Municipal School Districts of Shelby County
A Quick Look at Your Benefits and Enrollment Municipal School Districts of Shelby County Open Enrollment April 20 – May 15 This brochure represents the 2015–2016 benefits for the Municipal School Districts of Shelby County Arlington Community Schools Bartlett City Schools Collierville Schools Lakeland School System Millington Municipal Schools Pre-enrollment opportunities will be held at each school district. Look to your school district’s website for more information about meetings and 1 opportunities to enroll. Benefits covered inside this booklet include: Page 4: _____________________________________ Medical Page 5: _____________________________________ Dental Page 7: _______________________________ Vision Page 9: ___________________________ Basic/Supp Life Page 15: ______________________________________ FSA P age 16: ________________________STD /Cancer/Accident Page 20: ______________________________________LTD Page 25: ______________________________________EAP Page 26: _______________________________ Rates Page 28: __________________Convenient Resources/Tools Page 29__Biometric Screenings/Hlth&Wellness Clinics Page 30______Supplemental Retirement Opportunities Page 32__________________________Legal Notices Welcome to Meritain Health! Meritain Health Enroll with Meritain Health today to take your next step towards a healthier, balanced tomorrow. Meritain Health knows how important it is for healthcare consumers like you to really understand how your plan works. In this way, you can make the changes you want in your health and in your life. Healthcare benefits provide the support you need to reach your healthy balance. Chances are, you try every day to restore a healthy balance to your life, but time gets away from you, or other details come first. Meritain Health is here to help you focus, to support you every step of the way. Think of the benefits and programs as an important resource in the protection of your body, mind and spirit! Protecting your healthy balance with preventive care. Question: Which is better: Taking an hour or two out of your busy day to have your annual checkup—or missing hidden symptoms and paying the price in sick days, copays and missed events? Answer: Nothing makes more sense in these busy times than preventing illness before it happens. That’s why your plan offers excellent benefits for preventive services. Early detection, proper nutrition, and routine exercise are the key to living a long and healthy life, and will also help to control long-term healthcare costs. Your employer encourages you to take the necessary steps—available to you right now—to ensure early detection and treatment of diseases. 2 www.myMERITAIN.com Benefit Highlights Meritain Health Built into your health plan are preventive benefits that cover: Well-child care Physical exams Mammogram Bone density test Prostate blood exam Pap smear Fecal occult Healthcare for you and your family: When sickness or injury throw you off balance. Knowing that you’re in good hands when you’re sick is one of the most comforting feelings there is. You can be assured that your health plan has everything you’ll need to get the right care if something goes wrong. Balancing healthcare costs: What you pay and what the plan pays. After you pay your annual deductible and any up-front copays, the plan begins to pay a percentage of your provider’s charges, for example 80%. The remaining percentage, for example 20%, is your responsibility—your “out-of-pocket” costs. You’re protected from financial hardship by a maximum out-of-pocket amount each year—the most you’ll have to pay before the plan covers costs at 100%. (Copays do not always apply to the out-of-pocket maximum. This varies by plan). It's important when selecting a plan, to consider what your maximum financial risk is for the three plan options listed in this brochure. In addition, factoring in your current health needs ensures you apply for the plan option that will benefit you and your family the most. For more detailed information, see your summary plan description (SPD). What are Copays/Deductibles/Major Medical Copay is a set amount that you or your dependent is expected to pay at the time services are rendered. Examples where a copay might apply would be at your physician's office or at the pharmacy. Deductible is set amount you or your dependent is expected to pay before the plan plays on services that usually occur outside of a doctor's office. These type of services could be considered Major Medical. Examples of Major Medical services are In-Patient or Out-Patient Surgery, Diagnostic and Imaging test such as CAT Scans or MRIs. For a complete list, please see your plan's SPD. Save when you visit network providers. This plan offers a provider network of doctors and other healthcare professionals who have agreed to accept lower amounts than their standard charges, just for members of this plan. These lower amounts are negotiated and predetermined. That means when you see a network provider, your share of costs is based on a lower charge—so your costs are lower, too. Network providers are conveniently located in both urban and rural areas. Lower costs and convenient doctors and clinics are important ways that Meritain Health can support your efforts to stay well and have a healthy lifestyle—or to get care as simply as possible when you’re sick. Remember: If you go outside the network, you may still have benefits, but your share of costs will be higher, and the amount you pay will not be based on a lower rate. Nationwide provider access at a discount. When you and your family seek healthcare services, you have access to Aetna’s broad national provider network of healthcare providers and facilities. Aetna’s network contains more than 850,000 participating physicians and ancillary providers, with 6,900 hospitals. When you visit providers in the Aetna network, you will receive services at strong, negotiated rates, helping you to save on the cost of healthcare. Locate your preferred providers. With Aetna’s comprehensive provider participation, many of your preferred doctors may already be in the Aetna network. To verify whether or not a doctor or healthcare facility participates, visit http://www.aetna.com/docfind/custom/mymeritain/.Your network is Aetna Choice® POS II. 3 www.myMERITAIN.com Summary of Benefits EPO Network Only ***WELLNESS (Routine Care) Physical Exams (As required by ACA) Well Child Care (Including Immunizations) Mammogram (Test and Reading) Pap Smears (Test and Reading) Prostate Blood Test (Test and Reading) Fecal Occult Screening (Test and Reading) **Annual Health Fund Provided to Employees and Dependents Basic Plan Out-of Network In-Network HRA Plan In-Network Out-of Network Plan pays 100% (No Ded) Plan pays 100% (No Ded) Not Covered Plan pays 100% (No Ded) Not Covered Plan pays 100% (No Ded) Plan pays 100% (No Ded) Plan pays 100% (No Ded) Plan pays 100% (No Ded) Plan pays 100% (No Ded) Plan pays 100% (No Ded) Not Covered Plan pays 100% (No Ded) Not Covered Plan pays 100% (No Ded) Plan pays 100% (No Ded) Plan pays 100% (No Ded) Plan pays 100% (No Ded) Not Applicable Plan pays 50% (after Ded) Plan pays 100% (No Ded) Plan pays 50% (after Ded) Plan pays 50% (plus Ded) Plan pays 100% (No Ded) Plan pays 50% (after Ded) Plan pays 50% (plus Ded) Plan pays 100% (No Ded) Plan pays 50% (after Ded) Plan pays 50% (plus Ded) Plan pays 100% (No Ded) Plan pays 50% (after Ded) Not Applicable $500 Individual $750 Individual plus one $1,000 Family This is a change from last year’s benefits MAJOR MEDICAL *Deductible (Ded) $500/Individual $750/Individual plus one $1,000/Family $500/Individual $750/Individual plus one $1,000/Family $1,000/Individual $1,500/Individual plus one $2,000/Family $1,500/Individual $2,250/Individual plus $3,000/Family $3,000/Individual $4,500/Individual plus $6,000/Family Plan Payment (Coinsurance) Out-of-Pocket Maximum* (Including Deductible) Plan pays 100% $2,000/Individual $3,750/Individual plus one $5,500/Family Plan pays 80% $2,500/Individual $5,000/Individual plus one $7,500/Family Plan pays 50% $7,500/Individual $15,000/Individual plus one $22,500/Family Plan pays 80% $3,500/Individual $7,000/Individual plus one $10,500/Family Plan pays 50% $10,500/Individual $21,500/Individual plus one $31,500/Family Lifetime Maximum per Family Member HOSPITAL BENEFITS In-Patient Unlimited $500 Copay per admission, plus Ded Plan pays 80%(after Ded) Plan pays 50% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) Out-Patient $250 Copay per visit, plus Ded Plan pays 80%(after Ded) Plan pays 50% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) Emergency Room $150 Copay per visit, plus Ded $150 Copay per visit (plus Ded) Paid at the Participating Provider level of benefits Plan pays 80% (after Ded) Paid at the Participating Provider level of benefits Medical Emergency (Copay Waived if Admitted) Medical Emergency (Copay Waived If Admitted) Plan pays 100% (after Ded) Plan pays 100% (after Ded) Plan pays 80%(after Ded) Plan pays 50% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) Plan pays 80%(after Ded) Plan pays 50% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) Plan pays 100% after $20 Copay per visit Plan pays 100% after $35 Copay per visit Plan pays 100% (No Ded) Plan pays 100% after $25 Copay per visit Plan pays 100% after $35 Copay per visit Plan pays 80%(after Ded) Plan pays 50% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) Plan pays 50% (after Ded) 80% (after Ded) Plan pays 50% (after Ded) Plan pays 50% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) $10 Generic $25 Preferred $50 Non-Preferred $10 Generic $25 Preferred $50 Non-Preferred Plan pays 50% (after Ded) Plan pays 50% (after Ded) Plan pays 50% (after Ded) $10 Generic $25 Preferred $50 Non-Preferred Plan pays 50% (after Ded) Plan pays 50% (after Ded) Plan pays 50% (after Ded) $500 Copay (plus Ded) per admission Plan pays 100% after $20 per visit Plan pays 80%(after Ded) Plan pays 50% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) Plan pays 100%; after $25 Copay per visit Plan pays 50% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) ADDITIONAL MEDICAL BENEFITS Physical Therapies including Chiropractic (60 visits max) Plan pays 100% after $35 Copay per visit Plan pays 100%; after $35 Copay per visit Plan pays 50% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) Home Health Care (Precertification) Plan pays 100% (after Ded) (60 visits max) Plan pays 80% (after Ded) (60 visits max) Plan pays 50% (after Ded) (60 visits max) Plan pays 80% (after Ded) (60 visits max) Plan pays 50% (after Ded) (60 visits max) Extended Care Facility Plan pays 100% (No Ded) (60 visits max) Plan pays 100% (after Ded) $75 Copay per visit, plus Ded Plan pays 100% (after Ded) Plan pays 100% (after Ded) Plan pays 100% (No Ded) (60 visits max) Plan pays 80% (after Ded) $75 Copay per visit, plus Ded Plan pays 80% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) (60 visits max) Plan pays 50% (after Ded) Plan pays 80% (after Ded) (60 visits max) Plan pays 80% (after Ded) Plan pays 50% (after Ded) (60 visits max) Plan pays 50% (after Ded) $75 Copay per visit, plus Ded Plan pays 50% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) Plan pays 50% (after Ded) Plan pays 80% (after Ded) Plan pays 50% (after Ded) SURGICAL/PHYSICIAN BENEFITS In-Patient Out-Patient PHYSICIAN'S OFFICE VISIT SPECIALIST OFFICE VISIT DIAGNOSTIC X-RAY & LABORATORY SERVICES PRESCRIPTION DRUG CARD (Copay) MENTAL/NERVOUS & SUBSTANCE ABUSE In-Patient Physician’s Office Visit Hospice (Precertification) Urgent Care Ambulance Services Medical Supplies and Durable Equipment *Deductibles and Out of Pocket Expenses Accumulate on a calendar year basis. **The HRA Fund pays at the back end of the deductible and is funded 50% for enrollments beginning September 1. On January 1, the fund will be funded the full amount listed in this summary and any funds remaining at the end of the calendar year will be added to it. Please note that the fund cannot exceed 100% of the total deductible ***For a detailed listing of preventive services, please visit the U.S. Department of Health and Human Services website at: https://www.healthcare.gov/what‐are‐my‐preventive‐care‐benefits. The plan document is the governing document; therefore any discrepancies which may be found are not binding. The Plan Document may be found by going to your district’s Employee Portal and looking under “Documents/Links”. 4 www.myMERITAIN.com Dental Benefits Design - Met Life Meritain Health 1HWZRUN3'33OXV %HQHILW6XPPDU\ 3ODQ2SWLRQ±'332 3ODQ2SWLRQ'332 &RYHUDJH7\SH ,Q1HWZRUN 2XWRI1HWZRUN &RYHUDJH7\SH ,Q1HWZRUN 2XWRI1HWZRUN Type A – cleanings, oral examinations 100% of Negotiated Fee* 80% of Negotiated Fee* 60% of Negotiated Fee* 100% of R&C Fee** Type A – cleanings, oral examinations 100% of R&C Fee** 80% of R&C Fee** Type B – fillings 60% of R&C Fee** Type C –bridges and dentures 100% of Negotiated Fee* 80% of Negotiated Fee* 50% of Negotiated Fee* 50% of Negotiated Fee* 50% of R&C Fee** Type D – orthodontia (Adult & Child) 'HGXFWLEOH ,Q1HWZRUN 2XWRI1HWZRUN 'HGXFWLEOH Individual $25.00 $50.00 Individual Family $75.00 $150.00 $QQXDO0D[LPXP %HQHILW ,Q1HWZRUN Per Person $2,000 Type B – fillings Type C –bridges and dentures Type D – orthodontia (Adult & Child) 50% of R&C Fee** ,Q1HWZRUN 2XWRI1HWZRUN $50.00 $100.00 Family $150.00 $300.00 2XWRI1HWZRUN $QQXDO0D[LPXP %HQHILW ,Q1HWZRUN 2XWRI1HWZRUN $2,000 Per Person $1,500 $1,500 ,Q1HWZRUN 2XWRI1HWZRUN $1,500 $1,500 ,Q1HWZRUN 2XWRI1HWZRUN 2UWKRGRQWLD /LIHWLPH0D[LPXP Per Person $2,000 $2,000 Per Person * Negotiated Fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated Fee fees are subject to change. **R&C Fee refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of (1) the dentist’s actual charge, (2) the dentist’s usual charge for the same or similar services, or (3) the charge of most dentists in the same geographic area for the same or similar services as determined by MetLife. † Applies only to Type B & C Services. 5 50% of R&C Fee** 50% of Negotiated Fee* 2UWKRGRQWLD /LIHWLPH0D[LPXP www.myMERITAIN.com 80% of R&C Fee** *Negotiated Fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated Fee fees are subject to change. **R&C Fee refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of (1) the dentist’s actual charge, (2) the dentist’s usual charge for the same or similar services, or (3) the charge of most dentists in the same geographic area for the same or similar services as determined by MetLife. † Applies only to Type B & C Services. Dental Benefits (continued) /LVWRI3ULPDU\&RYHUHG6HUYLFHV/LPLWDWLRQV Type A – Preventive 3ODQ2SWLRQ'332 How Many/How Often Type A – Preventive 3ODQ2SWLRQ'332 How Many/How Often: 3URSK\OD[LVFOHDQLQJV y WLPHLQPRQWKV 3URSK\OD[LVFOHDQLQJV y WLPHLQPRQWKV 2UDO([DPLQDWLRQV y WLPHLQPRQWKV y 2QHIOXRULGHWUHDWPHQWSHUPRQWKVIRUGHSHQGHQWFKLOGUHQXSWR 2UDO([DPLQDWLRQV y WLPHLQPRQWKV y 2QHIOXRULGHWUHDWPHQWSHUPRQWKVIRUGHSHQGHQWFKLOGUHQXSWR 7RSLFDO)OXRULGH$SSOLFDWLRQV ;UD\V 6SDFH0DLQWDLQHUV WK ELUWKGD\ y )XOOPRXWK;UD\VRQHSHUPRQWKV y %LWHZLQJ;UD\VRQHVHWSHUPRQWKV y 6SDFH0DLQWDLQHUVIRUGHSHQGHQWFKLOGUHQXSWRWK ELUWKGD\RQFHLQ DOLIHWLPH y 2QHDSSOLFDWLRQRIVHDODQWPDWHULDOHYHU\PRQWKVIRUHDFKQRQ 6HDODQWV UHVWRUHGQRQGHFD\HGVW DQGQG PRODURIDGHSHQGHQWFKLOGXSWR WK ELUWKGD\ Type B - Basic Restorative How Many/How Often *HQHUDO$QHVWKHVLD y 5HSODFHPHQWRQFHHYHU\PRQWKV y :KHQGHQWDOO\QHFHVVDU\LQFRQQHFWLRQZLWKRUDOVXUJHU\H[WUDFWLRQV 6LPSOH([WUDFWLRQV y 1ROLPLW &URZQ'HQWXUHDQG%ULGJH 5HSDLU5HFHPHQWDWLRQV y WLPHLQPRQWKV (QGRGRQWLFV y 5RRWFDQDOWUHDWPHQWOLPLWHGWRRQFHSHUWRRWKLQDOLIHWLPH y 1ROLPLW y 3HULRGRQWDOVFDOLQJDQGURRWSODQLQJRQFHSHUTXDGUDQWHYHU\ )LOOLQJV 2UDO6XUJHU\ RURWKHUFRYHUHGGHQWDOVHUYLFHV 7RSLFDO)OXRULGH$SSOLFDWLRQV ;UD\V 6SDFH0DLQWDLQHUV 6HDODQWV WK ELUWKGD\ y )XOOPRXWK;UD\VRQHSHUPRQWKV y %LWHZLQJ;UD\VRQHVHWSHUPRQWKV y 6SDFH0DLQWDLQHUVIRUGHSHQGHQWFKLOGUHQXSWRWK ELUWKGD\RQFHLQ DOLIHWLPH y 2QHDSSOLFDWLRQRIVHDODQWPDWHULDOHYHU\PRQWKVIRUHDFKQRQ UHVWRUHGQRQGHFD\HGVW DQGQG PRODURIDGHSHQGHQWFKLOGXSWR WK ELUWKGD\ Type B - Basic Restorative )LOOLQJV *HQHUDO$QHVWKHVLD How Many/How Often y 5HSODFHPHQWRQFHHYHU\PRQWKV y :KHQGHQWDOO\QHFHVVDU\LQFRQQHFWLRQZLWKRUDOVXUJHU\H[WUDFWLRQV RURWKHUFRYHUHGGHQWDOVHUYLFHV PRQWKV y 3HULRGRQWDOVXUJHU\RQFHSHUTXDGUDQWHYHU\PRQWKV y 7RWDOQXPEHURISHULRGRQWDOPDLQWHQDQFHWUHDWPHQWVDQGSURSK\OD[LV 3HULRGRQWLFV FDQQRWH[FHHGWZRWUHDWPHQWVLQDFDOHQGDU\HDU Type C - Major Restorative How Many/How Often Type C - Major Restorative y ,QLWLDOSODFHPHQWWRUHSODFHRQHRUPRUHQDWXUDOWHHWKZKLFKDUHORVW ZKLOHFRYHUHGE\WKH3ODQ %ULGJHVDQG'HQWXUHV y 'HQWXUHVDQGEULGJHZRUNUHSODFHPHQWRQHHYHU\\HDUV y 5HSODFHPHQWRIDQH[LVWLQJWHPSRUDU\IXOOGHQWXUHLIWKHWHPSRUDU\ ZKLOHFRYHUHGE\WKH3ODQ %ULGJHVDQG'HQWXUHV GHQWXUHFDQQRWEHUHSDLUHGDQGWKHSHUPDQHQWGHQWXUHLVLQVWDOOHG ZLWKLQPRQWKVDIWHUWKHWHPSRUDU\GHQWXUHZDVLQVWDOOHG &URZQV,QOD\V2QOD\V y 5HSODFHPHQWRQFHHYHU\\HDUV How Many/How Often y ,QLWLDOSODFHPHQWWRUHSODFHRQHRUPRUHQDWXUDOWHHWKZKLFKDUHORVW y 'HQWXUHVDQGEULGJHZRUNUHSODFHPHQWRQHHYHU\\HDUV y 5HSODFHPHQWRIDQH[LVWLQJWHPSRUDU\IXOOGHQWXUHLIWKHWHPSRUDU\ GHQWXUHFDQQRWEHUHSDLUHGDQGWKHSHUPDQHQWGHQWXUHLVLQVWDOOHG ZLWKLQPRQWKVDIWHUWKHWHPSRUDU\GHQWXUHZDVLQVWDOOHG 6LPSOH([WUDFWLRQV y 5HSODFHPHQWRQFHHYHU\\HDUV y 1ROLPLW &URZQ'HQWXUHDQG%ULGJH 5HSDLU5HFHPHQWDWLRQV y WLPHLQPRQWKV (QGRGRQWLFV y 5RRWFDQDOWUHDWPHQWOLPLWHGWRRQFHSHUWRRWKLQDOLIHWLPH y 1ROLPLW y 3HULRGRQWDOVFDOLQJDQGURRWSODQLQJRQFHSHUTXDGUDQWHYHU\ &URZQV,QOD\V2QOD\V 2UDO6XUJHU\ PRQWKV 3HULRGRQWLFV y 3HULRGRQWDOVXUJHU\RQFHSHUTXDGUDQWHYHU\PRQWKV y 7RWDOQXPEHURISHULRGRQWDOPDLQWHQDQFHWUHDWPHQWVDQGSURSK\OD[LV FDQQRWH[FHHGWZRWUHDWPHQWVLQDFDOHQGDU\HDU Type D – Orthodontia How Many/How Often y y y y y <RX<RXU6SRXVHDQG<RXU&KLOGUHQXSWRDJHDUH FRYHUHGZKLOH'HQWDO,QVXUDQFHLVLQHIIHFW $OOGHQWDOSURFHGXUHVSHUIRUPHGLQFRQQHFWLRQZLWKRUWKRGRQWLF WUHDWPHQWDUHSD\DEOHDV2UWKRGRQWLD 3D\PHQWVDUHRQDUHSHWLWLYHEDVLV RIWKH2UWKRGRQWLD/LIHWLPH0D[LPXPZLOOEHFRQVLGHUHG DWLQLWLDOSODFHPHQWRIWKHDSSOLDQFHDQGSDLGEDVHGRQWKH SODQEHQHILW¶VFRLQVXUDQFHOHYHOIRU2UWKRGRQWLDDVGHILQHGLQ WKH3ODQ6XPPDU\ 2UWKRGRQWLFEHQHILWVHQGDWFDQFHOODWLRQRIFRYHUDJH Type D – Orthodontia How Many/How Often y <RX<RXU6SRXVHDQG<RXU&KLOGUHQXSWRDJHDUHFRYHUHG ZKLOH'HQWDO,QVXUDQFHLVLQHIIHFW y $OOGHQWDOSURFHGXUHVSHUIRUPHGLQFRQQHFWLRQZLWKRUWKRGRQWLF WUHDWPHQWDUHSD\DEOHDV2UWKRGRQWLD y 3D\PHQWVDUHRQDUHSHWLWLYHEDVLV y RIWKH2UWKRGRQWLD/LIHWLPH0D[LPXPZLOOEHFRQVLGHUHGDWLQLWLDO SODFHPHQWRIWKHDSSOLDQFHDQGSDLGEDVHGRQWKHSODQEHQHILW¶V FRLQVXUDQFHOHYHOIRU2UWKRGRQWLDDVGHILQHGLQWKH3ODQ6XPPDU\ y 2UWKRGRQWLFEHQHILWVHQGDWFDQFHOODWLRQRIFRYHUDJH Ǥ ǡ Ǥ ǁǁǁ͘ŵĞƚůŝĨĞ͘ĐŽŵͬŵLJďĞŶĞĨŝƚƐ 6 www.myMERITAIN.com IN-NETWORK BENEFITS Healthy eyes and clear vision are an important part of your overall health and plan helps you care quality of life. Your o vision v for your eyes while saving you money by offffering: Eye Examination Every September 1, Covered in full after $10 copayment Eyeglasses Every September 1, Covered in full Spectacle Lenses For standard single-vision, lined bifocal, or trifocal lenses after $20 copayment Every other September 1, Covered in full Paid-in-full eye examinations, eyeglasses and FRQWDFWV Any Fashion or Designer frame from Davis Vision’s Collection/1 (value up to $175) Frames OR Frame Collection: Your o ou plan includes a selection of designer, name brand frames that are completely covered in full./1 Contact Lens Collection: Select from the most popular contact lenses on the market today with Davis Vision’s Contact Lens Collection./1 One-year eyeglass breakage warranty included on SODQH\HZHDUDWQRDGGLWLRQDOFRVW $130 retail allowance toward any frame from provider, plus 20% offf balance/2 Contact Lenses Every September 1, Contact Lens Evaluation, Fitting & Follow Up Care Collection Contacts: Covered in full after $20 copayment OR Non Collection Contacts: Standard Contacts: 15% discount/2 Specialty Contacts/3: 15% discount/2 How to locate a Network Provider... Every September 1, Covered in full Just log on to the Open Enrollment section of our Member site at davisvision.com and click “Find a Provider” to locate a provider near you including: Any contact lenses from Davis Vision’s Contact Lens Collection/1 Contact Lenses (in lieu of eyeglasses) OR $150 retail allowance toward provider supplied contact lenses, plus 15% offf balance/2 ADDITIONAL DISCOUNTED LENS OPTIONS & COA ATINGS T Without Davis Vision $40 $64 $62 $154 $123 MOST POPULAR OPTIONS Savings based on in-network usage and average retail values. Scratch-Resistant Coating Polycarbonate Lenses 6WDQGDUG$QWL5HÀHFWLYH$5&RDWLQJ Standard Progressives (no-line bifocal) //5 Plastic Photosensitive (Transitions® ) Contact your Human Resources department today to enroll. For more details about the plan, just log on to the Open Enrollment section of our Member site at davisvision.com or call 1.877.923.2847 and enter Client Code 3148 With Davis Vision $0 $0/4-$30 $0 $0 $65 /RZHUFRVWVDQGPRUHEHQH¿WVSee the savings! Without Davis Vision With Davis Vision $100 $10 Bifocals $80 $20 Scratch-Resistant Coating $40 $0 $123 $65 Frame $150 $0 Total o $493 $95 Service Eye Examination Lenses /5 Transitions® 1/ The Davis Vision i a most participating independent provider locations. Collection Collection is available at is subject to change. Collection is inclusive of select toric and multifocal contacts. 2/ Additional discounts not applicable at Wa allmart or Sam’’s Club locations. 3/ Including, but not limited to toric, multifocal and gas permeable contact lenses. 4/ For dependent children, monocular patients and patients with prescriptions of 6.00 diopters or greaterr. 5/ Trransitions® is a registered trademark of Trransitions Optical Inc. Davis Vision i corre has made every effort to correctly summarize your vision plan features. In the event of a FRQÀLFWEHWZHHQWKLVLQIRUPDWLRQDQG\RXURUJDQL]DWLRQ¶VFRQWUDFWZLWK'DYLV9LVLRQWKHWHUPVRIWKH contract or insurance policy will prevail. Employee Contributions 20-Pay Employee Employee plus Spouse Employee plus Family $3.70 $7.07 $11.48 OE00757 6/9/14 7 www.myMERITAIN.com 7 ADDITIONAL OPTIONS WITHOUT WITH DAVIS VISION DAVIS VISION FRAMES Fashion Frame (from the Davis Vision Collection) $125 $0 Designer Frame (from the Davis Vision Collection) $175 $0 Premier Frame (from the Davis Vision Collection) $225 $25 All Ranges of Prescriptions and Sizes $90 $0 Plastic Lenses $33 $0 Oversized Lenses $20 $0 Tinting of Plastic Lenses $20 $0 Scratch-Resistant Coating $40 LENSES Value for our Members $FRPSUHKHQVLYHEHQH¿WHQVXULQJORZRXWRI pocket cost to members and their families. Our goal is 100% member satisfaction. Convenient Network Locations A national network of credentialed preferred providers throughout the 50 states. Freedom of Choice Access to care through either our network of independent, private practice doctors (optometrists and ophthalmologists) or select retail partners. Value-Added Features: Replacement contacts through LENS123® mail-order contact lens replacement service, saving both time and money. Laser Vision Correction discounts of up to 25% off the provider’s Usual & Customary fees, or 5% off advertised specials, whichever is lower. $0 /1 Polycarbonate Lenses $64 $0 or $30 Ultraviolet Coating $28 $12 6WDQGDUG$QWL5HÀHFWLYH$5&RDWLQJ $62 $0 Premium AR Coating $80 $13 Ultra AR Coating $113 $25 Intermediate-Vision Lenses $150 $30 Standard Progressive Addition Lenses $154 $0 Premium Progressives (Varilux® /2, etc.) $248 $40 High-Index Lenses $120 $55 Polarized Lenses $103 $75 Plastic Photosensitive Lenses $123 $65 Scratch Protection Plan (Single vision | Multifocal lenses) $20 | $40 1/ Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions 6.00 diopters or greater. 2/ Varilux® is a registered trademark of Societe Essilor International Contact Info 2XWRI1HWZRUN%HQH¿WV For more details about the plan, just log on to the Open Enrollment section of our Member site at davisvision.com or call 1.877.923.2847 and enter Client Code 3148. You may receive services from an out-of-network provider, although you will UHFHLYHWKHJUHDWHVWYDOXHDQGPD[LPL]H\RXUEHQH¿WGROODUVLI\RXVHOHFWD provider who participates in the network. If you choose an out-of-network provider, you must pay the provider directly for all charges and then submit a claim for reimbursement to: Vision Care Processing Unit P.O. Box 1525 Latham, NY 12110 OUT-OF-NETWORK REIMBURSEMENT SCHEDULE Eye Examination up to $30 | Frame up to $30 Spectacle Lenses (per pair) up to: Single Vision $25, Bifocal $35, Trifocal $45, Lenticular $60 Elective Contacts up to $75, Medically Necessary Contacts up to $225 8 www.myMERITAIN.com Basic & Supplemental Life - MetLife Meritain Health Explore the coverage that makes it easy to give yourself and your loved ones more security today…and in the future Basic Term Life and Accidental Death and Dismemberment Insurance (AD&D) Your employer provides you with Basic Term Life and Accidental Death and Dismemberment insurance coverage in the amount of 2 times your base annual earnings. Supplemental Term Life Insurance Coverage Options For You $10,000 increments to the maximum of the lesser of 5 times your annual salary or $500,000 For Your Spouse^ $5,000 to $250,000 in $5,000 increments, not to exceed 50% of your Supplemental Term Life coverage amount For Your Dependent Children*^ $10,000 or $20,000 *Child(ren)’s Eligibility: Dependent children ages from 15 days to 26 years old are eligible for coverage. ^Please note: Employees must be enrolled in the Supplemental life coverage to be eligible to add spouse and/or dependent child coverage Per Pay Period (20 Pay Periods) for Supplemental Term Life Insurance and Accidental Death and Dismemberment Insurance You have the option to purchase Supplemental Term Life Insurance. Listed below you will find your Per Pay Period Cost (20 Pay Periods) as well as those for your spouse (based on your age and the amount of coverage you want). Rates to cover your child(ren) are also shown. Age Per Pay Period Cost (20 Pay Periods) Per $1,000 of Coverage Spouse Per Pay Period Cost (20 Pay Periods) Per $1,000 of Coverage Under 30 $0.048 $0.048 30 – 34 $0.060 $0.060 35 – 39 $0.066 $0.066 40 – 44 $0.084 $0.084 45 – 49 $0.120 $0.120 50 – 54 $0.178 $0.178 55 – 59 $0.322 $0.322 60 – 64 65 – 69 $0.487 $0.926 $0.487 $0.926 70 + $1.495 $1.495 † Cost for your Child(ren) † Covers all eligible children 9 www.myMERITAIN.com $0.133 Use the table below to calculate your premium based on the amount of life insurance you will need. Example: $100,000 Supplemental Life Coverage 1. Enter the rate from the table (example age 36) 2. Enter the amount of insurance in thousands of dollars (Example: for $100,000 of coverage enter $100) 3. Per Pay Period premium (1) x (2) $0.066 $ 100 $6.60 $ Repeat the three easy steps above to determine the cost for each coverage selected. Features This insurance offering from your employer and MetLife comes with a variety of added features that can provide assistance to you and your family members today and during a difficult time. Accelerated Benefits Option1 For access to funds during a difficult time You can receive up to 80% of your Basic and Supplemental Term Life insurance proceeds to a maximum of $500,000 in the event that you become terminally ill and are diagnosed with less than 12 months to live. This can go a long way toward helping your family meet medical and other related expenses at this difficult time. The Accelerated Benefit Option is also available to spouses partners insured under Dependent Life insurance plans. This option is not available for dependent child coverage. Conversion For protection after your coverage terminates You can generally convert your Group Term Life insurance benefits to an Individual Whole Life insurance policy if your coverage terminates in whole or in part due to your retirement, termination of employment, or, a change in your employee class. Conversion is available on all Group Life insurance coverages. Please note that conversion is not available on AD&D coverage. If you experience an event that makes you eligible to convert your coverage, you can speak with a MetLife representative by calling 1-877-275-6387. Please contact your plan employer for more information. Waiver of Premiums for Total Disability (Continued Protection) Offering continued coverage when you need it most If you become Totally Disabled, you may qualify to continue certain insurance. You may also be eligible for waiver of your Basic and Supplemental Term Life and Personal Accidental Death and Dismemberment insurance premium until you reach age 65, die or recover from your disability, whichever is sooner, should you become unable to work due to a Total Disability. Total Disability or Totally Disabled means you are unable to do your job and any other job for which you are fit by education, training or experience, due to injury or sickness. The Total Disability must begin before age 60, and your waiver will begin after you have satisfied a 9-month waiting period of continuous disability. The Waiver of Premium will end when you turn age 65, die or recover. Please note that this benefit is available after you have participated in the Supplemental Term Life Plan for one year and it is only available to you. This one-year requirement applies to new participants in the plan. 10 www.myMERITAIN.com Portability So you can keep your coverage even if you leave your current employer Should you leave your employer for any reason, and your Basic and Supplemental and Dependent Term Life and Personal and Supplemental and Dependent Accidental Death and Dismemberment insurance under this plan terminates, you will have an opportunity to continue group term coverage (“portability”) under a different policy, subject to plan design and state availability. Rates will be based on the experience of the ported group and MetLife will bill you directly. Rates may be higher than your current rates. To take advantage of this feature, you must have coverage of at least $10,000 up to a maximum of $2,000,000. Portability is also available on coverage you’ve selected for your spouse and dependent child(ren). The maximum amount of coverage for spouses is $250,000; the maximum amount of dependent child coverage is $20,000. Increases, decreases and maximums are subject to state availability. Generally, there is no minimum time for you to be covered by the plan before you can take advantage of the portability feature. Please see your employer or certificate for specific details. Please note that if you experience an event that makes you eligible for portable coverage, please call a MetLife representative at 1-888-252-3607 or contact your plan employer for more information. Will Preparation Service2 To help ensure your decisions are carried out Like life insurance, a carefully prepared Will (Simple, Complex or Living) along with a Power of Attorney are important. With a will, you can define your most important decisions such as who will care for your children or inherit your property. Living Will: Ensures your wishes are carried out, and protects your loved ones from making these very difficult and personal medical decisions by themselves. Also called an “advanced directive,” it is a document authorized by statutes in all states. A person appoints someone as his/her proxy or representative to make decisions on maintaining extraordinary life-support if the person should become incapacitated so that he or she is unable to communicate his or her wishes. Powers of Attorney: Allows you to plan ahead by designating someone you know and trust to act on your behalf in the event of unexpected occurrences or if you become incapacitated. It is a written document that grants an individual the power to act on the grantor’s behalf. By enrolling for Supplemental Term Life coverage, you will have access to Hyatt Legal Plans’ network of 12,000 participating attorneys. When you enroll in this plan, you may take advantage of face-to-face access to a participating plan attorney to prepare or update a will, living will or powers of attorney.* When you use a participating plan attorney there will be no charge for the services*. To obtain the legal plan’s toll-free number and your company’s group access number please contact your employer or your plan administrator for this information. * You also have the flexibility of using an attorney who is not participating in the Hyatt Legal Plans’ network and being reimbursed for covered services according to a set fee schedule. In that case you will be responsible for any attorney’s fees that exceed the reimbursed amount. 11 www.myMERITAIN.com MetLife Estate Resolution ServicesSM—ERS3 Personal service and compassion to help your beneficiaries and others manage your estate during their time of need MetLife Estate Resolution Services—is a valuable service offered under the plan. When your estate representative uses a participating Hyatt Legal plan attorney there will be no charge for the services. A Hyatt Legal Plan attorney will consult face-to-face with your beneficiaries or by telephone regarding the probate process for your estate. The attorney will also handle the probate of your estate for your executor or administrator. This can help alleviate the financial and administrative burden upon your loved ones in their time of need. Transition Solutions4 Assistance identifying solutions for your financial situations Transition Solutions is a service designed to help provide assistance in making financial decisions based on the major events in your life including changes in employment, retirement or your benefits status. Contact your employer or plan administrator for more information. Delivering The Promise® For support when beneficiaries need it most Delivering The Promise® is a service designed to provide beneficiaries with the support and assistance they need during an especially difficult time. Services include assistance filing life insurance claims and consultation to help with the financial details and questions that arise upon the loss of a loved one. MetLife’s Center for Special Needs Planning5 Comprehensive Planning Assistance for Dependents with Special Needs MetLife’s Center for Special Needs Planning is a service that works with families who have dependents with special needs. To help them prepare for the complex financial, social, emotional, and educational issues facing them, MetLife’s Center for Special Needs Planning helps families with financial planning strategies. Funeral Planning Guide Provides beneficiaries a resource that outlines your final wishes. It highlights details of pertinent information including: how to plan for funeral costs, the death claim process, personal funeral preferences and more. Total Control Account®7 For immediate access to death proceeds The Total Control Account® settlement option provides your loved ones with a safe and convenient way to manage the proceeds of a life or accident policy for claim payments of $5,000 or more, backed by the financial strength and claims paying ability of Metropolitan Life Insurance Company. They'll have the convenience of immediate access to any or all of their proceeds, through an interest bearing account with unlimited draftwriting privileges. The Total Control Account gives beneficiaries time to decide what to do with their proceeds, which can be very helpful to them during a difficult time. What’s Not Covered? Like most insurance plans, this plan has exclusions. Supplemental and Dependent Life Insurance do not provide payment of benefits for death caused by suicide within the first two years (one year in North Dakota or Colorado) of the effective date of the certificate, or payment of increased benefits for death caused by suicide within two years (one year in North Dakota or Colorado) of an increase in coverage. Please note that a reduction schedule may apply. Please see your employer or certificate for specific details. 12 www.myMERITAIN.com -----------------------Accidental Death & Dismemberment (AD&D) coverage complements your Basic and Supplemental Life coverage insurance and helps protect you 24 hours a day, 365 days a year. Accidental Death & Dismemberment Coverage Options This valuable coverage is available to you even if you already have accident insurance. It provides benefits beyond your disability or life insurance for losses due to covered accidents — while commuting, traveling by public or private transportation and during business trips. MetLife’s AD&D insurance pays you benefits if you suffer a covered accident that results in paralysis or the loss of a limb, speech, hearing or sight, or brain damage or coma. If you suffer a covered fatal accident, benefits will be paid to your beneficiary. Supplemental AD&D Coverage Amounts for You Your Supplemental AD&D amount is equal to your Supplemental Term Life amount. Supplemental AD&D Coverage Amounts for Spouse and Child(ren) You can choose to cover your dependent spouse and child(ren) with AD&D coverage. Your dependents will be eligible for coverage amounts equal to their amounts of Dependent Term Life coverage. Covered Losses This AD&D insurance pays benefits for covered losses that are the result of an accidental injury or loss of life. The full amount of AD&D coverage you select is called the “Full Amount” and is equal to the benefit payable for the loss of life. Benefits for other losses are payable as a predetermined percentage of the Full Amount, and will be listed in your coverage in a Table of Covered Losses. Such losses include loss of limbs, sight, speech and hearing, various forms of paralysis, brain damage and coma. The maximum amount payable for all Covered Losses sustained in any one accident is capped at 100% of the Full Amount. Standard Additional Benefits Include Some of the standard additional benefits included in your coverage that may increase the amounts payable to you and/or defray additional expenses that result from accidental injury or loss of life are: Air Bag Benefit Seat Belt Benefit Common Carrier Benefit Child Care Center Benefit Child Education Benefit Spouse Education Benefit Hospitalization Benefit What Is Not Covered? Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or riot; committing or trying to commit a felony; any poison, fumes or gas, voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self-preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs. 13 www.myMERITAIN.com Additional Coverage Information How To Apply * Complete your enrollment and be sure to indicate your Beneficiary. Act Now During the Enrollment Period! Note: Even if you wish to keep your existing level of coverage, you must complete your enrollment. *All applications are subject to review and approval by Metropolitan Life Insurance Company based upon its underwriting rules. For Employee Coverage Enrollment in this Supplemental Term Life insurance plan is available without providing a Statement of Health form as long as: For Annual Enrollment effective the Summer of 2015 only: Your enrollment takes place before the enrollment deadline, and You are increasing coverage to an amount equal to/less than 3 times your basic annual earnings, or You are enrolling for coverage to an amount equal to/less than 3 times your basic annual earnings For all other Annual Enrollments: Your enrollment takes place before the enrollment deadline, and You are continuing the coverage you had in the last year For New Hires: Your enrollment takes place within 31 days from the date you become eligible for benefits, and You are enrolling for coverage equal to/less than 3 times your basic annual earnings If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form. For Dependent Coverage You must be covered the Supplemental Life in order to obtain coverage for your spouse and child(ren). Your spouse and dependent children do not need to provide a Statement of Health form as long as they are not home or hospital confined and not receiving or applying to receive disability payments and: For Annual Enrollment effective the Summer of 2015 only: The enrollment takes place prior to the enrollment deadline, and Your spouse and/or child(ren) is/are continuing coverage she/he/they had in the last year You are increasing coverage for your spouse to an amount equal to/less than $20,000, or You are enrolling your spouse for coverage equal to/less than $20,000, or You are increasing/enrolling your child(ren) for coverage For all other Annual Enrollments: The enrollment takes place prior to the enrollment deadline, and Your spouse and child(ren) is/are continuing coverage she/he/they had in the last year For New Hires The enrollment takes place within 31 days from the date you become eligible for benefits, and You are enrolling your spouse for coverage equal to/less than $20,000, or You are enrolling your child(ren) for coverage If you do not meet all of the conditions stated above, you will need to provide additional medical information by completing a Statement of Health form. 14 www.myMERITAIN.com Health & Dependent Care FSA - American Fidelity Are out-of-pocket medical expenses squeezing your budget? Flexible Spending Account (Health) A Health FSA can save you money by allowing you to set aside part of your pay, on a pre-tax basis, to reimburse yourself for eligible medical, dental and vision expenses such as co-payments, medical deductibles, prescriptions, and much more. Expenses incurred for you, your spouse, and other qualifying individuals are eligible for reimbursement. The maximum amount you may set aside is $2,500 per plan year. Flex Debit Card A flex debit card allows you to use Flexible Spending Account funds to pay for eligible medical, dental and vision expenses instead of paying out-of-pocket. It gives you direct access to your FSA funds and helps you avoid waiting on reimbursement checks! What Else Should I Know? The card cannot be used until your plan year begins. The card is only for eligible medical, dental and vision expenses. Dependent daycare expenses are not eligible. The card cannot be used for over-the-counter drugs filled with a prescription; you will need to file a manual claim. Save your receipts! There is a fee for replacement cards. Are you saving money with Dependent Day Care? Dependent Day Care FSA A Dependent Day Care FSA allows you to set aside pre-tax dollars to reimburse yourself for incurred eligible dependent care expenses. You may allocate up to $5,000 per plan year for reimbursement of dependent day care services ($2,500 if you are married and file a separate tax return). For a complete list of eligible expenses for the Health FSA and Dependent Day Care FSA, talk to your American Fidelity representative when enrolling. 15 www.myMERITAIN.com Accident Only Insurance Limited Benefit Accident Only Insurance Whether a weekend warrior with an active lifestyle or the stay at‐ home type, accidents can happen anytime, anywhere, without warning. Being prepared for the unexpected can make all the difference. American Fidelity’s Accident Only Insurance policy provides you a solution for those unforeseen accidents that life sometimes delivers. Our Limited Benefit Accident Only Insurance is designed to help pay for the unexpected medical expenses an individual may incur for the treatment of covered injuries received in an accident. How the Plan Works Our Accident Only Insurance policy pays according to a wide‐ranging schedule of benefits. In addition, the policy provides 24‐hour coverage for accidents that occur both on and off the job. All benefits are only paid as a result of Injuries received in an Accident that occurs while coverage is in force. All treatment, procedures, and medical equipment must be diagnosed, recommended and treated by a Physician. All benefits are paid once per Covered Person per Covered Accident unless otherwise specified in the Limitations and Exclusions section.1 Premium and amount of Benefits may vary dependent upon Plan selected. 1 American Fidelity Assurance Company Coverage Feature Plan Options: Enhanced and Enhanced Plus Choose the plan to meet your financial needs. Four Choices of Coverage: Individual, Individual and Spouse, Individual and Child, or Family Choose the coverage that fits your lifestyle. Wide‐Ranging Schedule of Benefits Covers all types of coveredinjuries. Wellness Benefit After the policy has been in force for 30 days, you receive a benefit for an annual routine exam, including immunizations and preventive testing once per policy per Receive a benefit when emergency treatment i n a Emergency room occurs within 72 hours of a covered accident. Accident Emergency Treatment Benefit Benefit Paid Directly to Guaranteed Renewable 24‐Hour Coverage Portable Optional Accident Disability Income Rider This rider covers you 24‐hours a day and pays a Monthly Benefit Amount when a Covered Person becomes Totally Disabled due to Injuries received in a Covered Accident after the Elimination Period. The monthly benefit will be paid directly to you to use as you see fit. What It Means For You Additional Coverage Options Payroll Deducted Use the benefit however best fits your financial needs. Keep your coverage aslong as premiums are paid as required. You are covered on or off the job. You own the policy. Take thecoverage with you if you choose toleaveyour current job. Your premiums will remain the same. Enhance the base plan by adding an optional rider. Enjoy the convenienceofhavingyour Premiums deducted straight from your paycheck. Limitations, exclusions and waiting periods apply. Refer to your policy for complete details. This product is inappropriate for people who are eligible for Medicaid coverage. The company has the right to change premiums by class(AO‐03Series). 16 www.myMERITAIN.com Cancer Insurance Limited Benefit Cancer Indemnity Insurance Policy A cancer diagnosis may be overwhelming. Even with a good medical plan, the out‐of‐pocket costs of cancer treatment, such as travel, childcare, and loss of income, are considerable and may not be covered. American Fidelity Assurance Company Coverage Feature Plan Options What It Means For You Choose the plan to meetyourfinancial needs. American Fidelity’s Cancer Insurance can help offer financial protection so you can focus your attention on fighting cancer. We offer plans that can help assist with out‐of‐pocket costs often associated with a cancer diagnosis. Three Choices of Coverage: Individual, Single Parent Family, or Family Wide‐Ranging Schedule of Benefits Choose the coverage that fits your lifestyle. How the Plan Works Benefit Paid Directly to You Use the money however best fits your financial needs. Keep your coverage aslong as premiums are paid as required. Our plan is designed to help cover expenses if you are diagnosed with a covered Cancer. With over 20 benefits available to you, this plan provides benefits for the treatment of cancer, transportation, hospitalization and more. We provide the money directly to you, to be used however you see fit. Optional Riders Guaranteed Renewable Diagnostic and Prevention Benefit Receive a benefit for visiting your doctor for a cancer screening test, which helps Transportation and Lodging Receive benefits if you travel more than 50 miles from yourhomeusing the most direct route forcovered treatment. Portable You own the policy. Take the coverage with you if you choose to leave your current job. Your premiums will remain the same. Additional Coverage Options Enhance the base plan by choosing from a selection of optional riders. Payroll Deducted Enjoy the convenience of having your premiums deducted straight from your paycheck. Enhance your base plan with the following riders: • Critical Illness Rider Includes a cancer benefit and a heart attack/stroke benefit • Hospital Intensive Care Unit Rider Covers a wide range oftreatments. Limitations, exclusions and waiting periods apply. Please refer to your policy for complete details. This product is inappropriate for people who are eligible for Medicaid coverage. The company has the right to change premiums by class. The premium and amount of benefits provided vary dependent upon the plan selected. 17 www.myMERITAIN.com Critical Illness Insurance Limited Benefit Hospital Indemnity Insurance Policy Surviving a critical illness, such as a heart attack or stroke, can come at a high price. With advances in technology to treat these diseases, the cost of treatment rises more and more every year. Even with medical insurance, the out‐of‐pocket expenses associated with a critical illness can affect anyone’s finances. American Fidelity Assurance Company’s Limited Benefit Critical Illness Insurance can be the solution that helps you and your family focus on recovery, and may help you with paying bills. Our plan can assist with the expenses that may not be covered by standard medical insurance. How the Plan Works If you are diagnosed with a covered Critical Illness, such as a heart attack or stroke, this plan is designed to pay a lump sum benefit amount to help cover expenses. Also, this plan offers a Recurrent Diagnosis Benefit that can provide an additional 50% of the Critical Illness benefit amount after the second occurrence date of the specified Critical Illness. Guaranteed Renewable You are guaranteed the right to renew your base policy until age 75 as long as you pay premiums when due or within the premium grace period. We have the right to increase premiums by class. Optional Benefit Riders Enhance your base plan with these riders: • Sudden Death D ue to a Cardiac Arrest Benefit Rider • Hospital Confinement Benefit Rider 18 www.myMERITAIN.com American Fidelity Assurance Company Coverage Feature What It Means For You Plan Options Choose from three lump sum benefit amounts: $15,000, $20,000 or $25,000. Four Choices of Coverage: Individual, Individual & Spouse, Single Parent Family, or Family Choose the coverage that fits your lifestyle. WellnessBenefit Receive a benefit for your annual screening test. Benefit Paid Directly to You Use the benefit however best fits your financial needs. Multiple Critical Illness Benefits You will be covered for 10 different critical illnesses. Portable You own the policy. Take the coverage with you if you choose to leave your current job. Your premiums will remain the same. Additional Coverage Options Enhance the base plan byadding an optional rider. Payroll Deducted Enjoy the convenience of having your premiums deducted straight from your paycheck. Limitations, exclusions and waiting periods apply. Please refer to your policy for complete details. This product is inappropriate for people who are eligible for Medicaid coverage. The company has the right to change premiums by class. The premium and amount of benefits provided vary dependent upon the plan selected. Short-Term Disability Income Insurance American Fidelity Assurance Company How do you pay for your mortgage, bills, food and other monthly expenses? If your paycheck stopped today, could you maintain your current lifestyle? American Fidelity’s Short‐Term Disability Income Insurance is designed to help protect you if you become disabled and cannot work due to a covered Accidental Injury or Sickness. How the Plan Works If you become disabled due to a covered accident or sickness, Short‐ Term Disability Income Insurance will pay up to 60% of your monthly income once you have satisfied the elimination period. Disability benefits will be payable up to the benefit period stated in your policy. Coverage Feature Benefit Paid Directly to You, Regardless of Other Coverage AgeatEntry Eligibility All full‐time employees and employees of members on active service working 25 hours or more per week. Applicant’s eligibility for this program may be subject to insurability. It is your responsibility to see the American Fidelity representative once you have satisfied your employer’s waiting period. 19 www.myMERITAIN.com Use the money however best fits your financial needs, regardless of other insurance. Your premiums will bebasedonthe date your policy becomeseffective. Accidental Death Benefit Receive a benefit if you die as the direct result of an Accidental Injury and death occurs within 90 days after the date of the Accidental Injury. Affordable Premiums Your monthly premiumscouldbe paid with only one hour ofa week’s paycheck. Payroll Deducted Enjoy the convenience of having your premiums deducted straight from your paycheck. Physician Benefit Receive a benefit if you receive treatment by a Physiciandue toa covered Injury. Accidental Death Benefit Receive a benefit if death occurs as a direct result of an Injury within 90 days after the Injury. GuaranteedIssue First‐time eligible employees may Be able to receive coveragewithout being subject to insurability. Age at Entry Premiums Premiums will be based on the date your policy becomes effective. Benefits Begin (Elimination Period) For the Short‐Term Disability Income plan, benefits can begin on the eighth day or 15th day, depending on the plan selected at the time of application. Benefits are payable for a covered Injury or Sickness up to 90 days or 180 days, based on the plan your employer has selected. Refer to your employer’s plan and your Certificate for details regarding benefit amounts and more. What It Means T oYou MaximumBenefitof60% Protect up to 60% of yourpaycheck. Of Your Monthly Gross Income Standard Insurance Company Voluntary Long Term Disability Coverage Highlights Municipal Schools of Shelby County I Voluntary Long Term Disability (LTD) Insurance Long Term Disability insurance is designed to pay a monthly benefit to you in the event you cannot work because of a covered illness or injury. This benefit replaces a portion of your income, thus helping you to meet your financial commitments in a time of need. Standard Insurance Company (The Standard) has developed this document to provide you with information about the optional coverage you may select through Municipal Schools of Shelby County. I Eligibility Requirements Policy • A minimum number of eligible employees must apply and qualify for the proposed plan before Voluntary LTD coverage can become effective Employee • A regular employee of Municipal Schools of Shelby County, other than Superintendents • Actively working at least 20 hours each week • A citizen or resident of the United States or Canada • Temporary and seasonal employees, full-time members o' the armed forces, leased employees and independent contractors are not eligible Premium • You pay 100 percent of the premium for this coverage through easy payroll deduction I Benefit Amount Benefit Percentage Your monthly benefit is 60 percent of the first $8,333 of your insured predisability earnings reduced by deductible income Plan Maximum Monthly Benefit $5,000 Plan Minimum Monthly Benefit $100 or 10 percent of the LTD benefit before reduction by deductible income, whichever is greater Note: • All late applications (applying 31 days after becoming eligible), requests for coverage increases and reinstatements are subject to medical underwriting approval. Employees eligible but not insured under the prior LTD insurance plan are also subject to medical underwriting approval. I Disability Needs Calculator Your family has a unique set of circumstances and financial demands. To help you figure out the amount of Disability insurance you may need if you become unable to work, The Standard has created a Disability Needs Calculator found at: http:l/www.standard.com/calculators/dineeds.html I Employee Coverage Effective Date To become insured, you must satisfy the eligibility requirements listed above, serve an eligibility waiting period, receive medical underwriting approval (if applicable), and be actively at work (able to perform all normal duties of your job) on the day before the scheduled effective date of insurance. If you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee. Please contact your human resources representative for more information regarding the requirements that must be satisfied for your insurance to become effective. 20 www.myMERITAIN.com Standard Insurance Company Voluntary Long Term Disability Coverage Highlights Municipal Schools of Shelby County I Understanding Your Plan Design Benefit Waiting Period If your claim for LTD benefits is approved by The Standard, benefits become payable after you have been continuously disabled for 180 days and remain disabled. Benefits are not payable during the benefit waiting period. Own Occupation Definition of Disability For the benefit waiting period and the first 24 months for which LTD benefits are paid, you are considered disabled when you are unable as a result of physical disease, injury, pregnancy or mental disorder to perform with reasonable continuity the material duties of your own occupation AND are suffering a loss of at least 20 percent of your indexed predisability earnings when working in your own occupation. You are not disabled merely because your right to perform your own occupation is restricted, including a restriction or loss of license. Any Occupation Definition of Disability After the own occupation period of disability, you will be considered disabled if you are unable as a result of physical disease, injury, pregnancy or mental disorder to perform with reasonable continuity the material duties of any occupation. Maximum Benefit Period If you become disabled before age 62, LTD benefits may continue during disability for five years. If you become disabled at age 62 or older, the benefit duration is determined by your age when disability begins: Age 62 63 64 65 66 67 68 69+ Deductible Income Maximum Benefit Period 3 years 6 months 3 years 2 years 6 months 2 years 1year 9 months 1year 6 months 1year 3 months 1year Deductible income is income you receive or are eligible to receive while LTD benefits are payable. Deductible income includes, but is not limited to: • Sick pay, annual or personal leave pay, severance pay or other forms of salary contribution (including donated amounts) paid • Benefits under any workers' compensation law or similar law • Amounts under unemployment compensation law • Social Security disability or retirement benefits, including benefits for your spouse and children • Disability benefits from any other group insurance • Disability or retirement benefits under your employer's retirement plan • Benefits under any state disability income benefit law or similar law • Earnings from work activity while you are disabled, plus the earnings you could receive if you work as much as your disability allows • Amounts due from or on behalf of a third party because of your disability, whether by judgment, settlement or other method • Any amount you receive by compromise, settlement or other method as a result of a claim for any of the above 21 www.myMERITAIN.com Standard Insurance Company Voluntary Long Term Disability Coverage Highlights Municipal Schools of Shelby County I Benefit Calculation Example The LTD benefit amount is determined by multiplying your insured predisability earnings by the specified benefit percentage. This amount is then reduced by deductible income. In the example below, the LTD benefit amount is 60 percent of insured predisability earnings. If your monthly earnings before becoming disabled were $4,500, and you now receive a monthly Social Security disability benefit of $1,200 and a monthly retirement benefit of $900,your monthly LTD benefit would be calculated as follows: Insured predisability earnings LTD benefit percentage Less Social Security disability benefit “less” retirement benefit Amount of LTD benefit $4,500 X 60% $2,700 $1,200 -$900 $600 I Additional Features Please see your human resources representative for additional information about the features and benefits below. 24 Hour Coverage 24-hour LTD plans provide coverage for disabilities occurring on or off the job. Rehabilitation Plan If you are participating in an approved Rehabilitation Plan, The Standard may include payment of some of the expenses you incur in connection with the plan including but not limited to; training and education expenses, family (child and elder) care expenses, job related expenses and job search expenses. Reasonable Accommodation Expense Benefit If your employer makes an approved work-site modification that enables you to return to work while disabled, The Standard will reimburse your employer up to a preapproved amount for some or all of the cost of the modification. Rehabilitation Incentive Benefit If you agree to participate in a rehabilitation plan that prepares you to return to work (plan must be approved by The Standard), you may be eligible to receive an additional benefit equal to 1O percent of your predisability earnings. When added to any other amount you receive from The Standard, your total benefit cannot exceed the maximum benefit allowed by the policy. Employee Assistance Program Includes an Employee Assistance Program and WorkLife Services to offer support, guidance and resources to help you and your household members resolve personal issues. Survivors Benefit If you die while LTD benefits are payable, and on the date you die you have been continuously disabled for at least 180 days, a survivors benefit equal to three time your unreduced LTD benefit may be payable (any survivors benefit payable will first be applied to any overpayment of your claim due to The Standard). Lifetime Security Benefit Your LTD benefit (amount in effect when the claim closes) payments will continue beyond the regular plan Maximum Benefit Period if you are unable to perform two or more Activities of Daily Living or are suffering severe cognitive impairment. I Exclusions Subject to state variations, you are not covered for a disability caused or contributed to by any of the following: • Your committing or attempting to commit an assault or felony, or your active participation in a violent disorder or riot • An intentionally self-inflicted injury, while sane or insane • War or any act of war (declared or undeclared, and any substantial armed conflict between organized forces of a military nature) • The loss of your professional or occupational license or certification • A preexisting condition or the medical or surgical treatment of a preexisting condition unless on the date you become disabled, you have been continuously insured under the group policy for a specified period 22of time, and you have been actively at work for at least one full day after the end of the exclusion period www.myMERITAIN.com Standard Insurance Company Voluntary Long Term Disability Coverage Highlights Municipal Schools of Shelby County I Preexisting Condition Provision A preexisting condition is a mental or physical condition whether or not diagnosed or misdiagnosed: • For which you or a reasonably prudent person would have consulted a physician or other licensed medical professional; received medical treatment, services or advice; undergone diagnostic procedures, including self- administered procedures; or taken prescribed drugs or medications • Which, as a result of any medical examination, including routine examination, was discovered or suspected Preexisting Condition Period The 90-day period just before your insurance becomes effective Exclusion Period 12 months I Limitations LTD benefits are not payable for any period when you are: • Not under the ongoing care of a physician in the appropriate specialty as determined by The Standard • Not participating in good faith in a plan, program or course of medical treatment or vocational training or education approved by The Standard, unless your disability prevents you from participating • Confined for any reason in a penal or correctional institution • Able to work and earn at least 20 percent of your indexed predisability earnings, but you elect not to work during the first 24 months after the end of the benefit waiting period the responsibility to work is limited to work in your own occupation; thereafter , the responsibility to work includes work in any occupation In addition, payment of LTD benefits is limited in duration: • If you reside outside the United States or Canada • If your disability is caused or contributed to by mental disorders, substance abuse or the environment, chronic fatigue conditions, chronic pain conditions, carpal tunnel or repetitive motion syndrome or temporomandibular joint disorder or craniomandibular joint disorder I When Benefits End LTD benefits end automatically on the earliest of: • The date you are no longer disabled • The date your maximum benefit period ends • The date you die • The date benefits become payable under any other LTD disability insurance plan under which you become insured through employment during a period of temporary recovery • The date you fail to provide proof of continued disability and entitlement to benefits I When Insurance Ends Insurance ends automatically on the earliest of the following: • The last day of the last period for which you make a premium contribution (except if premiums are waived while disabled) • The date your employment terminates • The date the group policy terminates • The date you cease to be a member (insurance may continue for limited periods under certain circumstances) • If applicable, the date your employer ceases to participate under the group policy I Group Insurance Certificate If coverage becomes effective, and you become insured, you will receive a group insurance certificate containing a detailed description of the insurance coverage including the definitions, exclusions, limitations, reductions and terminating events. The controlling provisions will be in the group policy. Neither the information presented in this summary nor the certificate modifies the group policy or the insurance coverage in any way. 23 www.myMERITAIN.com Standard Insurance Company Voluntary Long Term Disability Coverage Highlights Municipal Schools of Shelby County Rates If you have questions regarding how to determine your earnings, please contact your human resources representative. Premiums for this coverage will be deducted directly from your paycheck. Your Age Rate (as of September 1) % <25 0.065 25-34 0.082 35-44 0.120 45-54 0.270 55-64 0.594 65+ 0.680 To calculate your per pay period payroll deduction, use the formula indicated below: 1. Enter your average monthly earnings, not to exceed $8,333, on Line 1. Line 1: 2. Select your rate from the rate table and divide this by 100. Line 2: 3. Multiply Line 1 by the amount shown on Line 2. Line 3: 4. To calculate your bi-weekly premium, multiply Line 3 by 10 and divide by 20. Line 4: The amount shown on Line 4 is your estimated per pay period payroll deduction. Standard Insurance Company Voluntary Long Term Disability Coverage Highlights Municipal Schools of Shelby County Standard Insurance Company For more than 100 years we have been dedicated to our core purpose: to help people achieve financial well- being and peace of mind. We have earned a national reputation for quality products and superior service by always striving to do what is right for our customers. Headquartered in Portland, Oregon. The Standard is a nationally recognized provider of group Disability, life, Dental and Vision insurance and Individual Disability insurance. We provide insurance to more than 24,800 groups, covering over 8 million employees nationwide.• Our first group policy, written in 1951 and still in force today, stands as a testament to our commitment to building long-term relationships. To learn more about products from The Standard, Contact your human resources department or visit us at www.standard.com. ·As of June 30, 2013. Based on internal data developed by Standard Insurance Company. Standard Insurance Company 1100 SW Sixth Avenue Portland OR 97204 GP190-LTD/S399,GP399-LTD/TRUST,GP899-LTD, GP209-LTD, GP608-LTD,GP190-LTD/ASSOC/S399, GP190-LTDITRUST/S399, GP491-LTDITRUST/S399 24 www.myMERITAIN.com Your Employee Assistance Program Meritain Health Life situations can become very stressful, but we can help. When we begin to experience personal problems, reaching out to family, friends, or others can be very supportive and satisfying. However, if additional help is needed, your employer has made available to you and your immediate family a professional counseling service that can help you resolve these problems. The program is called CONCERN and it is your employee assistance program. The need for the program. Your employer knows that employees have many stresses when facing changes in life. The way employees manage these stresses can have a significant impact on their work as well as their personal life. When employees are effectively managing personal issues, they are generally much more productive. What does CONCERN cost? The services of CONCERN are a company-paid resource. There is no cost to you or your dependents if services are used. If you and your counselor decide that additional services are required beyond short-term CONCERN counseling, and these referral services are used, you will be responsible for any costs not covered by insurance CONCERN Counselors. The professional staff are master’s degreed counselors or clinical social workers. They are licensed and were required to have at least three years of clinical experience before joining CONCERN. When can I use CONCERN? Services are available when you need them. It is recommended that you use the program in early stages of problem development because it is easier to solve a problem in these early stages. CONCERN counselors can help you through a crisis or they can help you to manage common problems that anyone can experience. Common problems include family or marital difficulties, relationship problems, grief, emotional or psychological stress, financial and legal worries, alcohol or drug abuse, gambling problems, or a combination of the above. Some problems are big, some are small. You can bring any size problem to CONCERN. How does CONCERN work? If you need to talk over a problem with a CONCERN counselor, simply call for an appointment. During your first visit or two, the counselor will listen and try to gain a clear understanding of your problem, help you sort out options, and develop a problem-resolution plan with you. Help can usually be found through continued short-term counseling at CONCERN. If additional or specialized help is needed, your counselor will put you in touch with a qualified professional or a support group best suited to help. Your counselor will remain available to you until you feel the difficulties are under control. How confidential is the service? Strict confidentiality is maintained by CONCERN. The employee or dependent calls to make his own appointment. No one will know of your participation unless you tell them or give your counselor permission to speak with someone. CONCERN complies with all state and federal laws regarding confidentiality. To make an appointment call 901.458.4000 or 1.800.445.5011. 25 www.myMERITAIN.com Pay Period Rates for 2015 - 2016 Municipal School Districts of Shelby County 2015‐2016 Rates 20 pays Meritain Health For employees who received their Biometric Screening in early 2015, please see the discounted medical premiums listed below. For employees who did not receive the screenings, you have until December 31, 2015 to receive your screening in order to continue receiving the discounted medical premiums in red. MEDICAL PLANS HRA (Health Reimbursement Arrangement) EMPLOYEE EE + ONE FAMILY $ $ $ 92.47 198.82 267.47 $ $ $ BIOMETRIC SCREENING DISCOUNTED PREMIUMS 67.47 173.82 242.47 BASIC EMPLOYEE EE + ONE FAMILY $ $ $ 121.79 253.14 343.25 $ $ $ 96.79 228.14 318.25 EMPLOYEE EE + ONE FAMILY $ $ $ 139.91 295.37 402.16 $ $ $ 114.91 270.37 377.16 AETNA EPO (Exclusive Provider Organization) PER PAY PERIOD RATES (20 DEDUCTIONS) COVERAGE TIER DENTAL PLANS METLIFE COVERAGE TIER PLAN 1‐DPPO $2000 EMPLOYEE EE + ONE FAMILY PER PAY PERIOD RATES (20 DEDUCTIONS) $ 21.71 $ 45.61 $ 65.15 PLAN 2‐DPPO $1500 EMPLOYEE EE + ONE FAMILY $ $ $ 15.05 31.60 45.14 VISION PLAN 26 www.myMERITAIN.com DAVIS VISION COVERAGE TIER VISION EMPLOYEE EE + ONE FAMILY PER PAY PERIOD RATES (20 DEDUCTIONS) $ 3.70 $ 7.07 $ 11.48 Convenient Tools and Resources Meritain Health Visit your personalized member website, myMERITAIN.com, to find the benefits information you need. Once enrolled as a Meritain Health member, you will have access to myMERITAIN.com. When you log in, you’ll find everything you need to know about your benefits—from eligibility, to enrollment, to what’s covered. It’s another way we’re working with you to help you get the most from your benefits—so you can live a life that’s balanced and informed. Registration is easy! If you’re already registered to access your online account, simply enter www.myMERITAIN.com into your browser and login from the homepage. If you’re not yet registered, it’s OK. Registration is an easy 4-step process. 1. Go to www.myMERITAIN.com. Click on Create a new user account and follow the instructions. You will need to fill in your: o Group ID (you can find this on your ID Card). o Member ID (you can find this on your ID Card, as well. Enter with no spaces or dashes). o Date of birth. o Name. o Zip code. o Email address. 2. The system will display your username, which is your member ID. You will be asked to change your password. Enter and re-enter your new password, which you will need to create. 3. You will automatically be logged into your myMERITAIN account. The next time you login, use the same username and password from Step 3. Important Contact Information. Meritain Health Customer Service www.myMERITAIN.com 1.800.925.2272 Medical benefits In-network providers Aetna Provider Line www.aetna.com/docfind/custom/mymeritain 1.800.343.3140 Aetna Choice® POS II providers Scrip World Customer Service 1.866.475.7589 Prescription drug benefits Meritain Health Medical Management 1.800.242.1199 Precertification Healthy MeritsSM 1.877.348.4533 Health and wellness program details Meritain Health Disease Management 1.888.610.0089 Support for chronic conditions Met Life - www.metlife.com/mybenefits 1.800.GET.MET8 Dental - benefits/providers Davis Vision - www.davisvision.com 1.800.999.5431 Vision - benefits/providers Concern EAP 1.800.445.5011 1.901.458.4000 Employee Assistance Program American Fidelity 1.800.465.2129 FSA Administration http://www.afadvantage.com/for-individuals/afeslanding-pages/ municipal-schools-of-shelby- 1.901.458.9252 Short-term disability/accident/cancer Standard - www.standard.com 1.800.348.3226 Long-Term disability Employee Benefits 1.901.202.0855 Benefit administration 27 100% Enrolled with American Fidelity Meritain Health All eligible employees will enroll by using American Fidelity’s benefit enrollment tool. New health reform regulations have made it essential that every eligible employee enroll or waive coverage. American Fidelity is helping us achieve the 100% goal. Pre-Enrollment starts April 13th with representatives of American Fidelity scheduling times at each school location to enroll employees. Representatives will be able to explain all the benefits offered and assist employees’ enrollment. Regular enrollment begins April 20 - May 15. Benefits become effective September 1, 2015. Please look to your school district’s webpage for information on scheduling your enrollment opportunity. Please make sure you bring the following with you when you meet with American Fidelity to enroll: Social Security card of all family members you will enroll If applicable, Spouse Affidavit Form, enclosed in this brochure Once you receive your ID cards, please show them to your providers the first time you are seen. Medical: The card shows Meritain Health as your health plan administrator. Dental: MetLife does not issue ID cards, but you may register at www.metlife.com/mybenefits to review providers. Vision: The card shows Davis Vision. A list of providers is included. Card front Sample ID Card ■ Your healthcare plan includes a network of providers you can visit for healthcare services. When you visit providers in this network, you will receive the best service rate. Call the provider information number for participating providers. Plan: Aetna Choice POS II Name: COPAY: John Smith ID #: 123456789 Effective Date: 00-00-00 Group #: 12345 Div: 001 Group Name: ABC Company Coverage: Medical EMP/FAM RxBin: 001234 RxPCN: ABC RxGrp: RX1234 Customer Care: 800-xxx-xxxx Pharmacy Help Desk: 800-xxx-xxxx Office Visit: Emergency Room: Urgent Care Facility: Specialist: $xx $xx $xx $xx ■ Your name, identification number, medical group number and your group name, are used to identify you and your covered dependents’ benefits. Generic Copay: $xx Formulary Copay: $xx Non-Formulary Copay: $xx ■ Your medical copays are conveniently listed for you and your providers. ■ Your pharmacy coverage information is listed on the front of your card, and includes the Scrip World customer service number and prescription copays. Card back For Pre-Certification call: 999.999.9999 Failure to comply with your plan's pre-certification requirements may result in a reduction of benefits. For an Aetna provider: 800-xxx-xxxx Network Link: www.myMERITAIN.com * Aetna participating doctors, dentists and hospitals are independent providers and are neither agents nor employees of Aetna. SUBMIT ALL CLAIMS TO: Meritain Health P.O. Box 99999 City, State, zip Benefit/Claim Customer Service: 800-xxx-xxxx ■ Please ensure that you precertify with Meritain Health Medical Management, if required. ■ All claims should be submitted to Meritain Health at this address. ■ You or your provider can call Meritain Health to verify eligibility of benefits or check on your claims status. EDI: WebMD - #99999 24/7 Nurse line: 800-xxx-xxxx www.myMERITAIN.com 28 24-Hour Automated Customer Service: 800-xxx-xxxx or www.myMERITAIN.com ■ You can call for information on a doctor or specialist who is close to you and serves your specific needs. SCHEDULE YOUR BIOMETRIC SCREENING Lock in your discounted premium! In early January and February of 2015, many participated in the Biometric Screenings conducted by Meritain and Interactive Health. The purpose of the screenings were to bring attention on the need for health and wellness and to identify potential health issues. Many health issues don’t start as “The Major Event”. Usually it is “The Major Event” which calls attention to the warnings signs that may have been present all along. What if we could have prevented “The Major Event” before it happened? What would that cost? How much would it save? These screening are a ways to identify “risks or warning signs” which as we get older, only increase. With technology today, no longer are we satisfied to be “Reactive” to our health needs, but be “Proactive” instead. Those who participated in the Biometric Screenings took that first step in being “Proactive”. Knowing the “Risks or Warning Signs” helps us to stay on the path to great health. All who participated have been able to secure the discounted rates advertised in this brochure. If you have not scheduled your screening yet, it is not too late. With the opening of the District’s Health & Wellness Centers through CareHere in early fall, you may schedule your screening before January 2016, in order to lock in your discounted rates too. Take the first step to good health, by scheduling your screening in early Fall. 29 COMING SOON HEALTH & WELLNESS CLINICS We are excited to announce for the coming school year, the opening of two Health & Wellness Clinics, to be administered by CareHere. Please look for the official announcement in early fall 2015. These clinics, will be open to all employees of Arlington Community Schools, Bartlett City Schools, City of Bartlett, Collierville Schools, Town of Collierville, Lakeland School System, City of Lakeland and Millington Municipal Schools, who are participating in the district’s health plan through Meritain/Aetna. Listed below are just a few of the benefits this clinic model will provide for insured employees and their dependents: 1. No office copay 2. Dispensing of prescription medicine at the time of service with no copay 3. Dispensing of prescription maintenance drugs with no copay 4. Conduct all employee Biometric Screenings in order to maintain discounted premiums 5. Online Appointment Scheduler 6. No waiting office appointments 7. Smartphone application 8. 24/7 call center 9. Nutritional Counseling/Pre‐Diabetes Management 10. Tobacco Cessation Two opportunities to save TODAY for TOMORROW Great West My Money · My Future · My Tennessee 40 l (k) Deferred Compensation Program About the 401(k) plan VALIC Explore the Different Types of Retirement Plans by VALIC 403(b) Plan - Open to public education employers. Funded by the employee through elective, tax-deferred contributions. Total contributions are limited to the same contributions limits as the 401k A 401(k) plan is a retirement savings plan designed to allow eligible employees to supplement any existing retirement and pension benefits by saving and investing before-tax dollars through a voluntary salary contribution. Contributions and any earnings on contributions are tax-deferred until money is withdrawn. 403(b) Roth –Has the same withdrawal rules and contribution limit as a 403(b), but contributions are made after-tax so that when distributions are made at retirement that only the growth is taxable. One cannot exceed the maximum limit set for the combined annual limit of a 403(b) and 403(b) Roth. What is a Roth 401(k) contribution? 457 (b) Deferred Compensation Plan – Open to A Roth 401(k) contribution is an option under the 401(k) plan that allows eligible employees to supplement any existing retirement and pension benefits by saving and investing after-tax dollars through voluntary salary deferral. Distributions and any potential earnings are tax-free upon reaching the age of 59½ if taken after the required five-year holding period. You have the flexibility to designate all or a portion of your 401(k) elective deferrals as Roth contributions. Can employees contribute to multiple plans? Yes; however, if an employee contributes to another plan, such as a 403(b) plan, the combined total of all contributions cannot exceed the maximum limit of $18,000 in 2015, or $24,000 if age 50 or older. Governmental 457(b) plans have separate deferral limits, so employees who contribute to a 457 plan may be able to contribute an additional $18,000 to that plan in 2015 (plus any applicable catch-up contributions). For more information about contribution limits for multiple plans, visit www.irs.gov. If you are eligible to participate in the Program, you can enroll on a voluntary basis by: Enrolling online at www.gwrs.com. Click on “Let’s Get Started!” You will need your Social Security number and either a Personal Identification Number (PIN) or personal identifying information to enroll. 30 State and local government employers. The rules of withdrawal benefit those individuals who might begin drawing their pension at an earlier age. By combining a 403(b) with a 457 (b) employees can double the maximum of up to $36,000 in 2015. If age 50 or older in 2015, you may further increase that contribution to include the “catch-up” provision. What are the contribution limits for 401(k), 403(b), and 403(b) Roth & 457? In 2015, the maximum contribution amount is $18,000. It may be indexed for inflation in $500 increments after 2015. For a 401(k), 403(b) and 403(b) Roth, collectively you may not exceed the annual contribution level. The 457 (b) allows you to essentially double the annual contribution by allowing you to contribute the same as the 401(k), 403(b) or 403(b) Roth. If you turn age 50 or older in 2015, you may contribute an additional $6,000 for a maximum contribution of $24,000. If interested in enrolling please contact your district’s agent Bartlett City Schools, Germantown Municipal School District Karen Shrader – 901-237-8977 (cell) Collierville Schools, Arlington Community Schools David Stratton – 662-812-7698 (cell) Millington Municipal Schools, Bartlett City Schools, Lakeland School System Michael Seebeck – 901-825-8958 Spousal Healthcare Eligibility Affidavit Employee Name ___________________________ Employee ID ____________ Spouse Name ___________________________ Last four of SSN (Spouse) ____________ School District ___________________________ Section A: Must complete to enroll your spouse in Group Health Plan Coverage. Your Spouse is: #1 Not employed or is Retired #2 An employee of one of the Municipal School Districts or Cities listed below: (Please check one) Arlington Community Schools Bartlett City Schools Collierville Schools Lakeland School System Millington Municipal Schools City of Bartlett Town of Collierville City of Lakeland #3 *Employed or Self-Employed WITHOUT access to coverage from his/her employer (MUST COMPLETE SECTION B) #4 *Employed WITH access to coverage from his/her employer but employer pays less than 50% of the cost (MUST COMPLETE SECTION B) NOTE: *If none of the above applies then he or she is not eligible for the Group Health Plan. (He or she is eligible for other benefits such as dental, vision, life.) I hereby certify that the information provided above is correct. I understand that any misrepresentation in the information I have provided above will permit my employer to terminate my spouse’s coverage and seek any other legal remedies available including possible prosecution for insurance fraud. If applicable, I authorize the release of the health care plan coverage information requested below and authorize its use in accepting the application for the Group Health Plan coverage. Employee Signature _________________________________ Date ______________________ Spouse Signature ________________________________ Date ______________________ Section B: Must be completed by spouse’s employer or spouse if self-employed Is the person named above as Spouse eligible for coverage with your company? YES _____ NO _____ If yes, does the employee’s share, exceed 50% of the total cost of premiums for your cheapest individual coverage? YES ____ NO ____ Employer Name: __________________________________________________________ Employer Address: __________________________________________________________ Employer Phone Number: __________________________________________________________ Authorized Employer Name: ____________________________ Title: __________________________ Authorized Employer Signature ___________________________ Date:__________________________ 31 Please return completed document to the Employee Benefits office Email: [email protected], Fax: (901)202‐0854 LEGAL NOTICES Arlington Community Schools, Bartlett City Schools, Collierville Schools, Lakeland School System and Millington Municipal School System (MSSC) EMPLOYEE BENEFIT PLAN Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This notice will become effective on _04/08/2015___________. At, MSSC we respect your privacy and will protect your health information responsibly and professionally. This notice describes the privacy practices of the [medical][, dental,][vision] and prescription drug programs (the “Health Plan”) included in the MSSC Employee Benefit Plan. This notice does not apply to disability benefits, life insurance, or any non-health plans or benefits. As you read this notice, you’ll see the term “Protected Health Information” or PHI. Protected health information is health information that identifies you and relates to your medical history (i.e., the health care you receive or the amounts paid for that care) that is created or obtained by the Health Plan in connection with your eligibility for or receipt of benefits under the Health Plan. Federal law requires that the Health Plan maintain the privacy of protected health information, give you this notice of the Health Plan’s legal duties and privacy practices, and follow the terms of this notice as currently in effect. These protections will remain in effect with regards to your protected health information held by the Health Plan during your lifetime, and for at least 50 years following your death. MSSC contracts with claims administrators and other third parties to provide Health Plan services. For purposes of this notice, the “Health Plan” includes third parties when performing services for the Health Plan, including persons or entities creating, receiving, maintaining or transmitting your protected health information in connection with your health coverage (referred to in this notice as “business associates”). Protected health information may be shared among the components of the Health Plan and the third parties providing services for the components of the Health Plan in the course of payment, Health Plan operations, and treatment. The current claims administrators are listed under Contact Information, below. When their services involve the use of protected health information, the third parties and their subcontractors will be required to perform their duties in a manner consistent with this notice. How the Health Plan Uses and Shares PHI for Payment, Health Plan Operations, and Treatment Below are some examples of ways that the Health Plan may use or share information about you for treatment, payment, and Health Plan operations. For each category, a number of uses or disclosures will be listed, along with an example. However, not every use or disclosure in a category will be listed. The Health Plan may use or share your protected health information for: Payment: The Health Plan will use and disclose your protected health information to determine and pay for covered services. Payment activities include determining eligibility; conducting precertification, utilization, case management, and medical necessity reviews; coordinating care; calculating cost sharing amounts; coordination of benefits; reimbursement and subrogation; and responding to questions, complaints, and appeals. For example, the Health Plan may use your medical history and other health information to decide whether a particular treatment is medically necessary and what the payment should be. During that process, the Health Plan may disclose information to your provider. Any request for information or use of such information involving psychotherapy notes will only be done with your written authorization. The Health Plan will mail Explanation of Benefits forms and other information to the employee at the address it has on record for the employee. Health Plan Operations: The Health Plan will use and disclose your protected health information for Health Plan operations. Operational activities include quality assessment and improvement; performance measurement and outcomes assessment; health services research; and preventive health, disease management, case management, and care coordination. For example, the Health Plan may use protected health information to provide disease management programs for participants with specific conditions, such as diabetes, asthma, or heart failure. Other operational activities requiring use and disclosure of protected health information include administration of stop loss coverage, including underwriting of such coverage; legal, actuarial, and audit services; business planning and cost management; detection and investigation of fraud; administration of pharmaceutical programs and payments; and other general administrative activities, including data and information systems management and customer service. We will not use or disclose any genetic information involving you for underwriting purposes. Treatment: The Health Plan may use or disclose your protected health information to facilitate medical treatment or services by providers. The Health Plan may disclose protected health information to doctors, dentists, pharmacies, hospitals, and other health care providers who take care of you. For example, doctors may request medical information from the Health Plan to supplement their own records. The Health Plan may also send certain information to doctors for patient safety or other treatment-related reasons. The Health Plan may also disclose protected health information to providers or other health plans for the payment, treatment, and certain operational activities of the provider or other health plan. How the Health Plan Uses and Shares PHI for Communications about Benefits The Health Plan may use or disclose protected health information to send you treatment reminders for services such as mammograms or prostate cancer screenings. Also, the Health Plan may use or disclose your protected health information to give you information about alternative medical treatments and programs or health-related products and services that may be of interest to you. For example, the Health Plan might send you information about smoking cessation or weight-loss programs. Disclosures involving the sale of your health information to another entity for marketing purposes, or for any purpose not disclosed in this notice, will only be done with your written authorization. Disclosures that the Health Plan May Make to Others Involved in Your Health Care The Health Plan may disclose protected health information to a family member, a friend, or any other person you identify, provided the information is directly relevant to that person’s involvement with your health care or payment for that care. For example, if a family member or a caregiver calls the Health Plan with prior knowledge of a claim, the Health Plan may confirm whether or not the claim has been received and paid. You may instruct the claims administrator to stop or limit this kind of disclosure. We will continue to permit such disclosure to these individuals following your death, unless doing so is inconsistent with any prior expressed preference made by you that is known to us. Disclosures You May Authorize the Health Plan to Make The Health Plan will not use or disclose your protected health information for any reason other than those listed in this notice unless you provide a written authorization. -2- You may give the Health Plan written authorization to use and/or disclose your protected health information to anyone for any purpose. If you give the Health Plan an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure made pursuant to your authorization while it was in effect. Disclosures that the Health Plan May Make to MSSC To determine if and when you and your family members are covered by the Health Plan, the Health Plan will share enrollment information about you and your family members with MSSC. The Health Plan will periodically disclose protected health information to MSSC Human Resources Representatives so that the Human Resources Representatives can assist participants with benefits questions and oversee the administration of the Health Plan. Also, the Health Plan will periodically disclose protected health information to the Finance Department of MSSC so that the Finance Department can perform financial planning and projections and monitor the performance of third parties. In addition, the Finance Department is responsible for paying the claims covered by the Health Plan. The Human Resources Representatives and the Finance Department will only use the protected health information for the purposes for which it was disclosed or as required by law.1 Specifically, MSSC certifies that it will: Not use or disclose protected health information for employment-related actions and decisions or in connection with any non-health benefits or another employee benefit plan sponsored by MSSC; Not use or further disclose protected health information other than as permitted or required by this notice or as required by law; Ensure that any business associates (including a subcontractor) to whom MSSC provides protected health information received from the Health Plan agree to the same restrictions and conditions that apply to MSSC with respect to such information. If any of our business associates fails to take adequate steps to safeguard and protect your health information, including controlling the activities of any of their subcontractors, and to perform the activities necessary to fulfill their responsibilities in regards to such information, including the corrective actions necessary due to a breach, we will terminate our relationship with such entities, if feasible; Provide training to our employees, including volunteers, trainees and others who are under are our direct control with access to protected health information maintained by the Health Plan on their responsibilities under the law, including the safeguarding and protection of the information. We will also establish and enforce disciplinary measures against such employees for violations of such responsibilities, and will require our business associates and their subcontractors to do the same; Report to the Health Plan’s Privacy Officer any use or disclosure of protected health information that is inconsistent with the uses or disclosures provided for of which MSSC becomes aware; Provide notification to you within a reasonable time of our discovery of an impermissible use or disclosures of your protected health information (breach), unless we reasonably determine that there is a low probability that such information has been. Such notification will also be provided to the media or the U.S. Secretary of Health and Human Services if required by law. We will also provide you with notification of any such breaches committed by our business associates, unless we have delegated the responsibility for such notifications to the business associate who is responsible for the breach; -3- Confirm that the Health Plan makes your protected health information available to you for access, amendment, and/or accounting, as described below; Make internal practices, books, and records relating to the use and disclosure of protected health information received from the Health Plan available to the Secretary of the U.S. Department of Health and Human Services for purposes of determining compliance by the Health Plan with federal law; Return protected health information to the Health Plan (when feasible), destroy protected health information (when return is not feasible and retention is not required by law), or continue to maintain the privacy of all protected health information (when return is not feasible and retention is required by law); Use its best efforts to request only the minimum necessary type and amount of protected health information to carry out the functions for which the information is requested; and Ensure adequate separation between the employees who are Human Resources Representatives or in the Finance Department and all other employees of MSSC with access to Health Plan information so that protected health information received by these individuals is not disclosed to other employees of MSSC or other individuals in violation of this notice. Other Uses and Disclosures of PHI There are state and federal laws that may require or allow the Health Plan to release your health information to others. The Health Plan may provide information for the following reasons: Health Oversight Activities: The Health Plan may disclose your protected health information to a government agency authorized to oversee the health care system or government programs, or its contractors (e.g., state insurance department, U.S. Department of Labor) for activities authorized by law, such as audits, examinations, investigations, inspections, and licensure activities. Legal Proceedings: The Health Plan may disclose your protected health information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances. Law Enforcement: The Health Plan may disclose your protected health information to law enforcement officials under limited circumstances. For example, in response to a warrant or subpoena; for the purpose of identifying or locating a suspect, witness, or missing person; or to provide information concerning victims of crimes. For Public Health Activities: The Health Plan may disclose your protected health information to a government agency that oversees the health care system or government programs for activities such as preventing or controlling disease or activities related to the quality, safety, or effectiveness of an FDA-regulated product or activity. Required by Law: The Health Plan may disclose your protected health information when required to do so by law. Workers’ Compensation: The Health Plan may disclose your protected health information when authorized by and to the extent necessary to comply with workers’ compensation laws and similar programs. -4- Victims of Abuse, Neglect, or Domestic Violence: The Health Plan may disclose your protected health information to appropriate authorities if the Health Plan reasonably believes that you’re a possible victim of abuse, neglect, domestic violence, or other crimes. Coroners, Funeral Directors, and Organ Donation: In certain instances, the Health Plan may disclose your protected health information to coroners or funeral directors and in connection with organ donation. Research: The Health Plan may disclose your protected health information to researchers, if certain established steps are taken to protect your privacy. Threat to Health or Safety: The Health Plan may disclose your protected health information to the extent necessary to prevent or lessen a serious and imminent threat to your health or safety or the health or safety of others. For Specialized Government Functions: The Health Plan may disclose your protected health information in certain circumstances or situations to a correctional institution if you are an inmate in a correctional facility, to an authorized federal official when it’s required for lawful intelligence or other national security activities, or to an authorized authority of the Armed Forces. For Cadaveric Organ, Eye, or Tissue Donation: The Health Plan may disclose your protected health information for the purpose of facilitating organ, eye, or tissue donation and transplantation. Your Rights You have the following rights regarding the protected health information that the Health Plan maintains about you. You have the right to ask the Health Plan to restrict its use and disclosure of protected health information for the purposes of treatment, payment, or health care operations. Your request must be in writing and sent to the claims administrator. If the information you for which you are requesting the restrictions involves health care services or supplies that were paid in full by you or on your behalf by another person, we will honor such request. Otherwise, the Health Plan will consider your request, but it is not required to agree to restrict the information. You have the right to ask to receive confidential communications. If you believe that normal communications would put you in danger, you may request that the Health Plan send communications with protected health information (e.g., an Explanation of Benefits) to you by alternative means or to an alternative location. Your request must be in writing and sent to the claims administrator. Your request must include the alternative location (e.g., fax number, address, etc.) to which you would like the Health Plan to send the information. Such requests, if reasonable, will be accommodated when you state in the request that you believe that normal communications would endanger you. You have the right to inspect and obtain a copy of the protected health information that the Health Plan maintains about you in a designated record set, including information maintained in paper or electronic formats. A designated record set contains protected health information that the Health Plan collects, maintains, or uses to administer or make decisions regarding your enrollment, payment, claims adjudication, or case management. Your request must be in writing. If the request pertains to records held by the claims administrator, you must complete an Access Request Form -5- and send it to the claims administrator. An Access Request Form can be obtained by contacting the claims administrator or by downloading the form from the claims administrator’s website. The Health Plan, or its designee, will respond within 30 days of the receipt of your request. The Health Plan may charge a reasonable, cost-based fee to provide you with the information. If you request such information be provided to you through unencrypted e-mail, you assume the risk on any unauthorized access or such protected health information during its transmission to you, and are responsible for safeguarding such information once it is delivered to you. There are exceptions as to what information can be accessed. For example, information compiled for legal proceedings cannot be accessed. If the Health Plan denies access to your information, in part or in whole, it will notify you in writing. The denial will include the reason for the denial, your review rights (if applicable), and information on how to file a complaint. You have the right to ask the Health Plan to amend protected health information about you that is contained in a designated record set (as described above) if you think that information is incorrect or incomplete. Your request must be in writing. If the request pertains to records held by the claims administrator, you must complete an Amendment Request Form and send it to the claims administrator. An Amendment Request Form can be obtained by contacting the claims administrator or by downloading the form from the claim administrator’s website. Your request must include the reason for the request. The Health Plan, or its designee, may deny your request if you ask the Health Plan to amend information that: is not part of the protected health information kept by or for the Health Plan; was not created by the Health Plan, unless the person or entity that created the information is no longer available to make the amendment; is not part of the information that you would be permitted to inspect and copy; or is accurate and complete. If the Health Plan denies the request, you may file a written statement of disagreement with the Health Plan. You have the right to request an accounting of certain disclosures of protected health information. Your request must be in writing and must specify the time period for which you are requesting information. The period cannot start earlier than April 14, 2003, or go back more than six years from the date of your request. Your request must be in writing. If the request pertains to records held by the claims administrator, you must complete an Accounting Request Form and send it to the claims administrator. An Accounting Request Form can be obtained by contacting the claims administrator or by downloading the form from the claim administrator’s website. The accounting will not include disclosures made to you or with your written authorization or in the course of treatment, payment, or health care operations. If you request such an accounting more than once in a 12month period, the Health Plan will charge a reasonable fee. You have the right to a copy of this notice upon request. Your request must be in writing and sent to the Privacy Officer. A copy of the current notice will be sent to you. For more information, or to begin the formal process connected with these rights, see Contact Information, below. Contact Information If you want to exercise any of the rights described in this notice with respect to the records held, or the disclosures made, by one of the Health Plan’s claims administrators, you may contact that claims administrator. As of September 23, 2013, the claims administrators are: For matters concerning [medical] [dental][vision] benefits: For matters concerning prescription drug benefits: -6- Privacy Officer for MSSC 5650 Woodlawn, Bartlett, TN 38134 901-202-0855, Ext. 242 If you call a claims administrator, please tell the customer service representative that your call relates to the privacy of your protected health information. If you have questions regarding this notice, you may also contact the Health Plan’s Privacy Officer, c/o the Benefits Shared Service, 5650 Woodlawn, Bartlett, TN 38134. You may also contact the Health Plan’s Privacy Officer if you have any problems in exercising your rights. Complaints You have the right to file a written complaint with the Health Plan’s Privacy Officer if you think your privacy rights have been violated. Include your name, address, and telephone number. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. You won’t be retaliated against or denied any Health Plan benefit or service because you file a complaint. The Health Plan’s Privacy Officer will investigate and address any issues of noncompliance with this notice of which any one or more of these entities or persons is notified or becomes aware. Revisions to the Notice MSSC reserves the right to change the terms of this notice and to make the new notice effective for all protected health information maintained by the Health Plan. MSSC will promptly revise and distribute this notice whenever there is a material change to the uses or disclosures, your rights, the Health Plan’s duties, or other practices stated in this notice. Except when required by law, a material change to this notice will not be implemented before the effective date of the new notice in which the material change is reflected. -7- Important Notice from the Arlington Community Schools, Bartlett City Schools, Collierville Schools, Lakeland School System, Millington Municipal Schools (MSSC) About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the (MSSC) and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. The (MSSC) has determined that the prescription drug coverage offered by the Medical and Prescription Drug Plan Sponsored by the (MSSC) (all plan options) is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. __________________________________________________________________________ When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current coverage with the (MSSC) may be affected. If you do decide to join a Medicare drug plan and drop your current (MSSC) coverage, be aware that you and your dependents may not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with the (MSSC) and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the (MSSC) changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: Name of Entity/Sender: Contact--Position/Office: Address: Phone Number: 04-08-2015 (MSSC) Benefits, Shared Services 5650 Woodlawn, Bartlett, TN 38134 901-202-0855, Ext. 242 Women’s Health and Cancer Rights Act Enrollment Notice The following is language that group health plans may use as a guide when crafting the WHCRA enrollment notice: If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Therefore, the following deductibles and coinsurance apply: EPO – Deductibles Coinsurance $500, $750, $1,000 100% after copay and deductible met Basic - Deductibles Coinsurance $500, $750, $1,000 80% after copay and deductible met HRA $1,500, $2,250, $3,000 80% after deductible met Deductibles Coinsurance If you would like more information on WHCRA benefits, call your Plan Administrator 901-202-0855, Ext. 242. Intentionally left blank 32 Meritain Health 33
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