 per month for a nonoccupational injury or illness. Benefits begin after a 90 day elimination period.
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Long Term Care Insurance
CGI offers Voluntary Long Term Care insurance. You have the choice of 3 difference
benefit durations available: 3 year, 6 year or Lifetime.
Your Basic Life, AD&D, Voluntary Life Insurance, Voluntary Long Term Disability and Long
Term Care policies are underwritten by:
UNUM Life Insurance Company of America
2211 Congress Street
Portland, ME. 04122
Phone # 1-800-227-4165 E-mail www.unum.com
401k Retirement Plan
Provided by Great West Retirement Services
CGI is interested in assisting you secure your future retirement years. Employees are
eligible to enroll upon date of hire. CGI currently matches 25% of each dollar you contribute
up to 8% of your total withholding. You may check your account balances and make fund
changes via Great West Retirement Services Website at www.gwrs.com or by calling 1800-338-4015.
Employee Assistance
Program
The Employee Assistance Program is available to all employees and immediate family members
of CGI through MKS Performance Solutions, LLC. It is a completely confidential counseling
program that covers issues such as work/life balance, health/wellness, financial and legal
consultation, and other personal stressors. You can contact MKS 24 hours per day/ 7 days per
week at 888-657-7373, or you can visit their website at www.mksperformancesolutions.com.
CGI pays the full cost of this benefit for employees and their immediate family.
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Paid Time Off & Other
Benefits
CGI employees are provided 4 weeks of paid time off annually.
Holiday Schedule
The holidays normally observed by CGI Employee Benefits Group are as follows:
New Years Day
Martin Luther King Day
Presidents Day
Friday before Memorial Day
Memorial Day
Friday before Independence Day
Independence Day
Labor Day
Columbus Day
Thanksgiving Day
Thanksgiving Recovery Day
Friday before Christmas
Day after Christmas Day
2011 HOLIDAY SCHEDULE
Friday, December 31st
N/A
Monday, February 21st
Friday, May 27th
Monday, May 30th
Friday, July 1st
Monday, July 4th
Monday, September 5th
Monday, October 10th
Thursday, November 24th
Friday, November 25th
Friday, December 23rd
Monday, December 26th
2012 HOLIDAY SCHEDULE
Monday, January 2nd
Monday, January 16th
Monday, February 20th
Friday, May 25th
Monday, May 28th
N/A
Wednesday, July 4th
Monday, September 3rd
Monday, October 8th
Thursday, November 22nd
Friday, November 23rd
Monday, December 24th
Tuesday, December 25th
CGI Health and Medication Service
We have partnered with The Prescription Center, a full service independent,
neighborhood pharmacy located in New Hampshire. The Prescription Center offers
prescriptions, medical supplies, and natural products. Since our goal is to provide you with
the highest level of service, we believe this partnership will only strengthen our continued
commitment to your health and wellness. There is not cost for these voluntary benefits.
Detailed information is available from Human Resources.
Wellness
CGI’s wellness program is intended to provide employees with opportunities to educate and
improve their quality of life and reduce sick time. During the year, various seminars,
challenges and screening are offered all at no cost to our employees. Through
comprehensive programming, CGI strives to provide a culture of wellness.
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Additional Information to All Eligible Employees
COBRA Information: COBRA continuation coverage is a temporary extension of coverage under the group health plan.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would
otherwise lose your group health coverage. It can also become available to other members of your family who are
covered under the Plan when they would otherwise lose their group health coverage. For additional information about
your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description
or contact the Plan Administrator.
HIPAA Information: - Special Enrollment Right Mandated by the Health Insurance Portability and Accountability Act of
1996
Group health plans and health insurance insurers are required to provide special enrollment periods during which
individuals who previously declined coverage for themselves and their dependents may be allowed to enroll without
having to wait for the plan’s next open enrollment period. A special enrollment period can occur if a person with other
health coverage loses that coverage or if a person becomes a new dependent through marriage, birth, adoption or
placement for adoption. If you refuse enrollment for yourself or your dependents for medical coverage, you may later
enroll within 30 days of a change in family status or loss of health coverage.
Individuals may not be denied eligibility or continued eligibility to enroll for benefits under the terms of the plan based on
specified health factors. In addition, an individual may not be charged more for coverage than similarly situated
individuals based on these specific health factors.
Effective April 1, 2009, the Children’s Health Insurance Reauthorization Act of 2009 (CHIPRA) created a new 60 day
special enrollment period for eligible employees and dependents to immediately enroll in the plan if they become ineligible
for Medicaid or any state’s Children’s Health Insurance Program (CHIP) and lose coverage or become eligible for that
state’s premium assistance program. The employee must request coverage within 60 days after the termination of
coverage or the determination of subsidy eligibility.
Women’s Health and Cancer Rights Act of 1998 (WHCRA): WHCRA requires a group health plan to notify you, as a
participant or a beneficiary, of your potential rights related to coverage in connection with a mastectomy. Your plan may
provide medical and surgical benefits in connection with a mastectomy and reconstructive surgery. If it does, coverage will
be provided in a manner determined in consultation with your attending physician and the patient for a) all stages of
reconstruction on the breast on which the mastectomy was performed; b) surgery and reconstruction of the other breast to
produce a symmetrical appearance; c) prostheses; and d) treatment of physical complications of the mastectomy,
including lymphedema. The coverage, if available under your group health plan, is subject to the same deductible and
coinsurance applicable to other medical and surgical benefits provided under the plan. For specific information, please
refer to your summary plan description or benefits booklet, or contact Human Resources.
THIS IS ONLY A SUMMARY, NOT A CERTIFICATE OF INSURANCE. The information contained in this benefit
summary and or plan comparison is designed to help you, the employee, understand the general provisions of your group
insurance benefits. The utmost care has been given to provide you with the most up-to-date and accurate information. In
all cases where a discrepancy from this document and the actual plan exists, the plan provisions provided from the insurer
will govern. This document should not be used as a certified outline of your benefits. This can only come from the insurer.
This summary does not constitute in any way an agreement to pay any and all claims or benefits which they are not
obligated by contract to pay.
© CGI Employee Benefits Group 2011
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