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Port Lavaca Clinic 2024-2025Benefits Guide
HOWTOENROLLYouwillbeabletocompleteyourenrollmentbyfollowingthestepslistedbelow. ENROLLMENTOPTIONS 01You canenrollindependently throughouronline EnrollmentPlatform. Logininstructionsareincludedon the nextpage.02YoucanmeetwithanenrolleronINSERT DATE HERE between10amand5pm.
_________________________________EMPLOYEE BENEFITS: HOWTO LOGINTOBERNIE PORTALACCOUNTBelow are the instructions for how to login both with and without an email address:How to login with email:Go to: https://www.bernieportal.com/en/loginEmployee default logins:Username: email addressPassword: Selecttheforgotpasswordoption ifyou donotrememberorhavenotsetoneupbefore.ORHow to login without email:https://www.bernieportal.com/en/emplovercode/loginEmployee code logins:2-digit code: 2-digit birth month (Example:March=03)4-digit code: last 4 of socialEmployer code:____________Port Lavaca Clinice7ca83
____________________________________________thrivesonbalance–balancingprofessionalandpersonalworlds–balancingworkandrest–whilealwaysbalancingcostandvalue.Wealsounderstandthatbalancemustbeindividualized.Whatisrightforonepersonmaynotbeappropriateforanother.Itisourgoaltoofferchoicesallowingyoutotailoryourbenefitsplanspecificallytowhatisbestforyouandyourfamilymembers.YourChoices___ Providesacompletepackageofbenefitsaimedatprovidingflexibleinsuranceprotectionandprogramstomeetyourever-changingneeds.___ sharesthecostofsomebenefitswithyou,whilemakingadditionalbenefitsavailablethatyoupayforifyouchoosetoenroll.Thepartofthebenefitcoststhatyouareresponsibleforwillbeautomaticallydeductedfromyourpaycheck,eitherbeforeorafteryourtaxesarecalculated.BenefitPre-TaxorPostTaxWhopaysthecost?WhydoIpayforsomebenefitswithbefore-taxmoney?Whilenotallbenefitsqualifyforpre-taxcontribution,thereisadefiniteadvantagetopayingforthosethatdo:Takingthemoneyoutbeforeyourtaxesarecalculatedlowerstheamountofyourtaxableincome.Therefore,youpaylessintaxes.HowYourBenefitsWorkFull-timeemployeesareeligibleformostbenefitson_____________________________________ofhire.MakingChangesGenerally,youcanonlychangeyourbenefitschoicesduringtheannualBenefitsEnrollmentPeriod.However,youcanchangeyourbenefitschoicesduringtheyearifyouhavealifeeventchange.Lifeeventchangesincludebutarenotlimitedto:· Marriage· Divorce· Birth,adoption,orplacementforadoptionofaneligiblechild· Deathofyourspouseorcoveredchild· Changeinyouoryourspouse’sworkstatusthatresultsincancellationofyourbenefits· BecomingeligibleforMedicareorMedicaidduringtheyearIfyouhavealifeeventchange,youmustnotifyHumanResourceswithin31daysofthechange(forexample,amarriageorbirthcertificate).Ifyoudo notnotifyHumanResourceswithin31days,youwillhavetowaituntilthenextannualOpenEnrollmentperiodtomakebenefitschangesunlessyouhaveanotherlifeeventchange.Anychangesyoumaketoyourbenefitchoicesmustbedirectlyrelatedtothelifeeventchange.Port Lavaca ClinicPort Lavaca ClinicPort Lavaca Clinicthe first day of the month following 30 daysPort Lavaca ClinicPre-Tax Employer SharedPre-Tax Employee PaidPre-Tax Employee PaidPost-Tax Employee PaidPost-TaxPost-TaxEmployee PaidPost-Tax Employee PaidEmployee PaidPost-Tax Employee PaidEmployee PaidPost-TaxHealth InsuranceLong Term DisabilityDental InsuranceAccidentVision InsuranceVoluntary Life InsuranceHospital IndemnityShort Term DisabilityCritical Illness
PortabilityIfyouleavethecompany,someofyourbenefitsendandsomeofyourbenefitsareportable.Thismeansyoucantakethemwithyouifyouleave,aslongasyoucontinuetopaythepremiumsyourself.Onceterminated,youwillbenotifiedthroughthemailifanyofyourbenefitsareportable.WhenCoverageEndsBenefitsendonthelastdayofthemonthfollowingterminationorwhenyouceasetomeeteligibilityguidelines. Lookingahead……Nowlet’slookateachbenefitthatmakesupthebenefitsprogram.Inthefollowingpages,you’lllearnmoreaboutthevaluablebenefitsyouremployeroffers.You’llalsoseehowchoosingtherightcombinationofbenefitscanhelpprotectyouandyourfamily’shealth.NOTES:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Continuing Your CoverageUndercertaincircumstances,youmay continue yourhealthcarecoveragewhenitwouldotherwiseend.ThisiscalledCobraappliestotheseplans:· HealthInsurance· DentalInsurance· VisionInsuranceWhencan I continue coverage under____________________?Youand/oryourdependentsareeligibletocontinuehealthcarecoverageunder________________________If coverageislostbecause:· Your employment endsforanyreasonother than“grossmisconduct”.· Yourworkhours are significantlyreduced.· Youdie.· Youbecome entitled toandenrollinMedicarepriortolosingcoverage.· Youdivorceorbecomelegallyseparatedfromyourspouse.· Yourdependentlosesdependentstatus.________________CobraCobraCobraPort Lavaca Clinic
CarrierPlan NameNetworkInCoverageOutInOutDeductible$12,000 $12,000$6,000$6,000Family Deductible$24,000$24,000 $12,000$12,000Coinsurance50%100%50%100%Out-Of-Pocket$16,300($32,600)$8,150 ($16,300)$24,000 ($48,000)$6,000 ($12,000)Office Visit50% After Ded.$25 Copay50% After Ded.100% After Ded.Specialty Doctor Office Visit50% After Ded.$75 Copay50% After Ded.100% After Ded.Inpatient Hospital Services50% After Ded.100% After Ded.50% After Ded.100% After Ded.Preventative Lab & X-Ray50% After Ded.No Charge50% After Ded.No ChargeAdvanced Imaging50% After Ded.100% After Ded.50% After Ded.100% After Ded.Urgent Care50% After Ded.$50 Copay50% After Ded.100% After Ded.Emergency RoomRXSemi-MonthlyBi-WeeklySemi-MonthlyBi-Weekly$155.29$143.35$142.81$131.82$349.98$323.05$320.77$296.10$296.22$273.43$271.63$250.74$492.36$454.48$450.92$416.23$300/visit + Ded.100% After Ded.P6000i100LX21BChoice Plus PPOHPVV600021BChoice Plus HSA PPO100% After Ded.100% After Ded.Employee Rates per pay period Employee Only Employee + Spouse Employee + Child(ren)Employee + Family
Group DentalClassAll Eligible EmployeesPlan design and ratesPlan design summaryDental plan overviewEligible Employees:Effective Date: May 1, 2023Plan type PPODental PPO Network Sun Life Dental NetworkSMIn-NetworkReimbursementSun Life Dental NetworkSMOut-of-NetworkReimbursement90th Percentile of the Usual and Customary ChargeOrthodontic coverage(Type IV)This plan includes Child Only Orthodontic coverage.A person must be covered under a Dental Plan to be eligible for OrthodonticcoverageDependent CoverageChildrenChildren to age 26Open enrollment at Issueand each AnnualEnrollmentYesEmployee coveragecontributionsEmployee pays for a portion or all of the cost of Employee coverageDependent coveragecontributionsEmployee pays for a portion or all of the cost of Dependent coverageThe listed coinsurance percentages shown below represent the portion of Sun Life’s allowable charge for which theplan will be responsible. Network providers agree to accept the network's allowable charge for covered services aspayment in full. If covered employees or their eligible dependents receive services from a non-network provider,Sun Life will apply the coinsurance percentages shown below to 90th Percentile of the usual and customary chargefor covered services and they will be responsible for the difference up to the provider’s charge.All Full-Time United States Employees working in the United States who are scheduled to work a minimum of 30 hours per week Group Dental
Calendar Year DeductibleProcedure Type In-Network Deductible Out-of-Network DeductibleType I Preventive Services Not applicableType II Basic Services$50 individual / $150 family $50 individual / $150 familyType III Major ServicesType IV Ortho Services Not applicableDeductible values are combined between In-Network and Out-of-Network.CoinsuranceIn-Network Out-of-NetworkType I Preventive Services 100% 100%Type II Basic Services 80% 80%Type III Major Services 50% 50%Type IV Ortho Services 50% 50%Benefit Waiting Periods• A Late Entrant Benefit Waiting Period of 6 months for Type II Basic Restorations, 12 months for all otherType II Basic Services, and 12 months for Type III Major Services will apply to employees who enroll in thisdental plan more than 31 days after becoming eligible.• A Late Entrant Benefit Waiting Period of 12 months for Type IV Orthodontic Services will apply to employeeswho enroll in this dental plan more than 31 days after becoming eligible.Calendar Year Maximum BenefitIn-Network Out-of-NetworkTypes I, II and III(Preventive, Basic andMajor) Services$1,500 per person $1,500 per personType IV Ortho Services$1,500 lifetimeper child under age 26$1,500 lifetimeper child under age 26
Covered expensesType I Preventive covereddental expensesCoverage limitationsOral Evaluations 2 in any 12 consecutive monthsDental Prophylaxis(Cleanings)2 per 12 months - is limited to 2 of these services in any 12 consecutive monthperiodFluoride TreatmentsCovered Persons under age 141 in any 6 consecutive monthsSealantsCovered Persons under age 14Once per tooth per 36 consecutive months on permanent first and second molarsBite-Wing X-Rays 1 in 12 consecutive monthsIntraoral X-Rays 4 Films in any 12 month periodType II Basic covereddental expensesCoverage limitationsFull Mouth X-Rays 1 in 24 consecutive monthsPalliative TreatmentPaid as a separate benefit only if no treatment, except x-rays, was rendered duringthe visitSimple Extractions No LimitationAmalgam Restorations Once per tooth surface in any 24 consecutive monthsComposite and SilicateRestorationsOnce per tooth surface in any 24 consecutive months and excluding posterior teethSpace MaintainersCovered Persons under age 19Once per tooth in any 3 year periodType III Major covereddental expensesCoverage limitationsInlays and OnlaysCovered if tooth cannot be restored by fillingsOnce per tooth in any 10 years periodCrownsCovered if tooth cannot be restored by filling or other meansOnce per tooth in any 10 years periodCrown Buildup Once per 10 yearsFull or Partial Dentures Once in any 10 yearsFixed Bridges Once in any 10 yearsPeriodontal MaintenancePeriodontal Maintenance following active Periodontal Therapy -2 per 12 months.Periodontics (Non-Surgical):Scaling and Root PlaningOnce per 24 consecutive months per area of the mouthSurgical Periodontics Once per 36 consecutive months per area of the mouthEndodontics:Root Canal TherapyRoot Canal Therapy is limited to 1 time per tooth in any consecutive 24 monthsperiodOral Surgery:Surgical Extraction ofErupted and Impacted TeethMultiple surgical services on 1 area of the mouth will be based on the most inclusiveprocedureGeneral AnesthesiaBenefits payable as a separate expense only when required for the surgicalextraction of an impacted tooth
Type IV Orthodonticcovered expensesCoverage limitationsOrthodontic TreatmentOrthodontic treatment is limited to the Dependent Children or student age listedaboveDental rates and premiumMonthly RateEmployee only $27.93Employee + spouse $54.99Employee + child(ren) $70.80Employee + Family $105.81
Group VisionVision Insurance Schedule - Full ServiceBenefitFrequencyIn-Network Member CostOut-of-Network BenefitExam ServicesWellVision Exam®1 per 12 months$10Up to $45Laser Vision CorrectionDiscountOnce per eye per lifetime·Average 15% off theregular price or 5% off thepromotional price.·Discounts only availablefrom contracted facilities.N/ALensesSingle LinedBifocal LinedTrifocalLenticularNecessary Contacts1 per 12 months$25(lenses and frame)Up to $30Up to $50Up to $60Up to $100Up to $210Lens EnhancementsStandard progressivePremium progressiveCustom progressiveNo cost$95 - $105 copay$150 - $175 copayAverage savings of 20-25%on other lens enhancementsN/AFramesIncludes a wide selection offrames at Walmart®.1 per 24 months·$150 for the frame ofyour choice and 20% offthe amount over yourallowance·$80 allowance atCostco®*Up to $70Elective Contact LensesContact lenses are in place oflenses and frame.1 per 12 months·Up to $60 / 15% savingsfor your contact lensexam (fitting andevaluation)·$150 for contact lensesUp to $105Additional Glasses andSunglasses Discount20% off additional glasses and sunglasses, including lensoptions, from the same VSP doctor on the same day as yourexam. Or get 20% off from any VSP doctor within 12 months ofyour last exam.N/ACoverage with RetailProviders*Coverage with retail providers may be different. Check withCostco® and Walmart®for VSP member pricing. The Costcoallowance is equivalent to the allowance at preferred providersand other retail providers. Group Vision
Vision Rates and PremiumEmployee only Employee + spouse Employee + child(ren)Employee + family Monthly Rate$8.79$15.74$17.41$26.52
Voluntary Life and AD&D Plan DesignPLAN ELEMENTClass 1ALL ACTIVE FULL TIME EMPLOYEESBenefit amountIncrements of $10,000Maximum benefit5 times BAE up to $300,000Guaranteed issue amount$100,000AD&D Benefit amountSame as Voluntary Life benefitAD&D Maximum benefitSame as Voluntary Life benefitAD&D Minimum benefitSame as Voluntary Life benefitContributionsContributoryParticipation requirement41% of eligible employeesPLAN ELEMENTClass 1ALL ACTIVE FULL TIME EMPLOYEESSpouse Benefit amountIncrements of $5,000Spouse Maximum amount100% of Employee Voluntary Amount up to $100,000Spouse GI Amount$25,000Spouse Term ageN/AChild benefit6 mo or olderIncrement of$2,000birth to <6 mo$1,000Child Maximum benefit50% of Employee Voluntary Amount up to $10,000Child eligibilityUnmarried dependent children from birth to age 21 or to age 25 if a full-time studentParticipation requirementMinimum of 10 employees electing spouse coverageVoluntary Life and AD&D Plan Design - Dependent Voluntary Life and AD&D
Plan Design SummaryPlan 1Included BenefitsLife waiver of premiumLife waiver of premium | Included - premium is waived to age 67 if disabled prior to age 60; with no elimination period to satisfyContinuation of Life coverageLayoff or leave of absence - up to 2 monthsSabbatical - up to 12 monthsInjury/Sickness - up to 12 monthsEmployees who are insured for life and LTD with SLF/MGIS, and who do not qualify for life waiver, may continue their life coverage, with premium payment, if they are receiving an LTD benefit from Sun LifeAccelerated Death benefitUp to 75% of benefit to maximum of $500,000PortabilityIncludedConversionIncludedEmployee age reductionsAge 65: 65% of pre-65 benefit.Age 70: 50% of pre-65 benefit.Spouse age reductionsAge 65: 65% of pre-65 benefit.Age 70: 50% of pre-65 benefit.Special AD&D benefit: Air Bag benefit10% of AD&D benefit to a maximum of $5,000 Child Care benefit2% of AD&D benefit to a maximum of $2,000 Dependent Child Education benefit3% of AD&D benefit to a maximum of $2,500 Dependent Spouse Education benefitUp to a maximum of $3,000 Seat Belt benefit25% of AD&D benefit to a maximum of $25,000
Plan Design SummaryPlan 1Voluntary Life and AD&D RatesAGE BANDEmployee Rate per $1,000Spouse Rate per $1,0000-19$0.029$0.03820-24$0.029$0.03825-29$0.029$0.03830-34$0.059$0.08035-39$0.089$0.12040-44$0.130$0.16045-49$0.230$0.30050-54$0.390$0.58055-59$0.600$1.00060-64$0.900$1.60065-69$1.000$1.80070-74$1.500$2.00075-79$1.500$2.00080-84$1.500$2.00085+$1.500$2.000Child life rate per $1000$0.200Employee AD&D rate per $1000$0.030Spouse AD&D rate per $1000$0.030Child AD&D rate per $1000$0.050
Accident insuranceSun Life’s Accident Plan provides accident insurance protection for a wide range of covered benefits.Injured employees and their dependents may use the cash benefits however they want—to satisfydeductibles, pay out-of-pocket medical expenses, or pay household bills, for example. Here are somehighlights:·Guaranteed Issue.·A Wide Range of Covered Benefits: Benefits for injuries are payable once for each coveredaccident (unless stated otherwise in the certificate), and benefits for hospital stays and related careare payable up to a specific number of days or visits for each covered accident.·Categories of Coverage:·For Injuries:Insureds will receive a payment for covered dislocations, fractures, lacerations,burns, and other injuries.·For Diagnosis and Services: Insureds will receive a payment for related covered medicalservices (ranging from X-rays to office visits), hospital services (including emergency roomadmissions and ambulance rides), surgeries and emergency dental (crown and extraction).·For Loss: The plan includes accidental death and dismemberment coverage and pays benefitsfor loss of hearing and for loss of sight occurring as a result of a covered accident.·Coverage for Families: Employees can add coverage for spouses and dependent children.·Wellness screening benefit: To promote healthy lifestyles and early detection, we will payemployees a defined amount, once per calendar year, when we receive proof of an eligible healthscreening, like an electrocardiogram. We may also pay the employee for spouse or child screening(see Plan Design and Rates).·Portable: Employees who terminate employment and who meet other eligibility criteria may applyto port accident insurance.Accident insurance is a limited benefit policy. It provides accident coverage only. It does notprovide basic hospital, basic medical, or major medical insurance. The certificate and its ridershave exclusions and limitations that may affect any benefits payable. Benefits payable are subjectto all terms and conditions of the certificate. The policy, certificate, and any rider may not beavailable in all states.If permitted by the Employer's employee benefit plan and not prohibited by state law, or if the group's situs state is Oregon orWashington, the term “spouse” in this benefit includes any individual who is either recognized as a spouse, a registered domesticpartner, or a partner in a civil union, or otherwise accorded the same rights as a spouse. Group Accident
Accident insurancePlan design and ratesAccident Insurance plan designEligible employees All Full-Time United States Employees working in the United States who arescheduled to work a minimum of 20 hours per weekEffective Date May 1, 2023Participation requirement 5 enrolled employeesClass 1Class description All Eligible EmployeesEligibility Waiting Period First of the month following 30 days of employmentContributions ContributoryMember direct billing Not includedCovered benefitsLife and Dismemberment Losses *Accidental Death $50,000Accidental Death Common Carrier $200,000Catastrophic Loss: Both arms or bothhands, both legs or both feet, one handand one foot or one arm and one leg, orirrecoverable loss of sight of both eyes $25,000One hand, one foot, one leg, one arm $15,000Loss of sight of one eye or loss of oneeye $15,000Two or more fingers or toes $3,000One finger or one toe $1,500Loss of hearing of one ear or loss of oneear $5,000DislocationsOpen ClosedHip $8,000 $4,000Knee, ankle, or bones of the foot $4,000 $1,000Elbow, wrist, Shoulder, Collarbone,bones of the hand or Lower jaw $2,000 $1,000Finger(s) or toe(s) $400 $200
FracturesOpen ClosedHip or thigh $6,000 $3,000Skull-depressed $10,000 $5,000Skull-simple $5,000 $2,500Vertebral processes, Bones of the face,Nose, Upper jaw, upper arm, Lower jaw,Collarbone, Shoulder, Forearm, Hand,Wrist, Foot, Ankle, Kneecap, Elbow orHeel $1,500 $750Leg, Vertebrae or Sternum $3,000 $1,500Pelvis $3,200 $1,600Rib, Finger, Toe or Coccyx $600 $300Multiple ribs $2,000 $1,000Additional InjuriesEye Injury - surgical repair $250Eye Injury - object remove $250Gunshot wound $500Paralysis—paraplegia $25,000Paralysis—quadriplegia $50,000Coma $10,000Concussion $100LacerationsNo sutures and treated by doctor $35Single laceration under 5 cm with sutures $655-15 cm with sutures (total of alllacerations) $250Greater than 15 cm with sutures (total ofall lacerations) $500Burns2nd Degree 3rd Degree20-40 square centimeters $400 $1,00040-65 square centimeters $800 $2,00065-160 square centimeters $1,200 $6,000160-225 square centimeters $1,600 $14,000More than 225 square centimeters $2,000 $20,000Skin graft 50% of the applicable Burn Benefit
Medical ServicesDiagnostic ExamArteriogram, Angiogram, CT, CAT, EKG,EEG, or MRI (1 time per benefit year) $200Diagnostic ExamX-ray (1 time per covered accident) $100Accident Emergency Treatment, non-emergency room (once per coveredaccident) $150Physician's Follow-up Treatment officevisit (per visit, up to 6 times per coveredaccident) $100Physical Therapy (per visit up to 10 visitsper covered accident) $50Medical Devices $500Epidural Pain Management (up to 2times per covered accident) $150Prescription drug $50Prosthesis (one) $500Prosthesis (two) $1,000Blood, Plasma, or Platelet Transfusion $200HospitalHospital Admission (once per benefityear) $2,000Hospital Confinement (per day up to 365days per covered accident) $400Intensive Care Unit Admission (once perBenefit Year; payable instead of HospitalAdmission benefit if Confinedimmediately to ICU) $3,000Intensive Care Unit Confinement (perday up to 14 days, payable in addition toany Hospital Confinement benefit) $500Ambulance (Ground) $400Ambulance (Air) $2,000Emergency Room Admission $200Family Lodging (per day up to 30 daysper benefit year) $100Transportation (100 or more miles up to3 times per covered accident) $500Rehabilitation Unit (per day up to 30days per covered accident) $100SurgeryMiscellaneous Surgery requiring generalanesthesia (not covered by any otherbenefit) $750Open Surgery $2,500Exploratory Surgery or Debridement $500Tendon/Ligament/Rotator Cuff Tear $1,250Torn Knee Cartilage $1,250Ruptured/Herniated Disc $1,250
Emergency DentalEmergency Dental extraction $65Emergency Dental crown $200WellnessWellness Screening Benefit (once perbenefit year) $50Unless otherwise specified, the above benefits will be payable only once for each Covered Accident as applicable.* Life and dismemberment losses: Benefits displayed are payable for the employee only. Spouse benefits are 100% of theemployee benefit amount for death and 100% of the employee benefit amount for dismemberment. Dependent childrenbenefits are 50% of the employee benefit amount for death and 50% of the employee benefit amount for dismemberment.
Accident Plan monthly ratesAccident PlanOff JobEmployee only $10.51Employee and Spouse $17.32Employee and Children $19.93Employee and Family $26.74
Group Critical Illness coverage is underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA)under Policy Form Series 12-GP-01, 12-SD-C-01, 13-SD-C-01, 16-SD-C-01, 15-GP-01, 12-SDPort-C-01, 13-SDPort-C-01, 16-SDPort-C-01, 12-SD-R-01and 13-SD-R-01, subject to state availability.Proposal for Port Lavaca Clinic Associates, P.A.March 1, 2023Case ID: 2160848rev. 06090615 GCIOT-6288Critical IllnessPlan design and ratesEligible employeesMay 1, 2023Effective DateClass 1All Eligible EmployeesClass descriptionCHILDSPOUSEEMPLOYEEBenefit amountBenefit amounts mayrange from $5,000 to$10,000 in $5,000increments.Benefit amounts mayrange from $5,000 to$10,000 in $5,000increments.Amount cannot exceed100% of the employeeamount.Benefit amounts mayrange from $2,500 to$5,000 in $2,500increments.Amount cannot exceed50% of the employeeamount.$5,000$10,000$10,000Guaranteed issue amountFirst of the monthEligibility waiting periodfollowing 30 days ofN/AN/AemploymentContributoryContributoryContributoryContributionsNot includedNot includedNot includedMember direct billing0%0%0%Employer contributionN/AN/A15%Participation requirementN/AN/A5 enrolled employeesPolicy issue requirementClass 1All Eligible EmployeesClass descriptionRecurrenceInitial DiagnosisCore conditions100% of face amount100%Heart attack100% of face amount100%Stroke100% of face amount100%Major organ failure100% of face amount100%End-stage kidney diseaseN/A100%Occupational HIV/Hepatitis B, C, or D25% of face amount25%Coronary artery bypass graft5% of face amount5%AngioplastyCancer conditions100% of face amount100%Invasive cancer25% of face amount25%Non-invasive cancer5% of face amount5%Skin cancerSupplemental conditions option 1N/A100%Complete blindnessN/A100%Loss of speechN/A100%Complete loss of hearingSupplemental conditions option 2N/A100%Benign brain tumorN/A100%ParalysisN/A100%ComaN/A100%Severe burnsAll Full-Time United States Employees working in the United States who are scheduled to work a minimum of 30 hours per week Group Critical Illness
Supplemental conditions option 3Advanced ALS or Lou Gehrig's disease 100% N/AAdvanced Alzheimer's 25% N/AAdvanced Parkinson's 25% N/AChildhood conditions - child onlyDown syndrome 100% N/ACerebral palsy 100% N/ACystic fibrosis 100% N/ACleft lip/palate 100% N/AType 1 diabetes mellitus 100% N/AMuscular dystrophy 100% N/AComplex congenital heart disease 100% N/ASpina bifida 100% N/AWellness benefitAnnual wellness screening benefit Employee: $50Spouse: $50Child: $50Additional Provisions:Additional occurrence waiting period 6 Months between diagnosisMaximum benefit 1 time per conditionRecurrence waiting period 12 monthsCancer recurrence waiting period 12 monthsRecurrence maximum UnlimitedPre-existing conditions limitation 12/12
Critical Illness ratesClass 1Employee benefitAge bandUni-TobaccoMonthly rate*Under age 25 $0.5725-29 $0.6430-34 $0.8335-39 $1.1640-44 $1.6845-49 $2.4050-54 $3.3855-59 $4.3660-64 $5.3365-69 $6.6770-74 $8.8675 and over $11.73Rate basis: Per $1,000 of coverageClass 1Spouse benefitAge band**Uni-TobaccoMonthly rate*Under age 25 $0.5725-29 $0.6430-34 $0.8335-39 $1.1640-44 $1.6845-49 $2.4050-54 $3.3855-59 $4.3660-64 $5.3365-69 $6.6770-74 $8.8675 and over $11.73Rate basis: Per $1,000 of coverage**The employee’s age is used to determine rates.Class 1Child benefitCoverage Monthly rateAll age bands $0.13Rate basis: Per $1,000 of coverageMonthly Wellness Premium(if included in your choice)Monthly add-on rateWellness BenefitEmployee Spouse Child$50 $1.25 $1.25 No charge*The wellness premium will be added to the elected Critical Illness premium amounts.
Hospital IndemnityHelp employees with out-of-pocket medical costs incurred with a hospital stay. Sun Life’s Hospital Indemnity plan providesflexible options that make it easy to meet cost and coverage goals. Employees with hospital stays of 10 days or more mayreceive additional Extended Hospitalization benefits.Here are some benefits available under our Hospital Indemnity plan.You can work with your employee benefitsrepresentative to customize your plan with these benefits. Please refer to the plan design and rates section of thisproposal for the benefits being proposed for your employees. State variations will apply.·No health questions required to enroll.·Covered conditions:Plans can include coverage for hospital confinements due to accident and sickness, mental andnervous disorders, substance abuse, routine pregnancy, and newborn routine care.·Benefit options:Benefits are available for hospital confinements, stays in rehabilitation units, intensive care units,intermediate step down units, emergency room treatment and more.·First Day benefits:Benefits can include a First Day Hospital &/or First Day ICU.·Benefits can add up:Add additional value to your plan by including the option for benefits, such as First Day,Hospital Confinement, or ICU benefits, to be paid on the same day.·Extended Hospitalization benefit:Covered employees and dependents with hospital/ICU confinements of 10consecutive days or more can receive additional benefits for the duration of their confinement.·No lifetime maximums:There is no limit to the number of hospital claims that may be submitted. This may be ofparticular interest to employees with chronic conditions.·Portable:In approved states, employees who terminate employment and who meet other eligibility criteria may applyto port this insurance. In other states, Continuation will be available.·Complements other plans:Hospital Indemnity complements Critical Illness, Cancer and Accident coverage in theirgoal to help protect employees from out-of-pocket medical expenses. Benefits are paid regardless of what othercoverages employees may have.·Wellness Screening Benefit:When included, this benefit can help to promote healthy lifestyles and early detection.We will pay employees a defined amount, once per benefit year, when we receive proof of an eligible health screening(full list enclosed if included). We may also pay the employee for spouse or child screening.Hospital Indemnity Insurance is a limited benefit policy. It does NOT provide basic hospital, basic medical, ormajor medical insurance. It is not a Medicare Supplement policy. The certificate has exclusions, limitations, andbenefit waiting periods for certain conditions that may affect any benefits payable. Benefits payable are subjectto all terms and conditions of the certificate. The policy, certificate and any rider, if applicable, may not beavailable in all states and may vary based on state laws and regulations. Group Hospital Indemnity
Hospital Indemnity insurancePlan design and ratesEligible employeesEffective Date May 1, 2023Policy issue requirement 5 enrolled employeesClass 1Class description All Eligible EmployeesEligibility Waiting Period First of the month following 30 days ofemploymentContributions ContributoryMember direct billing Not includedEmployer contributions Employee: 0%Spouse: 0%Child(ren): 0%Family: 0%First Day BenefitsPayable per benefit yearFirst Day Hospital $500 per day1 dayFirst Day ICU $1,000 per day1 dayConfinement BenefitsPayable per benefit yearHospital Confinement $100 per day30 daysICU Confinement $100 per day15 daysAdditional & Enhanced BenefitsPayable per benefit yearWellness Screening $50 per day1 day per insured per benefit yearCovered ConditionsNewborn Care Complications only; payable underHospital or ICU ConfinementComplications of Pregnancy IncludedNormal Pregnancy IncludedNormal Pregnancy Waiting Period 9 MonthsMental/Nervous IncludedSubstance Abuse IncludedSickness and Accidents Sickness: 24-hour coverage;Accident: 24 Hour coveragePre-existing Condition Limitation Not includedHospital Indemnity monthly ratesAll Full-Time United States Employees working in the United States who are scheduled to work a minimum of 30 hours per weekEmployee only$25.48Employee and Spouse$43.24Employee and Children $37.02Employee and Family $54.78
DefinitionsState variations may apply and not all definitions below may apply to your plan.Benefit year means a calendar year beginning on January 1 of any year and ending on December 31 of that year.Confinement means on the advice of a Physician, the assignment of a person to a bed as a resident inpatient in aHospital for not less than 20 continuous hours. There must be a charge for room and board. The requirement that anInsured be charged for room and board does not apply to confinement in a Veteran’s Administration Hospital or otherfederal government operated Hospital. Observation unit is not covered under First day Hospital Confinement or First DayICU benefit. An Observation Unit stay of 20 hours or more will be covered under the Daily Hospital Confinement Benefit.Confinement does not include that period of time during which an Insured is in a Hospital Emergency Room, ObservationRoom, a freestanding surgical facility or an outpatient facility. Confinement does not include a newborn child’s initialconfinement in a Hospital following birth for routine medical and nursing care, except as specifically provided for in theNewborn Nursery Confinement if covered under your plan.Covered Accident means an Accident that is not excluded by the Policy or applicable riders or endorsements attached toit.Covered Sickness means a Sickness that is not excluded by the Policy or applicable riders or endorsements attached toit.Hospital means a facility licensed in the applicable jurisdiction that provides medical care and Treatment to sick andinjured persons on an Inpatient basis with 24 hour nursing service by or under the supervision of a Physician. Hospitaldoes not include a rest home; a Skilled Nursing Facility; an extended care facility; a place of convalescence; aRehabilitation Unit; a Hospice Facility; a place providing custodial care; a Mental and Nervous Disorder Facility or aSubstance Abuse Facility.Hospital Intensive Care Unit (ICU) means a specifically designated part of a Hospital called an intensive care unit thatprovides the highest level of medical care and is restricted to patients who are critically ill or injured and who requireintensive comprehensive observation and care, including a neonatal intensive care unit specializing in the care of ill orpremature newborn infants; is separate and apart from the surgical recovery room and from rooms, beds and wardscustomarily used for patient confinement; is permanently equipped with special lifesaving equipment for the care of thecritically ill or injured; is under constant and continuous observation by a specially trained nursing staff assignedexclusively to the intensive care unit on a 24 hour basis and has an assigned Physician on a full-time basis.A hospital intensive care unit is not any of the following step-down units: a progressive care unit; an intermediate careunit; a private monitored room; sub-acute intensive care unit or an Observation Unit.Inpatient or Inpatient Treatment means the Insured who receives Treatment as a resident patient using and beingcharged for the room and board facilities of a Hospital. The requirement that an Insured be charged does not apply toconfinement in a Veteran’s Administration Hospital or other federal government operated Hospital.Observation Unit means a specified area within a Hospital, apart from the Emergency Room, where a patient can bemonitored by a Physician and which is under the direct supervision of a Physician or registered nurse; is staffed by nursesassigned specifically to that unit; and provides care seven days per week, 24 hours per day.
An observation unit stay lasting 20 hours or more is treated as a Hospital Confinement.Rehabilitation Unit means a distinct unit within a Hospital that provides rehabilitation care services on an Inpatient basis.Rehabilitation care services consist of multidisciplinary physical restorative services to achieve the highest possiblefunctional ability for disability due to Sickness or Injury. Services are provided by or under the supervision of a trained andexperienced rehabilitation Physician.A rehabilitation unit is not a freestanding rehabilitative facility; a nursing home; an extended care facility; a Skilled NursingFacility; a rest home or home for the aged; a Hospice Facility; a facility for the Treatment of alcoholism or drug addictionor an assisted living facility.Important Information· Please also refer to the Policy Disclosures for additional details.· The Confinement must occur on or after the effective date of insurance.· Based on the limited available regulatory guidance, Sun Life believes its Hospital Indemnity insurance is appropriatefor use with an HSA and may be purchased when the employee and/or their family members are covered under anHDHP. However, Sun Life cannot provide legal or tax advice. If there are legal or tax questions, we suggest that theemployee consult their own legal or tax advisor before purchasing this insurance.· This is a limited benefit policy. It does NOT provide basic hospital, basic medical, or major medical insurance. It is nota Medicare Supplement policy. The certificate has exclusions, limitations, and benefit waiting periods for certainconditions that may affect any benefits payable. Benefits payable are subject to all terms and conditions of thecertificate. The policy, certificate and any rider, if applicable, may not be available in all states and may vary based onstate laws and regulations.Included in this plan· No health questions required.· 36-month rate guarantee from the Effective Date.· Eligible Child(ren): to age 26.· Portability – greater of Up to Age 70 or 12 months.
About Your Benefits:You probably have insurance for your car or home, but what about the source of income that pays for it? You rely on yourpaycheck for so many things, but what if you were suddenly unable to work due to an accident or illness? How will you put foodon the table, pay your mortgage or heat your home? Disability insurance can help replace lost income and make a difficult time alittle easier. Protect your most valuable asset, your paycheck-enroll today!What Your Benefits Cover:PORT LAVACA CLINIC ASSOCIATES, P.A.Short-Term Disability Benefit SummaryGroup Number: 00357684Short-Term Disability.Coverage amount 60% of salary to maximum $1000/weekMaximum payment period: Maximum length of time you canreceive disability benefits.26 weeksAccident benefits begin: The length of time you must be disabledbefore benefits begin.Day 15Illness benefits begin: The length of time you must be disabledbefore benefits begin.Day 15Evidence of Insurability: A health statement requiring you toanswer a few medical history questions.Health Statement may be requiredGuarantee Issue: The ‘guarantee’ means you are not required toanswer health questions to qualify for coverage up to and includingthe specified amount, when applicant signs up for coverage during theinitial enrollment period.We Guarantee Issue $1000 in coverageMinimum work hours/week: Minimum number of hours you mustregularly work each week to be eligible for coverage.Planholder DeterminesPre-existing conditions: A pre-existing condition includes anycondition/symptom for which you, in the specified time period priorto coverage in this plan, consulted with a physician, receivedtreatment, or took prescribed drugs.3 months look back; 12 months after 2 week limitationPremium waived if disabled: Premium will not need to be paidwhen you are receiving benefits.YesUNDERSTANDING YOUR BENEFITS—DISABILITY (Some information may vary by state)l Earnings definition: Your covered salary excludes bonuses and commissions.
Short-Term Disability Plan Monthly Cost Illustration:To determine the most appropriate level of coverage, you should consider your current basic monthly expenses. To help you assessyour needs, you can also go to Guardian Anytime and view a video:https://www.guardiananytime.com/gafd/wps/portal/fdhome/employees/products-coverage/disabilityPORT LAVACA CLINIC ASSOCIATES, P.A. ALL ELIGIBLE EMPLOYEES Benefit SummaryThe Guardian Life Insurance Company of America, New York, NYPolicy amounts shown based on sample salary amounts only.Your premium rate$0.780$10,000 Annual Salary$115 Weekly Benefit $8.97 Deduction$15,000 Annual Salary$173 Weekly Benefit $13.49 Deduction$20,000 Annual Salary$231 Weekly Benefit $18.02 Deduction$25,000 Annual Salary$288 Weekly Benefit $22.46 Deduction$30,000 Annual Salary$346 Weekly Benefit $26.99 Deduction$35,000 Annual Salary$404 Weekly Benefit $31.51 Deduction$40,000 Annual Salary$462 Weekly Benefit $36.04 Deduction$45,000 Annual Salary$519 Weekly Benefit $40.48 Deduction$50,000 Annual Salary$577 Weekly Benefit $45.01 Deduction$55,000 Annual Salary$635 Weekly Benefit $49.53 Deduction$60,000 Annual Salary$692 Weekly Benefit $53.98 Deduction$65,000 Annual Salary$750 Weekly Benefit $58.50 Deduction$70,000 Annual Salary$808 Weekly Benefit $63.02 Deduction$75,000 Annual Salary$865 Weekly Benefit $67.47 Deduction$80,000 Annual Salary$923 Weekly Benefit $71.99 Deduction$85,000 Annual Salary$981 Weekly Benefit $76.52 Deduction$90,000 Annual Salary$1,000 Weekly Benefit $78.00 Deduction$95,000 Annual Salary$1,000 Weekly Benefit $78.00 Deduction$100,000 Annual Salary$1,000 Weekly Benefit $78.00 Deduction
$105,000 Annual Salary$1,000 Weekly Benefit $78.00 Deduction$110,000 Annual Salary$1,000 Weekly Benefit $78.00 Deduction$115,000 Annual Salary$1,000 Weekly Benefit $78.00 DeductionManage Your Benefits:Go to www.GuardianAnytime.com to access secure informationabout your Guardian benefits. Your on-line account will be set upwithin 30 days after your plan effective date.A SUMMARY OF DISABILITY PLAN LIMITATIONSAND EXCLUSIONSn Evidence of Insurability is required on all late enrollees. This coverage willnot be effective until approved by a Guardian underwriter. This proposal ishedged subject to satisfactory financial evaluation. Please refer to certificateof coverage for full plan description.n You must be working full-time on the effective date of your coverage;otherwise, your coverage becomes effective after you have completed aspecific waiting period.n Employees must be legally working in the United States in order to beeligible for coverage. Underwriting must approve coverage for employees ontemporary assignment: (a) exceeding one year; or (b) in an area under travelwarning by the US Department of State. Subject to state specific variations.n For Short-Term Disability coverage, benefits for a disability caused orcontributed to by a pre-existing condition are limited, unless the disabilitystarts after you have been insured under this plan for a specified period oftime. We do not pay short term disability benefits for any job-related oron-the-job injury, or conditions for which Workers' Compensation benefitsare payable.n We do not pay benefits for charges relating to a covered person: taking partin any war or act of war (including service in the armed forces) committing afelony or taking part in any riot or other civil disorder or intentionallyinjuring themselves or attempting suicide while sane or insane. We do notpay benefits for charges relating to legal intoxication, including but notlimited to the operation of a motor vehicle, and for the voluntary use of anypoison, chemical, prescription or non-prescription drug or controlledsubstance unless it has been prescribed by a doctor and is used asprescribed. We limit the duration of payments for long term disabilitiescaused by mental or emotional conditions, or alcohol or drug abuse. We donot pay benefits during any period in which a covered person is confined toa correctional facility, an employee is not under the care of a doctor, anemployee is receiving treatment outside of the US or Canada, and theemployee’s loss of earnings is not solely due to disability.n This policy provides disability income insurance only. It does not provide"basic hospital", "basic medical", or "medical" insurance as defined by theNew York State Insurance Department.n If this plan is transferred from another insurance carrier, the time an insuredis covered under that plan will count toward satisfying Guardian'spre-existing condition limitation period. State variations may apply.n When applicable, this coverage will integrate with NJ TDB, NY DBL, CASDI, RI TDI, Hawaii TDI and Puerto Rico DBA.Contract # GP-1-STD-15-1.0 et al.This document is a summary of the major features of the referenced insurance coverage. It is intended for illustrative purposes only and does notconstitute a contract. The insurance plan documents, including the policy and certificate, comprise the contract for coverage. The full plan description,including the benefits and all terms, limitations and exclusions that apply will be contained in your insurance certificate. The plan documents are the finalarbiter of coverage. Coverage terms may vary by state and actual sold plan. The premium amounts reflected in this summary are an approximation; ifthere is a discrepancy between this amount and the premium actually billed, the latter prevails.