EMPLOYEE BENEFITS PLAN HOPEWELL CITY PUBLIC SCHOOLS PLAN YEAR: JULY 1, 2022 - JUNE 30, 2023
www.piercegroupbenefits.com
EMPLOYEE BENEFITS GUIDE
TABLE OF CONTENTS Welcome to the Hopewell City Public Schools comprehensive benefits program. This booklet highlights the benefits offered to all eligible employees for the plan year listed below. Benefits described in this booklet are voluntary, employee-paid benefits unless otherwise noted.
ENROLLMENT PERIOD: APRIL 25, 2022 - MAY 20, 2022 EFFECTIVE DATES: JULY 1, 2022 - JUNE 30, 2023 Benefits Plan Overview
page
2
Disability Benefits
page
40
Online Enrollment Instructions
page
5
Accident Benefits
page
44
Health Benefits
page
7
Medical Bridge Benefits
page
48
Health Rates - 2022 - 2023
page
10
Life Insurance
page
54
Health Savings Account
page
12
Pre-Paid Legal Plan
page
57
Dental Benefits
page
14
Additional Benefits Available
page
59
Required Notices
page
60
Cobra Continuation Of Coverage Rights
page
64
Authorization Form
page
66
21
Notice Of Insurance Information Practices
page
67
Continuation Of Coverage for Benefits Form
page
68
Vision Benefits
EAP
Employee Assistance Program
Dependent Care Flexible Spending Account
page
page
page
18 20
Cancer Benefits
page
23
Critical Illness Benefits
page
32
Rev. 04/18/2022
PRE-TAX & POST-TAX BENEFITS
HOPEWELL CITY PUBLIC SCHOOLS ENROLLMENT PERIOD: APRIL 25, 2022 - MAY 20, 2022 EFFECTIVE DATES: JULY 1, 2022 - JUNE 30, 2023
PRE-TAX BENEFITS Dental Insurance
Health Insurance
Sun Life
Anthem
Vision Insurance
UnitedHealthcare
Health Savings Accounts
Anthem • Employee Maximum $3,650/year • Family Maximum $7,300/year HSA plans can only be established in conjunction with a qualified High-Deductible Health Plan (HDHP) Hopewell City Public Schools will contribute $1,800 per benefit year to an HSA, per employee enrolled in the High-Deductible Health Plan (HDHP)
Dependent Care Flexible Spending Account*
Flex Facts • Dependent Care Reimbursement FSA Maximum: $5,000/year
Cancer Benefits
Colonial Life
Accident Benefits
Colonial Life
Medical Bridge Benefits
Colonial Life
*You will need to re-sign for the Flexible Spending Account if you want it to continue next year. IF YOU DO NOT RE-SIGN, YOUR CONTRIBUTION WILL STOP EFFECTIVE JUNE 30, 2022.
POST-TAX BENEFITS Disability Benefits Colonial Life
Critical Illness Benefits Colonial Life
Life Insurance
Colonial Life • Term Life Insurance • Whole Life Insurance
Pre-Paid Legal Plan
Legal Resources Please note your insurance products will remain in effect unless you speak with a representative to change them.
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QUALIFICATIONS & IMPORTANT INFO
THINGS YOU NEED TO KNOW QUALIFICATIONS: • Employees must work 20 hours or more per week to be eligible for benefits.
IMPORTANT FACTS: • The plan year for Anthem Health, Sun Life Dental, UnitedHealthcare Vision, Health Savings Accounts, Dependent Care Flexible Spending Accounts, Colonial Insurance products and Legal Resources Pre-Paid Legal Plan lasts from July 1, 2022 through June 30, 2023. • Deductions for Anthem Health, Sun Life Dental and UnitedHealthcare Vision will begin June 2022. Deductions for Health Savings Accounts, Dependent Care Flexible Spending Accounts, Colonial Insurance products and Legal Resources Pre-Paid Legal Plan will begin July 2022. • Your employer offers an Employee Assistance Program (EAP) for you and your eligible family members. An EAP is an employer-sponsored benefit that offers confidential support and resources for personal or work-related challenges and concerns. Please see the EAP pages of this benefit booklet for more details and contact information. • If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking with the Benefits Representative. • If you will be receiving a new debit card, whether you are a new participant or to replace your expired card, please be aware that it may take up to 30 days following your plan effective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses. Please note that your debit card is good through the expiration date printed on the card. • Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as defined by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time, or vice-versa. • Once a family status change has occurred, an employee has 30 days to notify the Pierce Group Benefits Service Center at 1-800-387-5955 to request a change in elections. • Flexible Spending Account expenses must be incurred during the Plan Year in order to be eligible for reimbursement. • An employee has 90 days after the plan year ends to submit claims for spending account expenses that were incurred during the plan year. Please note that if employment terminates during the plan year, that employee's plan year ends the day employment ends. The employee has 90 days after the termination date to submit claims. • With Dependent Care Flexible Spending Accounts, the maximum reimbursement you can request is equal to the current account balance in your Dependent Care account. You cannot be reimbursed more than has actually been deducted from your pay. • As a married couple, one spouse cannot be enrolled in a Medical Reimbursement FSA at the same time the other opens or contributes to an HSA. • The Health Screening Rider on the Colonial Medical Bridge plan has a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until July 31, 2022. • Additionally, some policies may include a pre-existing condition clause. Please read your policy carefully for full details. • Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution. • An employee taking a leave of absence, other than under the Family & Medical Leave Act, may not be eligible to re-enter the Flexible Benefits Program until the next plan year. Please contact your Benefit Administrator for more information.
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EMPLOYEE BENEFITS GUIDE
HOPEWELL CITY PUBLIC SCHOOLS IN PERSON
ONLINE
You may enroll or make changes online to your benefits plan. To enroll online, please see the information below and on the following pages.
During your open enrollment period, a Pierce Group Benefits representative will be available by appointment to answer any questions you may have and to assist you in the enrollment process.
ENROLLMENT PERIOD: APRIL 25, 2022 - MAY 20, 2022 YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT PERIOD: • • • • • • •
Enroll, change or cancel your Health Insurance. Enroll, change or cancel your Dental Insurance. Enroll, change or cancel your Vision Insurance. Enroll, change or cancel your Health Savings Account (HSA). Enroll/Re-Enroll in your Flexible Spending Account⁺ (Dependent Care). Enroll, change or cancel your Pre-Paid Legal*. Enroll, change or cancel your Colonial products (see the following pages for changes that can be completed online). ⁺You will need to re-sign for the Flexible Spending Account if you want it to continue each year. *Employees may access the Pre-Paid Legal forms on the BenSelect enrollment system, or meet with the Benefits Representative during the enrollment period to enroll or make changes.
ACCESS YOUR BENEFITS ONLINE WHENEVER, WHEREVER. Benefits Details | Educational Videos | Download Forms | Online Chat with Service Center To view your personalized benefits website, go to:
www.piercegroupbenefits.com/hopewellcitypublicschools or piercegroupbenefits.com and click “Find Your Benefits”.
IMPORTANT NOTE & DISCLAIMER
This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail. All information in this booklet including premiums quoted is subject to change. All policy descriptions are for information purposes only. Your actual policies may be different than those in this booklet.
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BENSELECT ONLINE ENROLLMENT:
BenSelect
COMPLETE THE STEPS BELOW TO BEGIN THE ONLINE ENROLLMENT PROCESS
HELPFUL TIPS:
• If you are a new employee and unable to log into the online system, please speak with the Benefits Representative assigned to your location, or contact Human Resources. • If you are an existing employee and unable to log into the online system, please contact Pierce Group Benefits at 888-662-7500 between 8:30am and 5:00pm, or speak with the Benefits Representative assigned to your location.
1.
Go to https://harmony.benselect.com/hopewell • Enter your User Name: Social Security Number with or without dashes (ex. 123-45-6789 or 123456789) • Enter your PIN: Last 4 numbers of your Social Security Number followed by last 2 numbers of your Date of Birth year (ex. 678970)
2.
The screen prompts you to create a NEW PIN [____________________________].
3.
Choose a security question and enter answer [______________________________________].
4.
Confirm (or enter) an email address.
5.
Click on ‘Save New PIN’ to continue to the enrollment welcome screen.
6.
From the welcome screen click “Next”.
7.
The screen shows ‘Personal Information’. Verify that the information is correct and enter the additional required information (marital status, work phone, e-mail address). Click ‘Next’.
8.
The screen allows you to add family members. It is only necessary to enter family member information if adding or including family members in your coverage. Click ‘Next’.
9.
The screen shows ‘Benefit Summary’. Review your current benefits and make changes/selections for the upcoming plan year. • HEALTH: You may enroll online in Health coverage. • DENTAL: You may enroll online in Dental coverage. • VISION: You may enroll online in Vision coverage. • HEALTH SAVINGS ACCOUNT Enter annual amount. EMPLOYEE MAX $3,650/year FAMILY MAX $7,300/year
HSA plans can only be established in conjunction with a qualified High Deductible Health Plan (HDHP) Hopewell City Public Schools will contribute $1,800 per benefit year to an HSA, per employee enrolled in the High-Deductible Health Plan (HDHP)
• DEPENDENT CARE FSA: Enter annual amount. MAX $5,000 • LEGAL PLAN: You may enroll online in Legal coverage.
*Employees may access the Pre-Paid Legal forms on the BenSelect enrollment system, or meet with the Benefits Representative during the enrollment period to enroll or make changes.
<<< enrollment instructions continued on next page >>>
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BenSelect
BENSELECT ONLINE ENROLLMENT CONT.:
• CANCER ASSIST You may enroll online in Cancer Assist coverage. • DISABILITY - EDUCATOR 1.0 You may enroll online in Educator 1.0 coverage. • ACCIDENT 1.0 You may enroll online in Accident 1.0; however persons over age 64 applying for coverage and employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative. • MEDICAL BRIDGE You may enroll online in Medical Bridge coverage. • CRITICAL ILLNESS 6000 You may enroll online in Critical Illness 6000 coverage. • TERM LIFE 5000 You may enroll online in Term Life 5000; however, employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative. • WHOLE LIFE 5000 Plus You may enroll online in Whole Life 5000 Plus; however, employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative.
10.
Click ‘Sign & Submit’ once you have decided which benefits to enroll in.
11.
Review your coverage. If any items are ‘Pending’, you will need to decide whether to enroll or decline this benefit.
12.
Click ‘Next’ to review and electronically sign the authorization for your benefit elections.
13.
Review the confirmation, then if you are satisfied with your elections, enter your PIN and click ‘Sign Form’.
14.
Click ‘Download & Print’ to print a copy of your elections, or download and save the document. Please do not forget this important step!
15.
Click ‘Log Out’.
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Hopewell City Public Schools July 1, 2022 - June 30, 2023 HealthKeepers POS OA 25/1500/30%/5000
Plan Year Deductible (applies as indicated)
HealthKeepers HSA 3000/20%/5000
KeyCare HSA 3000/20%/4000
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
$1,500
$3,000
$3,000
$6,000
$3,000
$6,000
$3,000
$6,000
$6,000
$12,000
$6,000
$12,000
Plan Year Out-of-Pocket Expense Limit
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
Individual Out of Pocket Maximum Family Out of Pocket Maximum
$5,000 $10,000
$10,000 $20,000
$5,000 $10,000
$10,000 $20,000
$4,000 $8,000
$10,000 $20,000
One Person Family (two or more people)
Lifetime Maximum
Unlimited for all plans
Covered Services Doctor's Visits (outpatient or in-office) $25 copay
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
100% Coverage (No Charge)
Deductible then 30%
Deductible then 30%
Deductible then 30%
Deductible then 30%
100% Coverage (No Charge) Deductible then 20%
Deductible then 30%
$50 copay
100% Coverage (No Charge) Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
$25 copay
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 30%
Deductible then 30%
Deductible then 20%
Deductible then 20%
Deductible then 20%
Deductible then 20%
Deductible then 30%
Deductible then 30%
Deductible then 20%
Deductible then 20%
Deductible then 20%
Deductible then 20%
Telehealth (Live Health Online)
$5 copay
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Urgent Care
$50 copay
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Inpatient Hospital Services
Deductible then 30%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Inpatient Physician and Other Services
Deductible then 30%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Ambulance Services
Deductible then 30%
Deductible then 30%
Deductible then 20%
Deductible then 20%
Deductible then 20%
Deductible then 20%
Outpatient Hospital and Diagnostic
Deductible then 30%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Advanced Diagnostic Services - Office
Deductible then 30%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Pre-natal & Post-natal Physican Services- Office
Deductible then $450 copay
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Hospital Services for Delivery (Including Labs, Diagnostic Tests, and X-Rays)
Deductible then 30%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 30%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
$25 copay
Deductible then 30%
Deductible then 20%
Deductible then 30%
Deductible then 20%
Deductible then 30%
Primary Care Physician Visits Preventative Care Specialist Diagnostic Lab in office Diagnostic X-ray in office Chiropractic Services Emergency Room Facility Charge Emergency Physicians and Other Services
100% Coverage (No Charge) Deductible then 30%
Deductible then 30%
Hospital and Other Covered Services Pre-certification may be required
Maternity
Behavioral Health Inpatient Treatment/Residential Treatment/Day Program Outpatient Professional Provider Doctor Office Visit
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Hopewell City Public Schools July 1, 2022 - June 30, 2023 Prescription Drug Benefit
HealthKeepers POS OA 25/1500/30%/5000
HealthKeepers HSA 3000/20%/5000
KeyCare HSA 3000/20%/4000
In Network
In Network
In Network
$10 copay
$10 copay after deductible
$10 copay after deductible
$40 copay
$40 copay after deductible
$40 copay after deductible
*See SPD for out of network Rx benefits Tier 1 Tier 2 Tier 3 Tier 4
Home Delivery Services (Mail Order) SPD for out of network Rx benefits
See
$60 copay
$60 copay after deductible
$60 copay after deductible
20% coinsurance up to $250 per prescription
20% coinsurance up to $250 per prescription after deductible is met
20% coinsurance up to $250 per prescription after deductible is met
Tier 1- $25 copay Tier 2- $100 copay Tier 3- $150 copay Tier 4 - 20% coinsurance up to $250
Tier 1- $25 copay Tier 2- $100 copay Tier 3- $150 copay Tier 4 - 20% coinsurance up to $250
Tier 1- $25 copay Tier 2- $100 copay Tier 3- $150 copay Tier 4 - 20% coinsurance up to $250
This is a brief highlight of services only. This policy has exclusions and limitations, please refer to your full Summary Plan Description for all plan details.
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Say hi to Sydney Anthem’s new app is simple, smart — and all about you With Sydney, you can find everything you need to know about your Anthem benefits -- personalized and all in one place. Sydney makes it easier to get things done, so you can spend more time focused on your health.
Get started with Sydney Download the app today!
Ready for you to use quickly, easily, seamlessly — with one-click access to benefits info, Member Services, wellness resources and more.
Sydney acts like a personal health guide, answering your questions and connecting you to the right resources at the right time. And you can use the chatbot to get answers quickly.
With just one click, you can:
Find care and check costs
Check all benefits
See claims
Get alerts, reminders and tips directly from Sydney. Get doctor suggestions based on your needs. The more you use it, the more Sydney can help you stay healthy and save money.
Already using one of our apps?
Get answers even faster with our chatbot
View and use digital ID cards
It’s easy to make the switch. Simply download the Sydney app and log in with your Anthem username and password.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 115993MUMENABS 06/19
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Hopewell City Public Schools July 1, 2022- June 30, 2023 Full-Time Employees - Contribution Schedule (30 hours or more)
Health Keepers 3000 - High Deductible Health Plan Employer provides $1,800 in HSA Contribution
Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution
Employee Only
Employee + Children
Employee + Spouse
Employee + Family
$592.64
$983.78
$1,250.49
$1,795.71
$542.64
$787.78
$1,010.49
$1,455.71
$50.00
$196.00
$240.00
$340.00
Health Keepers 1500 Copay Plan
Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution
Employee Only
Employee + Children
Employee + Spouse
Employee + Family
$692.35
$1,149.30
$1,460.88
$2,097.83
$417.35
$502.30
$593.88
$802.83
$275.00
$647.00
$867.00
$1,295.00
Out of Area Plan Plans- Key Care 3000 High Deductible Health Plan Employer provides $1,800 in HSA Contribution
Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution
Employee Only
Employee + Children
Employee + Spouse
Employee + Family
$664.45
$1,102.99
$1,402.01
$2,013.29
$371.45
$587.99
$756.01
$1,119.29
$293.00
$515.00
$646.00
$894.00
10
Hopewell City Public Schools July 1, 2022- June 30, 2023 Part-Time Employees - Contribution Schedule (20 hours or more) Health Keepers 3000 - High Deductible Health Plan Employer provides $1,800 in HSA Contribution
Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution
Employee Only
Employee + Children
Employee + Spouse
Employee + Family
$592.64
$983.78
$1,250.49
$1,795.71
$327.64
$487.78
$625.99
$899.21
$265.00
$496.00
$624.50
$896.50
Health Keepers 1500 Copay Plan
Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution
Employee Only
Employee + Children
Employee + Spouse
Employee + Family
$692.35
$1,149.30
$1,460.88
$2,097.83
$250.35
$320.30
$385.88
$527.83
$442.00
$829.00
$1,075.00
$1,570.00
Out of Area Plan Plans- Key Care 3000 High Deductible Health Plan Employer provides $1,800 in HSA Contribution
Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution
Employee Only
Employee + Children
Employee + Spouse
Employee + Family
$664.45
$1,102.99
$1,402.01
$2,013.29
$216.45
$346.49
$444.51
$653.29
$448.00
$756.50
$957.50
$1,360.00
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Using your Health Savings Account (HSA) Learn how to make the most of your benefi ts
A health plan with a Health Savings Account (HSA) gives you access to many doctors and hospitals in your plan and helps pay for your costs when you need care. This plan also comes with a spending account and debit card you can use to pay for certain medical expenses. Let’s take a closer look at how your HSA works and how to make the most of it.
HSA ACCOUNT
Activate your debit card Your debit card will arrive in the mail. Once you activate it, use your debit card to pay for medical expenses like copays, lab tests, deductibles, prescriptions, hospital visits, urgent and emergency care, your percentage of the costs (coinsurance). See a full list of qualified medical and dental expenses at irs.gov/pub502.
Register on anthem.com Register at anthem.com and download our mobile app. From there you’ll be able to:
View all your plan benefits, account balance and review your claims.
Set your account preferences and keep your email address updated so we can send you plan information. You’ll also want to opt in to receive eStatements and avoid paying a monthly paper statement fee.
Set up one-time or reoccurring tax-free contributions to your account. Transfer money from your personal bank account or automatically deduct funds from your paycheck if offered by your employer. Visit irs.gov/pub969 to see the maximum amount you’re allowed to add to your HSA this year.
Check out the How it all Works tab to learn more about all the benefits your HSA offers. Get tips, watch a video or use a spending account calculator to help manage your expenses for the year.
Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
108286VAMENBVA VPOD 6/18
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More perks of your HSA
The money you put into your HSA, the interest you earn, and even the money you take out to pay for health care costs is all tax-free.
All the money in your HSA rolls over from year to year, and it’s yours even if you change health plans, jobs or retire.
You can earn rewards by taking certain steps to improve your health.
If you’re 55 or older you can contribute an extra $1,000 a year.
Check out how it all works Learn about all the benefits your plan offers and the tools that will help you manage your health care expenses. Just log in at anthem.com and select Spending Accounts under the Menu tab.
Questions about your HSA? Contact Member Services anytime at the number on the back of your ID card or HSA debit card.
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Dental Insurance
PROTECTS YOUR SMILE.
You can feel more confident with dental insurance that encourages routine cleanings and checkups. Dental insurance helps protect your teeth for a lifetime. PREVENTS OTHER HEALTH ISSUES. COMMONLY COVERED
Exams and cleanings X-rays Fillings Tooth extractions
Just annual preventive care alone can help prevent other health issues such as heart disease and diabetes. Many plans cover preventive services at or near 100% to make it easy for you to use your dental benefits. LOWERS OUT-OF-POCKET EXPENSES.
Seeing an in-network dentist can reduce your fees approximately 30% from their standard fees. Add the benefits of your coinsurance to that and things are looking good for your wallet.
Child braces
DENTAL FAST FACTS
Periodontal disease can lead to receding gums, bone damage, loss of teeth, and can increase the risk of other health problems such as heart disease and diabetes.1
Treatment of gum disease in people with type 2 diabetes can lower blood sugar over time.2
HOPEWELL CITY PUBLIC SCHOOLS All Eligible Employees POLICY # 908907 Sun Life Assurance Company of Canada
1660850 DEN2 CL1 04/12/2021 13:04:13
800-247-6875 • sunlife.com/us
Dental Insurance
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Good news! Your plan covers routine services
What’s covered
like cleanings and exams at 100%.
IN-NETWORK
OUT-OF-NETWORK
$2,000 per person
$2,000 per person
$2,000 lifetime per child
$2,000 lifetime per child
PLAN YEAR MAXIMUM Type II, III (Basic and Major Services) Type IV Ortho Service
Type I Preventive Services do not count toward your Plan Year maximum
PLAN YEAR DEDUCTIBLE
IN-NETWORK
PROCEDURE Type I Preventive Services Type II, III (Basic and Major Services)
OUT-OF-NETWORK
N/A
N/A
$0 individual/$0 family
$50 individual/$150 family
N/A
N/A
Type IV Ortho Services
THE PLAN PAYS THE FOLLOWING PERCENTAGE FOR PROCEDURES
IN-NETWORK
OUT-OF-NETWORK
Type I Preventive Services
100%
100%
PROCEDURE Type II Basic Services
100%
80%
Type III Major Services
60%
50%
Type IV Ortho Services
50%
50%
SERVICES Type I Preventive Dental Services, including: • Oral evaluations – 2 in any benefit year • Routine dental cleanings – 2 in any benefit year • Fluoride treatment – 1 in any 6 month period. Only for children under age 19 • Sealants – no more than 1 per tooth in any 36 month period, only for permanent molar teeth. Only for children under age 16 • Space maintainers – only for children under age 19 • Bitewing x-rays – 1 in any 12 month period • Intraoral complete series x-rays – 1 in any 36 month period • Genetic test for susceptibility to oral diseases
• Localized delivery of antimicrobial agents • Stainless steel crowns – only for children under age 19 • Major gum disease (surgical periodontics)
Type II Basic Dental Services, including: • New fillings • Simple extractions, incision and drainage • Surgical extractions of erupted teeth, impacted teeth, or exposed root • Biopsy (including brush biopsy) • Endodontics (includes root canal therapy) – 1 per tooth in any 24 month period • General anesthesia/IV sedation – medically required • Minor gum disease (non-surgical periodontics) • Scaling and root planing – 1 in any 24 month period per area • Periodontal maintenance – 2 in any benefit year
For a complete description of services and waiting periods, please review your certificate of insurance. If you were covered under your employer’s prior plan the wait will be waived for any type of service covered under the prior plan and this plan.
Type III Major Dental Services, including: • Dentures and bridges – subject to 5 year replacement limit • Inlay, onlay, and crown restorations – 1 per tooth in any 5 year period • Dental implants – subject to 5 year replacement limit Type IV Ortho Services, including: • Orthodontic treatment is limited to the dependent children or student age listed above Waiting Periods
800-247-6875 • sunlife.com/us
• No waiting period for preventive, basic or major services • No waiting period for orthodontic services
Dental Insurance
15
Frequently asked questions How does a PPO work? PPO stands for Participating Provider Organization. With a dental PPO plan, dental providers agree to participate in a dental network by offering discounted fees on most dental procedures. When you visit a provider in the network, you could see lower out-of-pocket costs because providers in the network agree to these prenegotiated discounted fees on eligible claims. How do I find a dentist? Simply visit www.sunlife.com/findadentist. Follow the prompts to find a dentist in your area who participates in the PPO network. You do not need to select a dentist in advance. The PPO network for your plan is the Sun Life Dental Network® with 130,000+ unique dentists. Do I have to choose a dentist in the PPO network? No. You can visit any licensed dentist for services. However, you could see lower out-of-pockets costs when you visit a dentist in the network. Are my dependents eligible for coverage? Yes. Your plan offers coverage for your spouse3 and dependent children. An eligible child is defined as a child to age 26.4 What if I have already started dental work, like a root canal or braces, that requires several visits? Your coverage with us may handle these procedures differently than your prior plan. To ensure a smooth transition for work in progress, call our dental claims experts before your next visit at 800-442-7742.
common questions when it’s convenient for you. What value added benefits does my plan include? Your plan includes our Lifetime of Smiles® program, with benefits many people prefer, such as brush biopsies for the early detection of oral cancer. Your plan also includes Preventive Max Waiver® which allows covered dental expenses for preventive services to not apply to the annual maximum. Sun Life Dental (12 month)
EE Paid $18.92 $44.16 $44.16 $81.17
ER Paid $33.60 $44.17 $44.17 $63.26
Total $52.52 $88.33 $88.33 $144.43
Sun Life Dental (12 month) Part Time EE Paid Employee Only $30.80 Employee + Spouse $57.97 Employee + Child(ren) $57.97 Employee + Family $99.27
ER Paid $21.72 $30.36 $30.36 $45.16
Total $52.52 $88.33 $88.33 $144.43
Employee Only Employee + Spouse Employee + Child(ren) Employee + Family
Do I have to file the claim? Many dentists will file claims for you. If a dentist will not file your claim, simply ask your dentist to complete a standard American Dental Association (ADA) claim form and mail it to:
CONSIDER A PRE-DETERMINATION OF BENEFITS
Sun Life P.O. Box 2940 Clinton, IA 52733
They allow us to review your provider’s treatment plan to let you know before treatment is started how much of the work should be covered by the plan, and how much you may need to cover. We recommend them for any dental treatment expected to exceed $300.
How can I get more information about my coverage or find my dental ID card? After the effective date of your coverage, you can view benefit information online at your convenience through your Sun Life account. To create an account go to www.sunlife.com/account and register. You can also access this information from our mobile app—Benefit Tools, which is available for Apple and Android devices. Or you can call Sun Life’s Dental Customer Service at 800442-7742. You can also call any time, day or night, to access our automated system and get answers to
1. American Academy of Periodontology http://www.perio.org/consumer/love_the_gums_you%27re_with. (accessed on 06/06/19) 2. https://www.cdc.gov/diabetes/ndep/pdfs/150-Healthy-teeth-matter.pdf (accessed 06/06/19) 3. If permitted by the Employer’s employee benefit plan and not prohibited by state law, the term “spouse” in this benefit includes any individual who is either recognized as a spouse, a registered domestic partner, or a partner in a civil union, or otherwise accorded the same rights as a spouse. 4. Please see your employer for more specific information.
Read the Important information section for more details including limitations and exclusions 800-247-6875 • sunlife.com/us
Dental Insurance
16
Important information
Benefit adjustments Benefits will be coordinated with any other dental coverage. Under the Alternative Treatment provision, benefits will be payable for the most economical services or supplies meeting broadly accepted standards of dental care. Late entrant If you or a dependent apply for dental insurance more than 31 days after you become eligible, you or your dependent are a late entrant. The benefits for the first 12 months for late entrants will be limited as follows: TIME INSURED CONTINUOUSLY UNDER THE POLICY
BENEFITS PROVIDED FOR ONLY THESE SERVICES
Less than 6 months
Preventive Services
At least 6 months but less than 12 months
Preventive Services and fillings under Basic Services
At least 12 months
Preventive, Basic, Major and Ortho Services
We will not pay for treatments subject to the late entrant limitation, and started or completed during the late entrant limitation period. To become insured, you must meet the eligibility requirements set forth by your employer. Your coverage effective date will be determined by the Policy and may be delayed if you are not actively at work on the date your coverage would otherwise go into effect. Similarly, dependent coverage, if offered, may be delayed if your dependents are in the hospital (except for newborns) on the date coverage would otherwise become effective. Refer to your Certificate for details. Limitations and exclusions The below exclusions and limitations may vary by state law and regulations. This list may not be comprehensive. Please see your Certificate or ask your benefits administrator for details. Dental We will not pay a benefit for any Dental procedure, which is not listed as a covered dental expense. Any dental service incurred prior to the Effective date or after the termination date is not covered, unless specifically listed in the certificate. A member must be a covered dental member under the Plan to receive dental benefits. The Plan has frequency limitations on certain preventive and diagnostic services, restorations (fillings), periodontal services, endodontic services, and replacement of dentures, bridges and crowns. All services must be necessary and provided according to acceptable dental treatment standards. Treatment performed outside the United States is not covered, except for emergency dental treatment, subject to a maximum benefit. Dental procedures for Orthodontics; TMJ; replacing a tooth missing prior the effective date; implants and implant related services; or occlusal guards for bruxism are not covered unless coverage is elected or mandated by the state. This Overview is preliminary to the issuance of the Policy. Refer to your Certificate for details. Receipt of this Overview does not constitute approval of coverage under the Policy. In the event of a discrepancy between this Overview, the Certificate and the Policy, the terms of the Policy will govern. Product offerings may not be available in all states and may vary depending on state laws and regulations.
This plan does not provide coverage for pediatric oral health services that satisfies the requirements for “minimum essential coverage” as defined by The Patient Protection and Affordable Care Act (PPACA). Sun Life companies include Sun Life and Health Insurance Company (U.S.) and Sun Life Assurance Company of Canada (collectively, “Sun Life”). Group insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states, except New York, under Policy Form Series 15-GP-01 and 16-DEN-C-01. © 2019 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us. GVBH-EE-8384
SLPC 29579
800-247-6875 • sunlife.com/us
Dental Insurance
17
Hopewell City Public Schools
Vision Benefit Summary Powered by Spectera Eyecare Networks Customer Service and Provider Locator: (800) 638-3120 myuhcvision.com
UnitedHealthcare vision has been trusted for more than 50 years to deliver affordable, innovative vision care solutions to the nation’s leading employers through experienced, customer-focused people and the nation’s most accessible, diversified vision care network. Exam with Materials Benefit Frequency Comprehensive Exam(s) Eyeglass Lenses Frames Contact Lenses instead of Eyeglasses
Once every 12 months Once every 12 months Once every 24 months Once every 12 months In-Network Services
Copays $ 10.00 Exam(s) Eyeglasses (lenses and frame) $ 25.00 $ 25.00 Contact lenses instead of Eyeglasses Frame Benefit (for frames that exceed the allowance, an additional 30% discount may be applied to the overage)¹ Private Practice Provider $130.00 retail frame allowance Retail Chain Provider $130.00 retail frame allowance Lens Options Standard Scratch-resistant Coating, Polycarbonate Lenses for Dependent Children (up to age 19) - covered in full. Contact Lens Benefit² Elective contact lenses Allowance is applied toward the purchase of contact lenses. Contact lens copay is waived. Elective contact lens fitting and evaluation Allowance is applied toward the contact lens fitting/evaluation fees. 3 Necessary contact lenses Children's and Maternity Eye Care Benefit
$130.00 $60.00 Covered in full after copay (if applicable).
Members age 0-12 and members pregnant or breastfeeding are eligible for a 2nd exam. Members age 0-12 and members pregnant or breastfeeding are also eligible for a replacement frame and lenses if they have a prescription change of 0.5 diopter or more. The 2nd exam and replacement benefits are the same as the initial exam, frame and lens benefits. Out-of-Network Reimbursements (Copays do not apply) Exam(s) Up to $40.00 Frames Up to $45.00 Single Vision Lenses Up to $40.00 Lined Bifocal and Progressive Lenses Up to $60.00 Lined Trifocal Lenses Up to $80.00 Lenticular Lenses Up to $80.00 Elective Contacts instead of Eyeglasses² Up to $105.00 Contact Lens Fitting and Evaluation Up to $0.00 3 Necessary Contacts instead of Eyeglasses Up to $210.00
United Healthcare Vision Employee Only Employee + Spouse Employee + Child(ren) Employee + Family
18
12-month $6.46 $11.05 $11.58 $17.34
Discounts Laser vision UnitedHealthcare has partnered with QualSight LASIK, the largest LASIK manager in the United States, to provide our members with access to discounted laser vision correction providers. Member savings represent up to 35% off the national average price of Traditional LASIK. Contracted prices start at $945 per eye for Traditional LASIK and $1,395 per eye for Custom LASIK. Discounts are also provided on newer technologies such as Custom Bladeless (all laser) LASIK. For more information, visit myuhcvision.com. Additional Material At a participating in-network provider you will receive up to a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare shall neither pay nor reimburse the provider or member for any funds owed or spent. Additional materials do not have to be purchased at the time of initial material purchase. Hearing Aids As a UnitedHealthcare vision plan member, you can save on custom-programmed hearing aids when you buy them from UnitedHealthcare Hearing. To find out more go to UHCHearing.com. When placing your order use promo code MYVISION to get the special price discount. ¹30% discount available at most participating in-network provider locations. May exclude certain frame manufacturers. Please verify all discounts with your provider. ²Contact lenses are instead of eyeglass lenses and/or eyeglass frames. ³Necessary contact lenses are determined at the provider's discretion for one or more of the following conditions: Following cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with eyeglass lenses and/or frames; with certain conditions such as anisometropia, keratoconus, irregular corneal/astigmatism, aphakia, pathological myopia, aniseikonia, aniridia, facial deformity, or corneal deformity. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare vision confirming the reimbursement that UnitedHealthcare will make before you purchase such contacts.
Important to Remember: In-Network • Always identify yourself as a UnitedHealthcare vision member when making your appointment. This will assist the provider in obtaining your benefit information. • Patient lens options which are not covered-in-full may be available at a discount at participating providers. Based on state guidelines, lens materials and options may not be available at these discounted prices at all provider locations. Please ask your provider for details. The Lens Options list can be found at myuhcvision.com. Choice and Access of Vision Care Providers UnitedHealthcare offers its vision program through a national network including both private practice and retail chain providers. To access the Provider Locator service or for a printed directory, visit our website myuhcvision.com or call (800) 638-3120, 24 hours a day, seven days a week. You may also view your benefits, search for a provider or print an ID card online at myuhcvision.com. Retain this UnitedHealthcare vision benefit summary which includes detailed benefit information and instructions on how to use the program. Please refer to your Certificate of Coverage for a full explanation of benefits. In-Network Provider - Copays and non-covered patient options are paid to provider by program participant at the time of service. Out-of-Network Provider - Participant pays all billed charges to the provider, and UnitedHealthcare reimburses the participant for services rendered up to the maximum allowance. Copays do not apply to out-of-network benefits. Receipts for payments should be submitted within 90 days after the date of service to the following address: UnitedHealthcare Vision, Attn. Claims Department, P.O. Box 30978, Salt Lake City, UT 84130. If it was not reasonably possible to give written proof in the time required, the Company will not reduce or deny the claim for this reason. However, proof must be filed as soon as reasonably possible, but no later than 1 year after the date of service unless the Covered Person was legally incapacitated. Customer Service is available toll-free at (800) 638-3120 from 8:00 a.m. to 11:00 p.m. Eastern Time Monday through Friday, and 9:00 a.m. to 6:30 p.m. Eastern Time on Saturday. This Benefit Summary is intended only to highlight your benefits and should not be relied upon to fully determine coverage. This benefit plan may not cover all of your healthcare expenses. More complete descriptions of benefits and the terms under which they are provided are contained in the certificate of coverage that you will receive upon enrolling in the plan. If this Benefit Summary conflicts in any way with the Policy issued to your employer, the Policy shall prevail.
UnitedHealthcare vision coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut, UnitedHealthcare Insurance Company of New York, located in Islandia, New York, or its affiliates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affiliates Plans sold in Texas use policy form number VPOL.18.TX and associated COC form number VCOC.INT.18.TX or VCOC.CER.18.TX. Plans sold in Virginia use policy form number VPOL.18.VA and associated COC form number VCOC.INT.18.VA or VCOC.CER.18.VA. If you opt to receive vision care services or vision care materials that are not covered benefits under this plan, a participating vision care provider may charge you their normal fee for such services or materials. Prior to providing you with vision care services or vision care materials that are not covered benefits, the vision care provider will provide you with an estimated cost for each service or material upon your request. This cost may be higher than if you had received only covered vision services and you may incur additional out-of-pocket expenses. Eyewear materials may be ordered through the Spectera Eyecare Networks lab network with which UnitedHealthcare has a business relationship. 02/20 © 2020 United HealthCare Services, Inc. NCA-03C (v4.0)
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Employee Assistance Program
Service Summary
Hopewell City Public Schools Available 24/7, 365 days a year Everything you share is confidential* Life can be full of challenges. Your Anthem Employee Assistance Program (EAP) is here to help you and your household members. EAP offers a wide range of no-cost support services and resources, including:
Dependent care and daily living resources
Counseling
Up to 3 visits per issue
In-person or online visits
Call EAP or use the online Member Center to initiate services
Online information about child care, adoption, elder care, and assisted living
Phone consultation with a work-life specialist
Help with pet sitting, moving, and other common needs
Legal consultation
30-minute phone or in-person meeting
Discounted fees to retain a lawyer
Free legal resources, forms, and seminars online
Other anthemEAP.com resources
Well-being articles, podcasts, and monthly webinars
Self-assessment tools for emotional health issues
Crisis consultation
Financial consultation
Phone meeting with financial professionals
Regular business hours; no appointment required
Free financial resources and budgeting tools online
Toll-free emergency number; 24/7 support
Online critical event support during crises
ID recovery
Help reporting to consumer credit agencies
Assistance with paperwork and creditor negotiations
We are ready to support you You can call us at 800-346-5484, or go to anthemEAP.com and enter your company code: HCPS
When something unexpected happens, EAP can help you figure out your next steps. Contact us today. * In accordance with federal and state law, and professional ethical standards. This document is for general informational purposes. Check with your employer for specific information on the services available to you. Language Access Services – (TTY/TDD: 711) Spanish – Tiene el derecho de obtener esta información y ayuda en su idioma en forma gratuita. Llame al número de Servicios para Miembros que figura en su tarjeta de identificación para obtener ayuda. Chinese – 您有權使用您的語言免費獲得該資訊和協助。請撥打您的 ID 卡上的成員服務號碼尋求協助。 Anthem complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Copies of Colorado network access plans are available on request from member services or can be obtained by going to anthem.com/co/networkaccess. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 108413MUMENABS VPOD BV Rev. 12/20
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Dependent Care FSA
Save up to $1,500 on dependent care expenses this year! Participating in a dependent care flexible spending account (DCA) is like receiving a 30% discount from your care provider.
How does a dependent care FSA work? A dependent care FSA is a flexible spending account that allows you to set aside pre-tax dollars for dependent care expenses, such as daycare, that allow you to work or look for work. You choose an annual election amount, up to $5,000 per family. The money is placed in your account via payroll deduction, in equal installments, and then used to pay for eligible dependent care expenses incurred during the plan year.
Why should I enroll in a dependent care FSA? Child and dependent care is a large expense for many families. Millions of people rely on child care to be able to work, while others are responsible for older parents or disabled family members. If you pay for care of dependents in order to work, you’ll want to take advantage of the savings this plan offers. Money contributed to a dependent care account is free from federal and most state taxes and remains tax-free when it is spent on eligible expenses. On average, participants enjoy a 30% tax savings on their annual contribution. This means you could be saving up to $1,500 per year on dependent care expenses!
Qualifying Dependents* Your qualifying child under the age of 13 Your spouse or qualifying adult child or relative who is physically or mentally incapable of self-care y y
*additional restrictions may apply. See Internal Revenue Code Section 152.
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How do I use my DCA to pay for dependent care expenses? You can use your Flex Facts Debit Card to pay your provider for eligible dependent care expenses, or pay with your personal funds and submit a claim for reimbursement.
Qualifying expenses What qualifies?
What doesn’t qualify?
yy Before school or after school care for children 12 and younger
yy Expenses incurred in a prior plan year
yy Custodial care for dependent adults
yy Educational expenses including kindergarten or private school tuition fees
Dependent care FSA funds can cover costs for:
Certain expenses are not eligible, for instance:
yy Expenses for non-disabled children 13 and older
yy Licensed day care centers yy Nanny / Au Pair
yy Food, clothing, sports lessons, field trips, and entertainment
yy Nursery schools or preschools
yy Overnight camp expenses
yy Late pick-up fees
yy Late payment fees for child care
yy Summer or holiday day camps
A comprehensive list of eligible expenses can be found at flexfacts.com.
Online & mobile access Get instant access to your account with the Flex Facts Portal and Mobile App. yy View your account balance and transaction history
yy View important alerts and communications
yy Submit and view claims
yy Sign up for direct deposit
yy Upload and store receipts
yy Sign up for text message alerts
Register for the Flex facts Participant Portal at www.flexfacts.com
Download the Flex Facts Mobile App on the App Store or Google Play store
Helpful hints y
You must have funds in your dependent care FSA before you can spend them.
y You can’t change your election amount during the plan year, unless you experience a change in status or qualifying event. y
Keep your receipts, as you will need an itemized invoice for all reimbursement requests.
y
If your employment terminates before the end of the plan year, your account will be terminated.
y Any unused funds that remain in your account at the end of the year will be forfeited (also known as the use-itor-loose-it rule).
www.FlexFacts.com • 1200 River Ave Suite 10E • Lakewood, NJ 08701 • 877-943-2287
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Cancer Insurance How would cancer impact your way of life? Hopefully, you and your family will never face cancer. If you do, a financial safety net can help you and your loved ones focus on what matters most — recovery. If you were diagnosed with cancer, you could have expenses that medical insurance doesn’t cover. In addition to your regular, ongoing bills, you could have indirect treatment and recovery costs, such as child care and home health care services.
Help when you need it most Cancer coverage from Colonial Life & Accident Insurance Company can help protect the lifestyle you’ve worked so hard to build. It provides benefits you can use to help cover: ■ Loss of income ■ Out-of-network treatment ■ Lodging and meals ■ Deductibles and co-pays
23
CANCER ASSIST
One family’s journey
DOCTOR’S SCREENING
Paul and Kim were preparing for their second child when they learned Paul had cancer. They quickly realized their medical insurance wouldn’t cover everything. Thankfully, Kim’s job enabled her to have a cancer insurance policy on Paul to help them with expenses.
SECOND OPINION
SURGERY
Wellness benefit
Travel expenses
Out-of-pocket costs
Paul’s wellness benefit helped pay for the screening that discovered his cancer.
When the couple traveled several hundred miles from their home to a top cancer hospital, they used the policy’s lodging and transportation benefits to help with expenses.
The policy’s benefits helped with deductibles and co-pays related to Paul’s surgery and hospital stay.
For illustrative purposes only
With cancer insurance: ■ Coverage options are available for you
and your eligible dependents. ■ Benefits are paid directly to you, unless
you specify otherwise. ■ You’re paid regardless of any insurance
you may have with other companies. ■ You can take coverage with you, even if you
change jobs or retire.
ONLY of ALL
CANCERS are
hereditary.
American Cancer Society, Cancer Facts & Figures, 2013
24
Cancer insurance provides benefits to help with cancer expenses — from diagnosis to recovery.
TREATMENT
RECOVERY
Experimental care
Follow-up evaluations
Paul used his plan’s benefits to help pay for experimental treatments not covered by his medical insurance.
Paul has been cancer-free for more than four years. His cancer policy provides a benefit for periodic scans to help ensure the cancer stays in check.
Our cancer insurance offers more than 30 benefits that can help you with costs that may not be covered by your medical insurance. Treatment benefits
(inpatient or outpatient)
Surgery benefits ■ Surgical procedures
■ Radiation/chemotherapy
■ Anesthesia
■ Anti-nausea medication
■ Reconstructive surgery
■ Medical imaging studies
■ Outpatient surgical center
■ S upportive or protective care drugs
■ Prosthetic device/artificial limb
and colony stimulating factors ■ Second medical opinion ■ B lood/plasma/platelets/
immunoglobulins ■ B one marrow or peripheral stem
LIFETIME RISK OF DEVELOPING CANCER
Travel benefits ■ Transportation ■ Companion transportation ■ Lodging
MEN 1 in 2
cell donation ■ B one marrow or peripheral stem
cell transplant ■ E gg(s) extraction or harvesting/
sperm collection and storage ■ Experimental treatment ■ H air/external breast/voice
box prosthesis ■ Home health care services ■ Hospice (initial or daily care)
Inpatient benefits ■ Hospital confinement ■ Private full-time nursing services ■ Skilled nursing care facility ■ Ambulance ■ Air ambulance
Additional benefits WOMEN
■ Family care
1 in 3
■ Cancer vaccine ■ Bone marrow donor screening ■ Skin cancer initial diagnosis ■ Waiver of premium
25
American Cancer Society, Cancer Facts & Figures, 2013
Optional riders For an additional cost, you may have the option of purchasing additional riders for even more financial protection against cancer. Talk with your benefits counselor to find out which of these riders are available for you to purchase. ■
Diagnosis of cancer rider — Pays a one-time, lump-sum benefit for the initial diagnosis of cancer. You may choose a benefit amount in $1,000 increments between $1,000 and $10,000. If your dependent child is diagnosed with cancer, we will pay two and a half times ($2,500 - $25,000) the chosen benefit amount.
■
Diagnosis of cancer progressive payment rider — Provides a lump-sum payment of $50 for each month the rider has been in force and before cancer is first diagnosed.
■
pecified disease hospital confinement rider — Pays $300 per day if S you or a covered family member is confined to a hospital for treatment for one of the 34 specified diseases covered under the rider.
ColonialLife.com
If cancer impacts your life, you should be able to focus on getting better — not on how you’ll pay your bills. Talk with your Colonial Life benefits counselor about how cancer insurance can help provide financial security for you and your family.
PRE-EXISTING CONDITION LIMITATION We will not pay benefits for the diagnosis of internal cancer or skin cancer that is a pre-existing condition, nor will we pay benefits for the treatment of internal cancer or skin cancer that is a pre-existing condition unless the covered person has satisfied the six-month pre-existing condition limitation period shown on the Policy Schedule. Pre-existing condition means a condition for which a covered person was diagnosed prior to the effective date of this policy, and for which medical advice or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of this policy. EXCLUSIONS We will not pay benefits for cancer or skin cancer: ■ If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or ■ For other conditions or diseases, except losses due directly from cancer. The policy and its riders may have additional exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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1-16 | 101481-VA
Cancer Insurance Level 4 Benefits BENEFIT DESCRIPTION
Cancer insurance helps provide financial protection through a variety of benefits. These benefits are not only for you but also for your covered family members.
BENEFIT AMOUNT
Air ambulance. . . ............................................................................... $2,000 per trip
Transportation to or from a hospital or medical facility [max. of two trips per confinement]
Ambulance. . . . . . . ............................................................................... $250 per trip Transportation to or from a hospital or medical facility [max. of two trips per confinement]
Anesthesia
Administered during a surgical procedure for cancer treatment ■ General anesthesia. ......................................................................... 25% of surgical procedures benefit ■ Local anesthesia............................................................................. $50 per procedure
Anti-nausea medication. ..................................................................... $60 per day administered or Doctor-prescribed medication for radiation or chemotherapy [$240 monthly max.]
per prescription filled
Blood/plasma/platelets/immunoglobulins. . ............................................. $250 per day A transfusion required during cancer treatment [$10,000 calendar year max.]
Bone marrow donor screening.............................................................. $50 Testing in connection with being a potential donor [once per lifetime]
Bone marrow or peripheral stem cell donation.......................................... $1,000 Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]
Bone marrow or peripheral stem cell transplant........................................ $10,000 per transplant
Transplant you receive in connection with cancer treatment [max. of two bone marrow transplant benefits per lifetime]
Cancer vaccine.. . ............................................................................... $50 An FDA-approved vaccine for the prevention of cancer [once per lifetime]
Companion transportation. ................................................................. $0.50 per mile
Companion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,500 per round trip]
Egg(s) extraction or harvesting/sperm collection and storage
Extracted/harvested or collected before chemotherapy or radiation [once per lifetime] ■ Egg(s) extraction or harvesting/sperm collection. ......................................... $1,500 ■ Egg(s) or sperm storage (cryopreservation). ............................................... $500
Experimental treatment. . .................................................................... $300 per day Hospital, medical or surgical care for cancer [$15,000 lifetime max.]
For more information, talk with your benefits counselor.
Family care. . . . . . . . .............................................................................. $60 per day Inpatient or outpatient treatment for a covered dependent child [$3,000 calendar year max.]
Hair/external breast/voice box prosthesis. ............................................... $500 per calendar year Prosthesis needed as a direct result of cancer
Home health care services................................................................... $175 per day Examples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 100 days per covered person per lifetime]
Hospice (initial or daily care)
An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both] ■ Initial hospice care [once per lifetime]...................................................... $1,000 ■ Daily hospice care. .......................................................................... $50 per day
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CANCER ASSIST – LEVEL 4
BENEFIT DESCRIPTION
BENEFIT AMOUNT
Hospital confinement
Hospital stay (including intensive care) required for cancer treatment ■ 30 days or less. . . ........................................................................................ $350 per day ■ 31 days or more. ........................................................................................ $700 per day
Lodging. . . . . . . . . . . . . ......................................................................................... $80 per day Hotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]
Medical imaging studies.................................................................................. $225 per study
Specific studies for cancer treatment [$450 calendar year max.]
Outpatient surgical center............................................................................... $400 per day Surgery at an outpatient center for cancer treatment [$1,200 calendar year max.]
Private full-time nursing services. ...................................................................... $150 per day Services while hospital confined other than those regularly furnished by the hospital
Prosthetic device/artificial limb......................................................................... $3,000 per device or limb A surgical implant needed because of cancer surgery [payable one per site, $6,000 lifetime max.]
Radiation/chemotherapy
[per day with a max. of one per calendar week] ■ Injected chemotherapy by medical personnel......................................................... $1,000 ■ Radiation delivered by medical personnel............................................................. $1,000 [per day with a max. of one per calendar month] ■ Self-injected . . . . . ........................................................................................ $400 ■ Pump. . . . . . . . . . . . ........................................................................................ $400 ■ Topical. . . . . . . . . . . ........................................................................................ $400 ■ Oral hormonal [1-24 months]. .......................................................................... $400 ■ Oral hormonal [25+ months]............................................................................ $350 ■ Oral non-hormonal...................................................................................... $400
Reconstructive surgery................................................................................... $60 per surgical unit
ColonialLife.com
A surgery to reconstruct anatomic defects that result from cancer treatment [min. $350 per procedure, up to $3,000, including 25% for general anesthesia]
Second medical opinion. ................................................................................. $300
A second physician’s opinion on cancer surgery or treatment [once per lifetime]
Skilled nursing care facility.............................................................................. $175 per day Confinement to a covered facility after hospital release [up to 100 days per covered person per lifetime]
Skin cancer diagnosis. .................................................................................... $600 A skin cancer diagnosis while the policy is in force [once per lifetime]
Supportive or protective care drugs and colony stimulating factors . ........................... $200 per day Doctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,600 calendar year max.]
Surgical procedures. ...................................................................................... $70 per surgical unit Inpatient or outpatient surgery for cancer treatment [min. $350 per procedure, up to $6,000]
Transportation.. . . . ........................................................................................ $0.50 per mile
Travel expenses when being treated for cancer more than 50 miles from home [up to $1,500 per round trip]
Waiver of premium. ....................................................................................... Is available No premiums due if the named insured is disabled longer than 90 consecutive days
The policy has limitations and exclusions that may affect benefits payable. Most benefits require that a charge be incurred. Coverage may vary by state and may not be available in all states. For cost and complete details, see your benefits counselor. This chart highlights the benefits of policy forms CanAssist-NJ and CanAssist-VA. This chart is not complete without form 101505-NJ or 101481-VA.
©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
28
1-16 | 101485-NJ-VA
Cancer Insurance Wellness Benefits
To encourage early detection, our cancer insurance offers benefits for wellness and health screening tests.
For more information, talk with your benefits counselor.
Part one: Cancer wellness/health screening Provided when one of the tests listed below is performed while the policy is in force. Payable once per calendar year, per covered person.
Cancer wellness tests
Health screening tests
■
Bone marrow testing
■
Blood test for triglycerides
■
Breast ultrasound
■
Carotid Doppler
■
CA 15-3 (blood test for breast cancer)
■
Echocardiogram (ECHO)
■
CA 125 (blood test for ovarian cancer)
■
Electrocardiogram (EKG, ECG)
■
CEA (blood test for colon cancer)
■
Fasting blood glucose test
■
Chest X-ray
■
■
Colonoscopy
erum cholesterol test for HDL S and LDL levels
■
Flexible sigmoidoscopy
■
Stress test on a bicycle or treadmill
■
Hemoccult stool analysis
■
Mammography
■
Pap smear
■
PSA (blood test for prostate cancer)
■
erum protein electrophoresis S (blood test for myeloma)
■
Skin biopsy
■
Thermography
■
ThinPrep pap test
■
Virtual colonoscopy
Part two: Cancer wellness — additional invasive diagnostic test or surgical procedure Provided when a doctor performs a diagnostic test or surgical procedure as the result of an abnormal result from one of the covered cancer wellness tests in part one. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.
ColonialLife.com The policy has exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable). ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
29
CANCER ASSIST WELLNESS | 8-15 | 101506-2
Individual Cancer Insurance Description of Benefits THE POLICY PROVIDES LIMITED BENEFITS. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Coverage is dependent on answers to health questions. Applicable to policy forms CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA. Cancer Insurance Benefits Level 1 Level 2 Level 3 Level 4 Air Ambulance, per trip $2,000 $2,000 $2,000 $2,000 Maximum trips per confinement 2 2 2 2 Ambulance, per trip $250 $250 $250 $250 Maximum trips per confinement 2 2 2 2 Anesthesia, General 25% of Surgical Procedures Benefit Anesthesia, Local, per procedure $25 $30 $40 $50 Anti-Nausea Medication, per day $25 $40 $50 $60 Maximum per month $100 $160 $200 $240 Blood/Plasma/Platelets/Immunoglobulins, per day $150 $150 $175 $250 Maximum per year $10,000 $10,000 $10,000 $10,000 Bone Marrow or Peripheral Stem Cell Donation, per lifetime $500 $500 $750 $1,000 Bone Marrow or Peripheral Stem Cell Transplant, per transplant $3,500 $4,000 $7,000 $10,000 Maximum transplants per lifetime 2 2 2 2 Companion Transportation, per mile $0.50 $0.50 $0.50 $0.50 Maximum per round trip $1,000 $1,000 $1,200 $1,500 Egg(s) Extraction or Harvesting or Sperm Collection, per lifetime $500 $700 $1,000 $1,500 Egg(s) or Sperm Storage, per lifetime $175 $200 $350 $500 Experimental Treatment, per day $200 $250 $300 $300 Maximum per lifetime $10,000 $12,500 $15,000 $15,000 Family Care, per day $30 $40 $50 $60 Maximum per year $1,500 $2,000 $2,500 $3,000 Hair/External Breast/Voice Box Prosthesis, per year $200 $200 $350 $500 Home Health Care Services, per day $50 $75 $125 $175 Benefit payable for at least and not more than 100 days per covered person per lifetime Hospice, Initial, per lifetime $1,000 $1,000 $1,000 $1,000 Hospice, Daily $50 $50 $50 $50 Maximum combined Initial and Daily per lifetime $15,000 $15,000 $15,000 $15,000 Hospital Confinement, 30 days or less, per day $100 $150 $250 $350 Hospital Confinement, 31 days or more, per day $200 $300 $500 $700 Benefit payable for up to 365 days per covered person per calendar year. Lodging, per day $50 $50 $75 $80 Maximum days per year 70 70 70 70 Medical Imaging Studies, per study $75 $125 $175 $225 Maximum per year $150 $250 $350 $450 Outpatient Surgical Center, per day $100 $200 $300 $400 Maximum per year $300 $600 $900 $1,200 Private Full-time Nursing Services, per day $50 $75 $125 $150 Prosthetic Device/Artificial Limb, per device or limb $1,000 $1,500 $2,000 $3,000 Maximum per lifetime $2,000 $3,000 $4,000 $6,000
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Cancer Insurance Benefits Level 1 Level 2 Level 3 Level 4 Radiation/Chemotherapy Benefit payable period can exceed but will not be less than 365 days per covered person per lifetime Injected chemotherapy by medical personnel, per day with a $250 $500 $750 $1,000 maximum of one per calendar week Radiation delivered by medical personnel, per day with a $250 $500 $750 $1,000 maximum of one per calendar week Self-Injected Chemotherapy, per day with a maximum of one per $150 $200 $300 $400 calendar month Pump Chemotherapy, per day with a maximum of one per $150 $200 $300 $400 calendar month Topical Chemotherapy, per day with a maximum of one per $150 $200 $300 $400 calendar month Oral Hormonal Chemotherapy (1-24 months), per day with a $150 $200 $300 $400 maximum of one per calendar month Oral Hormonal Chemotherapy (25+ months), per day with a $100 $150 $250 $350 maximum of one per calendar month Oral Non-Hormonal Chemotherapy, per day with a maximum of $150 $200 $300 $400 one per calendar month Reconstructive Surgery, per surgical unit $40 $40 $60 $60 Minimum per procedure $100 $150 $250 $350 Maximum per procedure, including 25% for general anesthesia $2,500 $2,500 $3,000 $3,000 Second Medical Opinion, per lifetime $150 $200 $300 $300 Skilled Nursing Care Facility, per day, up to days confined $50 $75 $125 $175 Benefit payable for at least and not more than 100 days per covered person per lifetime Skin Cancer Initial Diagnosis $300 $300 $400 $600 Supportive/Protective Care Drugs/Colony Stimulating Factors, per day $50 $100 $150 $200 Maximum per year $400 $800 $1,200 $1,600 Surgical Procedures $40 $50 $60 $70 Minimum per procedure $100 $150 $250 $350 Maximum per procedure $2,500 $3,000 $5,000 $6,000 Transportation $0.50 $0.50 $0.50 $0.50 Maximum per round trip $1,000 $1,000 $1,200 $1,500 Waiver of Premium Yes Yes Yes Yes Policy-Wellness Benefits Bone Marrow Donor Screening, per lifetime $50 $50 $50 $50 Cancer Vaccine, per lifetime $50 $50 $50 $50 One amount per account: $0, $25, $50, Part 1: Cancer Wellness/Health Screening, per year $75 or $100 Part 2: Cancer Wellness/Health Screening, per year Same as Part 1 Additional Riders may be available at an additional cost What is not covered by the policy Pre-Existing Condition Limitation We will not pay benefits for the diagnosis of internal cancer or skin cancer that is a pre-existing condition nor will we pay benefits for the treatment of internal cancer or skin cancer that is a pre-existing condition, unless the covered person has satisfied the six-month pre-existing condition limitation period. Pre-existing condition means a condition for which a covered person was diagnosed prior to the effective date of the policy and for which medical advice or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of the policy. We will not pay benefits for cancer or skin cancer: ■ If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or ■ For other conditions or diseases, except losses due directly from cancer. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. ADR1962-2018
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Group Critical Illness Insurance Plan 1
When life takes an unexpected turn due to a critical illness diagnosis, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps provide financial support by providing a lump-sum benefit payable directly to you for your greatest needs.
An unexpected moment changes life forever
Coverage amount: ____________________________
Chris was mowing the lawn when he suffered a stroke. His recovery will be challenging and he's worried, since his family relies on his income.
Critical illness benefit
HOW CHRIS’S COVERAGE HELPED
The lump-sum payment from his critical illness insurance helped pay for: Co-payments and hospital bills not covered by his medical insurance Physical therapy to get back to doing what he loves Household expenses while he was unable to work
For illustrative purposes only.
COVERED CONDITION¹
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Benign brain tumor
100%
Coma
100%
End stage renal (kidney) failure
100%
Heart attack (myocardial infarction)
100%
Loss of hearing
100%
Loss of sight
100%
Loss of speech
100%
Major organ failure requiring transplant
100%
Occupational infectious HIV or occupational infectious hepatitis B, C, or D
100%
Permanent paralysis due to a covered accident
100%
Stroke
100%
Sudden cardiac arrest
100%
Coronary artery disease
25%
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GCI6000 – PLAN 1 – CRITICAL ILLNESS
KEY BENEFITS
Available coverage for spouse and eligible dependent children at 50% of your coverage amount Cover your eligible dependent children at no additional cost Receive coverage regardless of medical history, within specified limits Works alongside your health savings account (HSA) Benefits payable regardless of other insurance
For more information, talk with your benefits counselor.
Subsequent diagnosis of a different critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with a different critical illness, 100% of the coverage amount may be payable for that particular critical illness.
Subsequent diagnosis of the same critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with the same critical illness,3 25% of the coverage amount may be payable for that critical illness.
Additional covered conditions for dependent children COVERED CONDITION¹
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Cerebral palsy
100%
Cleft lip or palate
100%
Cystic fibrosis
100%
Down syndrome
100%
Spina bifida
100%
Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.
1. R efer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D. THIS INSURANCE PROVIDES LIMITED BENEFITS Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.
EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS
We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.
ColonialLife.com
PRE-EXISTING CONDITION LIMITATION
We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
33
5-20 | 385403
Group Critical Illness Insurance Plan 2
When life takes an unexpected turn, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps relieve financial worries by providing a lump-sum benefit payable directly to you to use as needed.
Preparing for a lifelong journey Rebecca was born with Down syndrome. Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs. HOW THEIR COVERAGE HELPED
The lump-sum amount from the family coverage benefit helped pay for:
A hospital stay and treatment for corrective heart surgery Physical therapy to build muscle strength
Special needs daycare
Coverage amount: ____________________________
Critical illness and cancer benefits COVERED CRITICAL ILLNESS CONDITION¹
Benign brain tumor
100%
Coma
100%
End stage renal (kidney) failure
100%
Heart attack (myocardial infarction)
100%
Loss of hearing
100%
Loss of sight
100%
Loss of speech
100%
Major organ failure requiring transplant
100%
Occupational infectious HIV or occupational infectious hepatitis B, C, or D
100%
Permanent paralysis due to a covered accident
100%
Stroke
100%
Sudden cardiac arrest
100%
Coronary artery disease
25%
COVERED CANCER CONDITION¹ For illustrative purposes only.
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Invasive cancer (including all breast cancer)
100%
Non-invasive cancer
25%
Skin cancer initial diagnosis............................................................. $400 per lifetime
34
GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCER
KEY BENEFITS
Available coverage for spouse and eligible dependent children at 50% of your coverage amount Cover your eligible dependent children at no additional cost Receive coverage regardless of medical history, within specified limits Works alongside your health savings account (HSA) Benefits payable regardless of other insurance
Subsequent diagnosis of a different critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with a different critical illness, 100% of the coverage amount may be payable for that particular critical illness.
Subsequent diagnosis of the same critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with the same critical illness,3 25% of the coverage amount is payable for that critical illness.
Reoccurrence of invasive cancer (including all breast cancer) If you receive a benefit for invasive cancer and are later diagnosed with a reoccurrence of invasive cancer, 25% of the coverage amount is payable if treatment-free for at least 12 months and in complete remission prior to the date of reoccurrence; excludes non-invasive or skin cancer.
Additional covered conditions for dependent children COVERED CONDITION¹
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Cerebral palsy
100%
Cleft lip or palate
100%
Cystic fibrosis
100%
Down syndrome
100%
Spina bifida
100%
Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges. 1. R efer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D.
For more information, talk with your benefits counselor.
THIS INSURANCE PROVIDES LIMITED BENEFITS Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.
EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS
We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.
EXCLUSIONS AND LIMITATIONS FOR CANCER
We will not pay the Invasive Cancer (including all Breast Cancer) Benefit, Non-Invasive Cancer Benefit, Benefit Payable Upon Reoccurrence of Invasive Cancer (including all Breast Cancer) or Skin Cancer Initial Diagnosis Benefit for a covered person’s invasive cancer or non-invasive cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having invasive or non-invasive cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while the named insured is covered under the certificate, and who are continuously covered from the date of birth or adoption.
PRE-EXISTING CONDITION LIMITATION
We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date.
ColonialLife.com
This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
35
5-20 | 387100
Group Critical Illness Insurance First Diagnosis Building Benefit Rider
The first diagnosis building benefit rider provides a lump-sum payment in addition to the coverage amount when you are diagnosed with a covered critical illness or invasive cancer (including all breast cancer). This benefit is for you and all your covered family members.
First diagnosis building benefit Payable once per covered person per lifetime
¾ Named insured............................................................. Accumulates $1,000 each year ¾ Covered spouse/dependent children................................ Accumulates $500 each year The benefit amount accumulates each rider year the rider is in force before a diagnosis is made, up to a maximum of 10 years.
For more information, talk with your benefits counselor.
If diagnosed with a covered critical illness or invasive cancer (including all breast cancer) before the end of the first rider year, the rider will provide one-half of the annual building benefit amount. Coronary artery disease is not a covered critical illness. Non-invasive and skin cancer are not covered cancer conditions.
ColonialLife.com
THIS INSURANCE PROVIDES LIMITED BENEFITS. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-BB. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
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GCI6000 – FIRST DIAGNOSIS BUILDING BENEFIT RIDER | 5-20 | 387381
Group Critical Illness Insurance Infectious Diseases Rider
The sudden onset of an infectious or contagious disease can create unexpected circumstances for you or your family. The infectious diseases rider provides a lump sum which can be used toward health care expenses or meeting day-today needs. These benefits are for you as well as your covered family members.
Payable for each covered infectious disease once per covered person per lifetime COVERED INFECTIOUS DISEASE¹
PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
Hospital confinement for seven or more consecutive days for treatment of the disease
For more information, talk with your benefits counselor.
ColonialLife.com
Antibiotic resistant bacteria (including MRSA)
50%
Cerebrospinal meningitis (bacterial)
50%
Diphtheria
50%
Encephalitis
50%
Legionnaires’ disease
50%
Lyme disease
50%
Malaria
50%
Necrotizing fasciitis
50%
Osteomyelitis
50%
Poliomyelitis
50%
Rabies
50%
Sepsis
50%
Tetanus
50%
Tuberculosis
50%
Hospital confinement for 14 or more consecutive days for treatment of the disease Coronavirus disease 2019 (COVID-19)
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25%
GCI6000 – INFECTIOUS DISEASES RIDER
1. R efer to the certificate for complete definitions of covered diseases. THIS INSURANCE PROVIDES LIMITED BENEFITS.
EXCLUSIONS AND LIMITATIONS FOR INFECTIOUS DISEASES RIDER
ColonialLife.com
We will not pay benefits for a covered infectious disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a covered infectious disease.
PRE-EXISTING CONDITION LIMITATION
We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-INF. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
38
5-20 | 387523
Group Critical Illness Insurance Progressive Diseases Rider
The debilitating effects of a progressive disease not only impact you physically, but financially as well. Changes in lifestyle may require home modification, additional medical treatment and other expenses. These benefits are for you as well as your covered family members. Payable for each covered progressive disease once per covered person per lifetime PERCENTAGE OF APPLICABLE COVERAGE AMOUNT
COVERED PROGRESSIVE DISEASE¹
This benefit is payable if the covered person is unable to perform two or more activities of daily living2 and the 90-day elimination period has been met.
For more information, talk with your benefits counselor.
ColonialLife.com
Amyotrophic Lateral Sclerosis (ALS)
25%
Dementia (including Alzheimer’s disease)
25%
Huntington’s disease
25%
Lupus
25%
Multiple sclerosis (MS)
25%
Muscular dystrophy
25%
Myasthenia gravis (MG)
25%
Parkinson’s disease
25%
Systemic sclerosis (scleroderma)
25%
1. R efer to the certificate for complete definitions of covered diseases. 2. Activities of daily living include bathing, continence, dressing, eating, toileting and transferring. THIS INSURANCE PROVIDES LIMITED BENEFITS.
EXCLUSIONS AND LIMITATIONS FOR PROGRESSIVE DISEASES RIDER
We will not pay benefits for a covered progressive disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the preexisting condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a covered progressive disease.
PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-PD. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
39
GCI6000 – PROGRESSIVE DISEASES RIDER | 5-20 | 387594
Educator Disability Income Insurance
How long could you afford to go without a paycheck? Help protect your paycheck with Colonial Life’s short-term disability insurance. You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you couldn’t go to work due to an accident or sickness? Monthly Expenses:
$_________________
$_________________
$_________________
$_________________
$_________________
$_________________ Total $_________________
My Coverage Worksheet (For use with your Colonial Life Benefits Counselor) Who’s being covered?
You only You and your spouse You and your dependent children You, your spouse and your dependent children
How much coverage do I need? On-Job Accident/On-Job Sickness $______________ Off-Job Accident/Off-Job Sickness $______________ Select One Benefit Period Option:
On-Job
Off-Job
First 3 months
$_____________/month
$_____________/month
Next 9 months
$_____________/month
$_____________/month
First 6 months
$_____________/month
$_____________/month
Next 6 months
$_____________/month
$_____________/month
$_____________/month
$_____________/month
= Total Disability
Educator Disability 1.0-VA
Option A Option B = Partial Disability Up to 3 months
When will my benefits start? After an Accident: ___________ days
After a Sickness: ___________ days
How much will it cost? Your cost will vary based on the level of coverage you select.
40
Employee Coverage In addition to disability coverage, this plan also provides employees with benefits for medical fees related to accidents, hospital confinement, accidental death and dismemberment, as well as fractures and dislocations. Even if you’re not disabled, the following benefits are payable for covered accidental injuries:
Medical Fees for Accidents Only Doctor’s Office or Urgent Care Facility Visit (Once per covered accident)...................................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident)..............................................................................$75 Emergency Room Visit (Once per covered accident)....................................................................................................... $150
Hospital Confinement Benefit for Accident or Sickness Pays in addition to disability benefit. l
Benefits begin on the first day of confinement in a hospital for a covered accident or sickness. Up to 3 months..................................................................................................................... $1,200/month ($40/day) The Hospital Confinement benefit increases to $6,000/month ($200/day) when the Total Disability benefit ends at age 70
Accidental Death and Dismemberment Benefits Benefits payable for death or dismemberment. l l
l
l
Accidental Death............................................................................................................................................................... $25,000 Loss of a Finger or Toe Single Dismemberment.................................................................................................................................................. $750 Double Dismemberment.............................................................................................................................................$1,500 Loss of a Hand, Foot or Sight of an Eye Single Dismemberment...............................................................................................................................................$7,500 Double Dismemberment.......................................................................................................................................... $15,000 Accidental Death Common Carrier ........................................................................................................................... $50,000
Complete Fractures Complete Fractures requiring closed reduction Hip, Thigh .....................................................................................................................................................................................$1,500 Vertebrae . ...................................................................................................................................................................................... 1,350 Pelvis ................................................................................................................................................................................................ 1,200 Skull (depressed) ......................................................................................................................................................................... 1,125 Leg ........................................................................................................................................................................................................900 Foot, Ankle, Kneecap .....................................................................................................................................................................750 Forearm, Hand, Wrist . ....................................................................................................................................................................750 Lower Jaw ..........................................................................................................................................................................................600 Shoulder Blade, Collarbone .........................................................................................................................................................600 Skull (simple) . ...................................................................................................................................................................................525 Upper Arm, Upper Jaw ..................................................................................................................................................................525 Facial Bones .......................................................................................................................................................................................450 Vertebral Processes . .......................................................................................................................................................................300 Coccyx, Rib, Finger, Toe .................................................................................................................................................................120
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Complete Dislocations .Complete Dislocations requiring closed reduction with anesthesia Hip ..................................................................................................................................................................................................$1,350 Knee .....................................................................................................................................................................................................975 Collarbone - sternoclavicular.......................................................................................................................................................750 Shoulder .............................................................................................................................................................................................750 Collarbone - acromioclavicular separation.............................................................................................................................675 Ankle, Foot .........................................................................................................................................................................................600 Hand . ...................................................................................................................................................................................................525 Lower Jaw ..........................................................................................................................................................................................450 Wrist .....................................................................................................................................................................................................375 Elbow ...................................................................................................................................................................................................300 One Finger, Toe . ...............................................................................................................................................................................120 For a fracture or dislocation requiring an open reduction, your benefit would be 11/2 times the amount shown.
Additional Features l
Waiver of Premium
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Worldwide Coverage
Optional Spouse and Dependent Coverage You may cover one or all of the eligible dependent members of your family for an additional premium.
Medical Fees for Accidents Only Doctor’s Office or Urgent Care Facility Visit (Once per covered accident)...........................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident)......................................................................$75 Emergency Room Visit (Once per covered accident)............................................................................................... $150
Hospital Confinement Benefit for Accident or Sickness l
Up to 3 months........................................................................................................................ $1,200/month ($40/day)
Accidental Death and Dismemberment Benefits l
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Accidental Death..................................................................................................................................... Spouse $10,000 Child(ren) $5,000 Loss of a Finger or Toe Single Dismemberment............................................................................................................................................$75 Double Dismemberment...................................................................................................................................... $150
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Loss of a Hand, Foot or Sight of an Eye Single Dismemberment......................................................................................................................................... $750 Double Dismemberment...................................................................................................................................$1,500
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Accidental Death Common Carrier . ................................................................................................Spouse $20,000 Child(ren) $10,000
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Here are some
Colonial Life’s frequently asked questions about disability insurance: Will my disability income payment be reduced if I have other insurance?
What if I change employers?
You’re paid regardless of any other insurance you may have with other insurance companies. Benefits are paid directly to you (unless you specify otherwise).
If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable for life as long as you continue to pay your premiums when they are due.
When am I considered totally disabled?
Can my premium change? You may choose the amount of coverage to meet your needs (subject to your income). You can elect more or less coverage which will change your premium. Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued.
Totally disabled means you are: l
l
l
Unable to perform the material and substantial duties of your job; Not, in fact, engaged in any employment or occupation for wage or profit for which you are qualified by reason of education, training or experience; and
What is a covered accident or a covered sickness?
Under the regular and appropriate care of a doctor.
A covered accident is an accident. A covered sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an injury.
What if I want to return to work part-time after I am totally disabled? You may be able to return to work part-time and still receive benefits. We call this “Partial Disability.” This means you may be eligible for coverage if: l You are unable to perform the material and substantial duties of your job for more than 20 hours per week, l You are able to work at your job or your place of employment for 20 hours or less per week, l Your employer will allow you to return to your job or place of employment for 20 hours or less per week; and l You are under the regular and appropriate care of a doctor. The total disability benefit must have been paid for at least one full month immediately prior to your being partially disabled.
A covered accident or covered sickness: l Occurs after the effective date of the policy; l Occurs while the policy is in force; l Is of a type listed on the Policy Schedule; and l Is not excluded by name or specific description in the policy. EXCLUSIONS We will not pay benefits for injuries received in accidents or sicknesses which are caused by or are the result of: alcoholism or drug addiction; flying; giving birth within the first nine months after the effective date of the policy; felonies or illegal occupations; having a pre-existing condition as described and limited by the policy; psychiatric or psychological condition; committing or trying to commit suicide or injuring yourself intentionally; being exposed to war or any act of war or serving in the armed forces of any country or authority.
When do disability benefits end? The Total Disability Benefit will end on the policy anniversary date on or after your 70th birthday. The Hospital Confinement benefit increases when the Total Disability Benefit ends. A pre-existing condition is when you have a sickness or physical condition for which you were treated, had medical testing, received medical advice, or had taken medication within 12 months testing, or before the effective date of your policy. If you become disabled because of a pre-existing condition, Colonial Life will not pay for any disability period if it begins during the first 12 months the policy is in force. Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 6/11
©2011 Colonial Life & Accident Insurance Company. Colonial Life products are underwritten by Colonial Life & Accident Insurance Life products underwritten Colonial Life & Accident Company, for Colonial which Colonial Life are is the marketingbybrand. Insurance Company, for which Colonial Life is the marketing brand.
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Colonial Life and Making benefits count are registered service marks of Colonial Life &71381-1 Accident Insurance Company. 100252
Educator Disability 1.0-VA
For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ED DIS 1.0-VA. Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control.
What is a pre-existing condition?
Accident Insurance
Accidents happen in places where you and your family spend the most time – at work, in the home and on the playground – and they’re unexpected. How you care for them shouldn’t be. In your lifetime, which of these accidental injuries have happened to you or someone you know?
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Sports-related accidental injury Broken bone Burn Concussion Laceration
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Back or knee injuries
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Car accidents Falls & spills Dislocation Accidental injuries that send you to the Emergency Room, Urgent Care or doctor’s office
Accident 1.0-Preferred with Health Screening Benefit-VA
Colonial Life’s Accident Insurance is designed to help you fill some of the gaps caused by increasing deductibles, co-payments and out-of-pocket costs related to an accidental injury. The benefit to you is that you may not need to use your savings or secure a loan to pay expenses. Plus you’ll feel better knowing you can have greater financial security.
What additional features are included? l
Worldwide coverage
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Portable
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What if I change employers? If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable for life as long as you pay your premiums when they are due or within the grace period.
Compliant with Healthcare Spending Account (HSA) guidelines
Can my premium change?
Will my accident claim payment be reduced if I have other insurance?
Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued.
You’re paid regardless of any other insurance you may have with other insurance companies, and the benefits are paid directly to you (unless you specify otherwise).
How do I file a claim? Visit coloniallife.com or call our Customer Service Department at 1.800.325.4368 for additional information.
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Benefits listed are for each covered person per covered accident unless otherwise specified.
Initial Care l
Accident Emergency Treatment........... $125
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Ambulance........................................$200
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X-ray Benefit....................................................$30
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Air Ambulance.............................. $2,000
Common Accidental Injuries Dislocations (Separated Joint) Hip Knee (except patella) Ankle – Bone or Bones of the Foot (other than Toes) Collarbone (Sternoclavicular) Lower Jaw, Shoulder, Elbow, Wrist Bone or Bones of the Hand Collarbone (Acromioclavicular and Separation) One Toe or Finger Fractures Depressed Skull Non-Depressed Skull Hip, Thigh Body of Vertebrae, Pelvis, Leg Bones of Face or Nose (except mandible or maxilla) Upper Jaw, Maxilla Upper Arm between Elbow and Shoulder Lower Jaw, Mandible, Kneecap, Ankle, Foot Shoulder Blade, Collarbone, Vertebral Process Forearm, Wrist, Hand Rib Coccyx Finger, Toe
Non-Surgical
Surgical
$2,200 $1,100 $880 $550 $330 $330 $110 $110
$4,400 $2,200 $1,760 $1,100 $660 $660 $220 $220
Non-Surgical
Surgical
$2,750 $1,100 $1,650 $825 $385 $385 $385 $330 $330 $330 $275 $220 $110
$5,500 $2,200 $3,300 $1,650 $770 $770 $770 $660 $660 $660 $550 $440 $220
Your Colonial Life policy also provides benefits for the following injuries received as a result of a covered accident. l
Burn (based on size and degree).....................................................................................$1,000 to $12,000
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Coma..............................................................................................................................................................$10,000
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Concussion.......................................................................................................................................................... $60
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Emergency Dental Work........................................$75 Extraction, $300 Crown, Implant, or Denture Lacerations (based on size)............................................................................................................$30 to $500
Requires Surgery l
Eye Injury............................................................................................................................................................$300
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Tendon/Ligament/Rotator Cuff...........................................................$500 - one, $1,000 - two or more
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Ruptured Disc...................................................................................................................................................$500
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Torn Knee Cartilage........................................................................................................................................$500
Surgical Care l
Surgery (cranial, open abdominal or thoracic)................................................................................. $1,500
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Surgery (hernia)...............................................................................................................................................$150
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Surgery (arthroscopic or exploratory).....................................................................................................$200
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Blood/Plasma/Platelets.................................................................................................................................$300
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Transportation/Lodging Assistance If injured, covered person must travel more than 50 miles from residence to receive special treatment and confinement in a hospital. l l
Transportation..............................................................................$500 per round trip up to 3 round trips Lodging (family member or companion)................................................$125 per night up to 30 days for a hotel/motel lodging costs
Accident Hospital Care l
Hospital Admission*......................................................................................................... $1,000 per accident
Hospital ICU Admission*................................................................................................. $2,000 per accident * We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both. l
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Hospital Confinement.......................................................... $225 per day up to 365 days per accident
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Hospital ICU Confinement ....................................................$450 per day up to 15 days per accident
Accident Follow-Up Care l l
Accident Follow-Up Doctor Visit........................................................... $50 (up to 3 visits per accident) Medical Imaging Study.......................................................................................................$150 per accident (limit 1 per covered accident and 1 per calendar year)
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Occupational or Physical Therapy...................................................... $25 per treatment up to 10 days
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Appliances ........................................................................................... $100 (such as wheelchair, crutches)
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Prosthetic Devices/Artificial Limb .....................................................$500 - one, $1,000 - more than 1
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Rehabilitation Unit..................................................$100 per day up to 15 days per covered accident, and 30 days per calendar year. Maximum of 30 days per calendar year
Accidental Dismemberment l
Loss of Finger/Toe..................................................................................$750 – one, $1,500 – two or more
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Loss or Loss of Use of Hand/Foot/Sight of Eye......................$7,500 – one, $15,000 – two or more
Catastrophic Accident For severe injuries that result in the total and irrecoverable: l
Loss of one hand and one foot
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Loss of the sight of both eyes
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Loss of both hands or both feet
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Loss of the hearing of both ears
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Loss or loss of use of one arm and one leg or
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Loss of the ability to speak
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Loss or loss of use of both arms or both legs Named Insured................. $25,000
Spouse...............$25,000
Child(ren)..........$12,500
365-day elimination period. Amounts reduced for covered persons age 65 and over. Payable once per lifetime for each covered person.
Accidental Death Accidental Death
Common Carrier
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Named Insured
$25,000
$100,000
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Spouse
$25,000
$100,000
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Child(ren)
$5,000
$20,000
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Health Screening Benefit
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$50 per covered person per calendar year
Provides a benefit if the covered person has one of the health screening tests performed. This benefit is payable once per calendar year per person and is subject.
Tests include: l.
Blood test for triglycerides
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Hemoccult stool analysis
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Bone marrow testing
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Mammography
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Breast ultrasound
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Pap smear
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CA 15-3 (blood test for breast cancer)
l.
PSA (blood test for prostate cancer)
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CA125 (blood test for ovarian cancer)
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Carotid doppler
Serum cholesterol test to determine level of HDL and LDL
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CEA (blood test for colon cancer)
l.
l.
Chest x-ray
Serum protein electrophoresis (blood test for myeloma)
Colonoscopy
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Stress test on a bicycle or treadmill
Echocardiogram (ECHO)
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Skin cancer biopsy
Electrocardiogram (EKG, ECG)
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Thermography
Fasting blood glucose test
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ThinPrep pap test
Flexible sigmoidoscopy
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Virtual colonoscopy
My Coverage Worksheet (For use with your Colonial Life benefits counselor) Who will be covered? (check one) Employee Only
Spouse Only
One-Parent Family, with Spouse
Employee & Spouse Two-Parent Family
When are covered accident benefits available? (check one) On and Off -Job Benefits
Off -Job Only Benefits
EXCLUSIONS We will not pay benefits for losses that are caused by or are the result of: felonies or illegal occupations; sickness; suicide or self-inflicted injuries; war or armed conflict; in addition to the exclusions listed above, we also will not pay the Catastrophic Accident benefit for injuries that are caused by or are the result of: birth; intoxication. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form Accident 1.0-HS -VA. This is not an insurance contract and only the actual policy provisions will control.
Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 10/11
©2011 Colonial Life & Accident Insurance Company. Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. Colonial Life and Making benefits count are registered service marks of Colonial Life & Accident Insurance Company.
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74231-2
Accident 1.0-Preferred with Health Screening Benefit-VA
One-Parent Family, with Employee
One Child Only
Hospital Confinement Indemnity Insurance Plan 1 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.
Hospital confinement. ..................................................................... $__________________ Maximum of one benefit per covered person per calendar year
Observation room................................................................................... $100 per visit Maximum of two visits per covered person per calendar year
Rehabilitation unit confinement. ................................................................. $100 per day Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year
Waiver of premium Available after 30 continuous days of a covered hospital confinement of the named insured
Health savings account (HSA) compatible
For more information, talk with your benefits counselor.
ColonialLife.com
This plan is compatible with HSA guidelines. This plan may also be offered to employees who do not have HSAs. Colonial Life & Accident Insurance Company’s Individual Medical Bridge offers an HSA compatible plan in most states.
THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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IMB7000 – PLAN 1 | 5-16 | 101576-1
Hospital Confinement Indemnity Insurance Plan 3 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement. ......................................................................... $_______________ Maximum of one benefit per covered person per calendar year
Observation room................................................................................... $100 per visit Maximum of two visits per covered person per calendar year
Rehabilitation unit confinement. ................................................................. $100 per day Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year
Waiver of premium
Available after 30 continuous days of a covered hospital confinement of the named insured
Diagnostic procedure Tier 1. . . . . . .......................................................................................................... $250 Tier 2. . . . . . .......................................................................................................... $500 Maximum of $500 per covered person per calendar year for all covered diagnostic procedures combined
Outpatient surgical procedure Tier 1. . . . . . .......................................................................................... $_______________ Tier 2. . . . . . ........................................................................................... $_______________
For more information, talk with your benefits counselor.
Maximum of $___________ per covered person per calendar year for all covered outpatient surgical procedures combined
The following is a list of common diagnostic procedures that may be covered.
Tier 1 diagnostic procedures Breast – Biopsy (incisional, needle, stereotactic) Diagnostic radiology – Nuclear medicine test Digestive – Barium enema/lower GI series – Barium swallow/upper GI series – Esophagogastroduodenoscopy (EGD) Ear, nose, throat, mouth – Laryngoscopy Gynecological – Hysteroscopy – Amniocentesis – L oop electrosurgical – Cervical biopsy excisional procedure – Cone biopsy (LEEP) – Endometrial biopsy
Liver – biopsy Lymphatic – biopsy Miscellaneous – Bone marrow aspiration/biopsy Renal – biopsy Respiratory – Biopsy – Bronchoscopy – Pulmonary function test (PFT) Skin – Biopsy – Excision of lesion Thyroid – biopsy Urologic – Cystoscopy
Tier 2 diagnostic procedures Cardiac – Angiogram – Arteriogram – Thallium stress test – Transesophageal echocardiogram (TEE)
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Diagnostic radiology – Computerized tomography scan (CT scan) – Electroencephalogram (EEG) – Magnetic resonance imaging (MRI) – Myelogram – Positron emission tomography scan (PET scan) IMB7000 – PLAN 3
The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.
Tier 1 outpatient surgical procedures Breast
Gynecological
Cardiac
Liver
Digestive
Musculoskeletal system
– Axillary node dissection – Breast capsulotomy – Lumpectomy
– Dilation and curettage (D&C) – Endometrial ablation – Lysis of adhesions
– Pacemaker insertion
– Paracentesis
– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions
– Carpal/cubital repair or release – Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair) – Removal of orthopedic hardware – Removal of tendon lesion
Skin
– Laparoscopic hernia repair – Skin grafting
Ear, nose, throat, mouth – Adenoidectomy – Removal of oral lesions – Myringotomy – Tonsillectomy – Tracheostomy – Tympanotomy
Tier 2 outpatient surgical procedures Breast
Gynecological
Cardiac
Musculoskeletal system
– Breast reconstruction – Breast reduction
– Hysterectomy – Myomectomy
– Angioplasty – Cardiac catheterization
Digestive
– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy
Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty
Thyroid
– Excision of a mass
Eye
ColonialLife.com
– Arthroscopic knee surgery with meniscectomy (knee cartilage repair) – Arthroscopic shoulder surgery – Clavicle resection – Dislocations (open reduction with internal fixation) – Fracture (open reduction with internal fixation) – Removal or implantation of cartilage – Tendon/ligament repair
– Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy) – Vitrectomy
Urologic
– Lithotripsy
EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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1-16 | 101581-1
Hospital Confinement Indemnity Insurance Health Screening Individual Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.
Health screening. .............................................................................. $_____________ Maximum of one health screening test per covered person per calendar year; subject to a 30-day waiting period
Blood test for triglycerides Bone marrow testing Breast ultrasound CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) CEA (blood test for colon cancer) Carotid Doppler
Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy
Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy
For more information, talk with your benefits counselor.
Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels
ColonialLife.com
Waiting period means the first 30 days following any covered person’s policy coverage effective date, during which no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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IMB7000 – HEALTH SCREENING BENEFIT | 5-16 | 101579-1
Hospital Confinement Indemnity Insurance Medical Treatment Package
The medical treatment package for Individual Medical BridgeSM coverage can help pay for deductibles, co-payments and other out-of-pocket expenses related to a covered accident or covered sickness. The medical treatment package cannot be paired with Plan 1. Air ambulance. ............................................................................................. $1,000 Maximum of one benefit per covered person per calendar year
Ambulance..................................................................................................... $100 Maximum of one benefit per covered person per calendar year
Appliance. ...................................................................................................... $100 Maximum of one benefit per covered person per calendar year
Doctor’s office visit. ................................................................................... $25 per visit Maximum of three visits per calendar year for named insured coverage or maximum of five visits per calendar year for all covered persons combined
Emergency room visit.............................................................................. $100 per visit
For more information, talk with your benefits counselor.
Maximum of two visits per covered person per calendar year
X-ray. ................................................................................................ $25 per benefit Maximum of two benefits per covered person per calendar year
THIS POLICY PROVIDES LIMITED BENEFITS.
ColonialLife.com
EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-VA. This is not an insurance contract and only the actual policy provisions will control.
©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
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IMB7000 – MEDICAL TREATMENT PACKAGE | 9-16 | 101596-VA
Hospital Confinement Indemnity Insurance Optional Riders Individual Medical BridgeSM offers two optional benefit riders – the daily hospital confinement rider and the enhanced intensive care unit confinement rider. For an additional cost, these riders can help provide extra financial protection to help with out-of-pocket medical expenses.
Daily hospital confinement rider. ................................................................. $100 per day Per covered person per day of hospital confinement Maximum of 365 days per covered person per confinement
Enhanced intensive care unit confinement rider............................................... $500 per day Per covered person per day of intensive care unit confinement Maximum of 30 days per covered person per confinement
Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.
For more information, talk with your benefits counselor.
EXCLUSIONS
ColonialLife.com
We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the rider. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000 and R-EIC7000 (including state abbreviations where used, for example: R-DHC7000-TX and R-EIC7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy or rider provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 6-16 | 101582-1
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Term Life Insurance Life insurance protection when you need it most Life insurance needs change as life circumstances change. You may need different coverage if you’re getting married, buying a home or having a child. Term life insurance from Colonial Life provides protection for a specified period of time, typically offering the greatest amount of coverage for the lowest initial premium. This fact makes term life insurance a good choice for supplementing cash value coverage during life stages when obligations are higher, such as while children are younger. It’s also a good option for families on a tight budget — especially since you can convert it to a permanent cash value plan later.
With this coverage: n A beneficiary can receive a benefit that is typically free from income tax. n The policy’s accelerated death benefit can pay a percentage of the death benefit if the covered person is diagnosed with a terminal illness. n You can convert it to a Colonial Life cash value insurance plan, with no proof of good health, to age 75. n Coverage is guaranteed renewable up to age 95 as long as premiums are paid when due. n Portability allows you to take it with you if you change jobs or retire.
Talk with your Colonial Life benefits counselor to learn more.
ColonialLife.com
Spouse coverage options
Dependent coverage options
Two options are available for spouse coverage at an additional cost:
You may add a Children’s Term Life Rider to cover all of your eligible dependent children with up to $20,000 in coverage each for one premium.
1. Spouse Term Life Policy: Offers guaranteed premiums and level death benefits equivalent to those available to you –whether or not you buy a policy for yourself. 2. Spouse Term Life Rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).
The Children’s Term Life Rider may be added to either the primary or spouse policy, not both.
If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 7-19 | NS-16570-1
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Whole Life Plus Insurance
You can’t predict your family’s future, but you can be prepared for it.
ADVANTAGES OF WHOLE LIFE PLUS INSURANCE
Give your family peace of mind and coverage for final expenses with Whole Life Plus insurance from Colonial Life.
• P ermanent coverage that stays the same through the life of the policy
BENEFITS AND FEATURES Choose the age when your premium payments end — Paid-Up at Age 70 or Paid-Up at Age 100 Stand-alone spouse policy available even without buying a policy for yourself Ability to keep the policy if you change jobs or retire Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness2 Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses
• Premiums will not increase due to changes in health or age • Accumulates cash value based on a non-forfeiture interest rate of 3.75%1 • Policy loans available, which can be used for emergencies • Benefit for the beneficiary that is typically tax-free
Provides cash surrender value at age 100 (when the policy endows)
ADDITIONAL COVERAGE OPTIONS Spouse term rider Cover your spouse with a death benefit up to $50,000, for 10 or 20 years. Juvenile Whole Life Plus policy Purchase a policy (paid-up at age 70) while children are young and premiums are low — whether or not you buy a policy for yourself. You may also increase the coverage when the child is 18, 21 and 24 without proof of good health. Children’s term rider
Your cost will vary based on the amount of coverage you select.
You may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term rider may be added to either your policy or your spouse’s policy — not both.
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WHOLE LIFE PLUS (IWL5000)
Benefits worksheet For use with your benefits counselor How much coverage do you need?
YOU $________________________ Select the option:
Paid-Up at Age 70 Paid-Up at Age 100
Accidental death benefit rider The beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.
SPOUSE $___________________
Chronic care accelerated death benefit rider
Select the option:
If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.2 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.
Paid-Up at Age 70 Paid-Up at Age 100
DEPENDENT STUDENT
$_____________________________ Select the option:
Paid-Up at Age 70 Paid-Up at Age 100
Select any optional riders:
ADDITIONAL COVERAGE OPTIONS (CONTINUED)
Spouse term rider $ _____________face amount for _________-year term period
Children’s term rider $ ______________ face amount
Accidental death benefit rider Chronic care accelerated death benefit rider
Critical illness accelerated death benefit rider
Guaranteed purchase option rider
Waiver of premium benefit rider
Critical illness accelerated death benefit rider If you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.2 A subsequent diagnosis benefit is included. Guaranteed purchase option rider This rider allows you to purchase additional whole life coverage — without having to answer health questions — at three different points in the future. The rider may only be added if you are age 50 or younger when you purchase the policy. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options. Waiver of premium benefit rider Premiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.
1. Accessing the accumulated cash value reduces the death benefit by the amount accessed, unless the loan is repaid. Cash value will be reduced by any outstanding loans against the policy. 2. Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.
To learn more, talk with your benefits counselor.
EXCLUSIONS AND LIMITATIONS: If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC19IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-RIWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/RIWL5000-GPO. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.
ColonialLife.com
© 2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES
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6-21 | 642298
COMPREHENSIVE, AFFORDABLE
AND
IN DEMAND
OUR MISSION. OUR CLIENTS. OUR SERVICES. >> For more than 25 years, Legal Resources has been a group legal plan provider to employers. >> Today, over 700 employer groups offer the Legal Resources plan. >> Our benefit is designed to provide 100% coverage for the most often utilized legal services and covers the participating employee, spouse, and qualifying dependent children.
100% COVERED SERVICES INCLUDE: Wills and Estate Planning
Consultation and Advice
Criminal Law
Real Estate Transactions
Billing Disputes
Preparation of Legal Documents
Traffic Court Representation
Elder Law
Identity Theft Assistance
Family Law
Civil Actions
And Much More...
OUR PROVIDER NETWORK >> Our members have access to a network of top-rated full service law firms in their area, with over 13,000 attorneys nationwide. >> Members choose their law firm from our industry-leading provider network.
PLAN HIGHLIGHTS
Voluntary or employer paid benefit for employees. Nationwide 800.728.5768
Virginia Beach, VA. v080818
757.498.1220
Plan can’t be used against the employer.
Dedicated Account Management Team provides ongoing, on-site support year-round.
PUT THE LEGAL RESOURCES PLAN To Work for You and Your Employees 57
ADD-ON pro-active identity theft monitoring also available. Richmond, VA. 804.897.1700
Bethesda, MD. 301.354.9490
FULLY COVERED SERVICES LEGAL RESOURCES COVERS 100% OF THE ATTORNEY FEES FOR FULLY COVERED LEGAL SERVICES General Advice and Consultation
Wills and Estate Planning
• U nlimited in-person or telephone advice and consultation for fully covered services
• Will preparation and periodic updates • Advance medical directive • Financial powers of attorney • Contingent trust for minor children
Family Law • Uncontested domestic adoption • Uncontested divorce • Uncontested name change
Elder Law • Estate advice • P owers of attorney for members’ parents
Preparation and Review of Routine Legal Documents • U nlimited pages and occurrences
Real Estate • P urchase, sale, or refinance of primary residence • Deed preparation • Tenant-Landlord matters • L andlord-Tenant consultation
Traffic Violations • Traffic infractions and misdemeanors • Speeding • Reckless driving • D riving under the influence
Consumer Relations and Credit Protection • Warranty disputes • B illing disputes • Collection agency harassment
1st Offense
Criminal Matters
Civil Actions
• Defense of misdemeanor •M isdemeanor defense of juveniles
• Representation as defendant • Representation as plaintiff • Insurance matters • I nitial administrative hearing • S mall Claims Court advice
Fully covered for first offense involving alcohol or illegal drugs
Identity Theft • Prevention assistance • Education services • Identity recovery assistance
Don’t see your legal need listed?
You’re still covered!¹
The Legal Resources Plan offers a 25% discount on less common legal needs, such as...
Immigration
Tax Law Issues
Small Business Matters
Bankruptcy
Felonies
Including pre-existing legal matters and much more... Legal Resources Employee + Family
Per Month $17.00
This SUMMARY OF COVERAGE is intended to provide a broad general overview of plan coverage and is not a contract. Coverage may vary by organization. For specific coverage questions, please call Member Services at 800.728.5768. Member is responsible for all non-attorney costs such as filing fees, court costs, fines, etc. 1 Since your employer is the participating sponsor, you may not use the Plan in a dispute with your employer.
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ADDITIONAL BENEFITS THE HSASTORE
HEALTH SAVINGS WITH ZERO GUESSWORK
Your Health, Simplified
Everyday health and wellness essentials all in one place and guaranteed eligible. Pierce Group Benefits partners with the HSAstore to provide one convenient location for Health Savings Account holders to maximize their long-term health savings and help ease the financial burden of medical needs, should they arise. Through our partnership, we’re also here to help answer the many questions that come along with having a Health Savings Account! – The largest selection of guaranteed HSA-eligible products – Phone and live chat support available 24 hours a day / 7 days a week – Fast and free shipping on orders over $50 – Use your HSA card or any other major credit card for purchases
Other Great FSAstore Resources Available To You
– Eligibility List: A comprehensive list of eligible products and services – HSA Calculator: Estimate how much you can save with an HSA – Learning Center: Easy tips and resources for living with an HSA – Savings Center: Where you can save even more on HSA-eligible essentials – HSAPerks: Take your health and funds further with the HSAstore rewards program
Shop HSA Eligible Products Through Our Partnership with The HSA Store! BONUS: Get $20 off any order of $150+ with code PGB20HSA (one use per customer).
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Required Notices Newborn and Mothers’ Health Protection Act Group health plans and health insurance issuers generally may not, under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
Women’s Health and Cancer Rights Act In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully. As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits: 1. All stages of reconstruction of the breast on which the mastectomy has been performed: 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prostheses and treatment of physical complications of the mastectomy , including lymphedemas. Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan.
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Required Notices Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employersponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). COLORADO – Health First Colorado (Colorado’s Medicaid If you live in one of the –following ALABAMA Medicaid states, you may be eligible for assistance paying your Program) & Child Health Plan Plus (CHP+) employer health plan premiums. The following Health list ofFirst states is Website: current as of July 31, 2020. Colorado Contact your State for more information on eligibility – https://www.healthfirstcolorado.com/
Website: http://myalhipp.com/ Phone: 1-855-692-5447
ALASKA – Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx ARKANSAS – Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) CALIFORNIA – Medicaid Website:
https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx
Phone: 916-440-5676
Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-healthplan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/healthinsurance-buy-program HIBI Customer Service: 1-855-692-6442 FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery. com/hipp/index.html Phone: 1-877-357-3268 GEORGIA – Medicaid Website: https://medicaid.georgia.gov/health-insurancepremium-payment-program-hipp Phone: 678-564-1162 ext 2131 INDIANA – Medicaid Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584
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Required Notices IOWA – Medicaid and CHIP (Hawki)
Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563
MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084
KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884
NEBRASKA – Medicaid
Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178
KENTUCKY – Medicaid Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov
NEVADA – Medicaid
Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900
LOUISIANA – Medicaid Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)
NEW HAMPSHIRE – Medicaid Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext 5218
MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/publicassistance/index.html Phone: 1-800-442-6003 TTY: Maine relay 711
NEW JERSEY – Medicaid and CHIP
Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710
MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840
NEW YORK – Medicaid Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831
MINNESOTA – Medicaid
NORTH CAROLINA – Medicaid
Website: https://mn.gov/dhs/people-we-serve/children-andWebsite: https://medicaid.ncdhhs.gov/ families/health-care/health-care-programs/programs-andservices/medical-assistance.jsp [Under ELIGIBILITY tab, see “what Phone: 919-855-4100 if I have other health insurance?”] Phone: 1-800-657-3739
MISSOURI – Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005
NORTH DAKOTA – Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825
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Required Notices OKLAHOMA – Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742
OREGON – Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HI PP-Program.aspx Phone: 1-800-692-7462 RHODE ISLAND – Medicaid and CHIP
UTAH – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669 VERMONT– Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 VIRGINIA – Medicaid and CHIP Website: https://www.coverva.org/hipp/ Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282
WASHINGTON – Medicaid
Website: http://www.eohhs.ri.gov/ Website: https://www.hca.wa.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line) Phone: 1-800-562-3022 SOUTH CAROLINA – Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS – Medicaid Website: http://gethipptexas.com/ Phone: 1-800-440-0493
WEST VIRGINIA – Medicaid Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447) WISCONSIN – Medicaid and CHIP Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002 WYOMING – Medicaid Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
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General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction You are receiving this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • •
Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct.
If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • • • • • •
The parent-employee dies; The parent-employee’s hours of employment are reduced; The parent-employee’s employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a “dependent child.”
Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Hopewell City Public Schools, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).
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For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Missy Shores at Hopewell City Public Schools. Applicable documentation will be required i.e. court order, certificate of coverage etc. How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov. Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan Contact Information Hopewell City Public Schools Attn: Missy Shores, Human Resources 103 N 12th Street Hopewell, VA 23860 Phone: 804-541-6400 COBRA Administrator for Health, Dental and Vision Coverage PO Box 269009 Plano, TX 75026
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Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives. Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments. Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by those laws. This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202. You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, or Conservator. ________________________ (Printed name of individual subject to this disclosure)
_____________ (Social Security Number)
___________________ (Signature)
________________ (Date Signed)
If applicable, I signed on behalf of the proposed insured as __________________________ (indicate relationship). If legal Guardian, Power or Attorney Designee, or Conservator.
________________________________ (Printed name of legal representative)
_____________________________ (Signature of legal representative)
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___________ (Date Signed)
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YES! I want to keep my Colonial Life Coverage. My premiums are no longer being payroll-deducted.
Complete this form and mail it today — along with a check for your premium payment. Name: ____________________________________ Daytime Telephone Number: (______) ________________________ Mailing Address: ____________________________ Social Security Number or Date of Birth:_____________________ City: ______________________________________ State:_______________________ Zip: _____________________ Policy number(s) to be continued: ______________________,
______________________,
______________________,
______________________,
Which Colonial Life & Accident Insurance do you want to continue? (check one or more) Accident
Disability
Hospital Income
Cancer or Critical Illness
Life
Please choose one of the following payment options:
M 1. Deduct premiums monthly from my bank account. M 1st-5th M 6th-10th M 11th-15th M 16th-20th M 21st-26th Your draft will occur on one of the dates within the range you have selected. Please include a voided check or Routing #____________________________ and Account #________________________________
_______________________________ Signature of bank account owner
M 2. Bill me directly. (choose one of the following) M Quarterly
(Submit a payment 3 times your monthly premium)
Date: ____________________
M Semi-annually
(Submit a payment 6 times your monthly premium)
M Annually
(Submit a payment 12 times your monthly premium)
Policy Owner’s Signature:______________________________________________
Return To: Colonial Life & Accident Insurance Company P.O. Box 1365 Columbia, South Carolina 29202 1.800.325.4368 (phone) 1.800.561.3082 (fax)
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 10-16
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CONTACT INFORMATION: FLEX FACTS - DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
ANTHEM - HEALTH INSURANCE • • • •
Customer Service: 1-833-621-0308 LiveHealthOnline: www.livehealthonline.com or 1-844-784-8409 24/7 NurseLine: 1-800-337-4770 Website: www.anthem.com
ANTHEM - HEALTH SAVINGS ACCOUNT Contact Member Services anytime at the number on the back of your ID card or HSA debit card.
SUN LIFE - DENTAL INSURANCE
• Customer Service: 1-877-943-2287 • Website: www.FlexFacts.com • Claims Mailing Address: 1200 River Avenue, Suite 10E Lakewood, NJ 08701
MANAGE YOUR ACCOUNT ONLINE OR DOWNLOAD THE FLEX FACTS MOBILE APP • • • •
• Customer Service: 1-800-247-6875 • Website: www.sunlife.com/us
LEGAL RESOURCES - PRE-PAID LEGAL
UNITEDHEALTHCARE - VISION INSURANCE
• Customer Service: 1-800-728-5768 • Website: www.legalresources.com
• Customer Service: 1-800-638-3120 • Website: www.myuhcvision.com
TO VIEW YOUR BENEFITS ONLINE
ANTHEM - EMPLOYEE ASSISTANCE PROGRAM • Customer Service: 1-800-346-5484 • Website: www.anthemEAP.com
Check your Balance Submit and View Claims Check Claim Status Upload and Store Receipts
Visit www.piercegroupbenefits.com/
hopewellcitypublicschools
For additional information concerning plans offered to employees of Hopewell City Public Schools, please contact our Pierce Group Benefits Service Center at 1-800-387-5955
COLONIAL LIFE VISIT COLONIALLIFE.COM TO SET UP YOUR PERSONAL ACCOUNT • Website: www.coloniallife.com • Claims Fax: 1-800-880-9325
• Customer Service & Wellness Screenings: 1-800-325-4368 • TDD for hearing impaired customers call: 1-800-798-4040
If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 18 months, you need the name and date of the test performed as well as your doctor’s name and phone number. Colonial also needs to know if this is for you or another covered individual and their name and social security number. You may: • FILE BY PHONE! Call 1-800-325-4368 and provide the information requested by Colonial’s Automated Voice Response System, 24 hours per day, 7 days a week, or • SUBMIT ON THE INTERNET using the Wellness Claim Form at www.coloniallife.com, or • Write your name, address, social security number and/or policy/certificate number on your bill and indicate “Wellness Test.” Fax this to Colonial at 1-800-880-9325 or MAIL to PO Box 100195, Columbia, SC 29202 If your Wellness/Cancer Screening test was more than 18 months ago, you must fax or mail Colonial a copy of the bill or statement from your doctor indicating the type of procedure performed, the charge incurred and the date of service. Please write your full name, social security number, and current address on the bill. Please Note: If your cancer policy includes a second part to the screening benefit, bills for tests covered and a copy of the diagnostic report (reflecting the abnormal reading of your first test) must be mailed or faxed to us for benefits to be provided.
When you terminate employment, you have the opportunity to continue your Colonial coverage either through direct billing or automatic payment through your bank account. Please contact Colonial at 1-800-325-4368 to request the continuation of benefits form.