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2 7 Eligibility & Enrollment We offer a variety of options to help you select the benefit plans that best suit you and your family’s needs. Consider factors such as spousal benefits, dependent eligibility and qualifying life events as you make your benefits selections. Eligibility Regular full-time employees who work a minimum of 30 hours per week and their dependents are eligible for medical, dental, vision, life, and disability on the first day of the month following 60 days. Dependent children are covered on the medical plan up to age 26. How and When to Enroll We are excited to make enrollment in your benefits simple! Just follow the link to schedule a session with a benefit counselor. The counselor will call you at the time you select and assist with review of your current benefits. They will answer any questions and teach you about plans being offered this year. Once you make selections the counselor will enter those into the software for you. The session will give you the knowledge to feel comfortable with your selections to protect you and your family. Open enrollment period runs from May 31, 2024 through June 7, 2024. The benefits you elect will be in effective July 1, 2024 through June 30, 2025 How to Access Additional Benefit Information. You can access additional benefit plan information by visiting www.employeenavigator.com You can view plan summaries, contact information, required notices and more! Qualifying Life Events When one of the following events occurs, you have 30 days from the date of the event to notify the Benefits Department and/or request changes to your coverage. Your change in coverage must be consistent with your change in status. » Change in your legal marital status (marriage, divorce or legal separation) » Change in the number of your dependents (birth, death or adoption, or age) » Change in your spouse’s employment status (resulting in a loss or gain of coverage) » Change in your employment status from full-time to part-time, or part-time to full-time » Entitlement to Medicare or Medicaid » Change in your address or location that affects the plans for which you are eligible Important Contact Information Plan Carrier Group Number Contact Number Website Medical EMI Health 5627 800-662-5851 emihealth.com Dental Principal 1146231 800-247-4695 principal.com/denst Vision Principal 1146231 800-877-7195 vsp.com Worksite Colonial TBD 800-325-4368 Coloniallife.com/individuals/policyholder-support 23 When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Charlie’s Plumbing Inc. and don’t join a Medi-care drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For exam-ple, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare pre-scription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information: Sara Hursman 713-941-3162 Company Email: shursman@charliesplumbing.com NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Charlie’s Plumbing Inc. changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit www.medicare.gov Call your State Health Insurance Assistance Program for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For infor-mation about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, there-fore, whether or not you are required to pay a higher premium (a penalty).
2 7 Eligibility & Enrollment We offer a variety of options to help you select the benefit plans that best suit you and your family’s needs. Consider factors such as spousal benefits, dependent eligibility and qualifying life events as you make your benefits selections. Eligibility Regular full-time employees who work a minimum of 30 hours per week and their dependents are eligible for medical, dental, vision, life, and disability on the first day of the month following 60 days. Dependent children are covered on the medical plan up to age 26. How and When to Enroll We are excited to make enrollment in your benefits simple! Just follow the link to schedule a session with a benefit counselor. The counselor will call you at the time you select and assist with review of your current benefits. They will answer any questions and teach you about plans being offered this year. Once you make selections the counselor will enter those into the software for you. The session will give you the knowledge to feel comfortable with your selections to protect you and your family. Open enrollment period runs from May 31, 2024 through June 7, 2024. The benefits you elect will be in effective July 1, 2024 through June 30, 2025 How to Access Additional Benefit Information. You can access additional benefit plan information by visiting www.employeenavigator.com You can view plan summaries, contact information, required notices and more! Qualifying Life Events When one of the following events occurs, you have 30 days from the date of the event to notify the Benefits Department and/or request changes to your coverage. Your change in coverage must be consistent with your change in status. » Change in your legal marital status (marriage, divorce or legal separation) » Change in the number of your dependents (birth, death or adoption, or age) » Change in your spouse’s employment status (resulting in a loss or gain of coverage) » Change in your employment status from full-time to part-time, or part-time to full-time » Entitlement to Medicare or Medicaid » Change in your address or location that affects the plans for which you are eligible Important Contact Information Plan Carrier Group Number Contact Number Website Medical EMI Health 5627 800-662-5851 emihealth.com Dental Principal 1146231 800-247-4695 principal.com/denst Vision Principal 1146231 800-877-7195 vsp.com Worksite Colonial TBD 800-325-4368 Coloniallife.com/individuals/policyholder-support 23 When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Charlie’s Plumbing Inc. and don’t join a Medi-care drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For exam-ple, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare pre-scription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information: Sara Hursman 713-941-3162 Company Email: shursman@charliesplumbing.com NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Charlie’s Plumbing Inc. changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit www.medicare.gov Call your State Health Insurance Assistance Program for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For infor-mation about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, there-fore, whether or not you are required to pay a higher premium (a penalty).
22 HIPAA NOTICE OF SPECIAL ENROLLMENT RIGHTS If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contribung towards your or your dependents’ other coverage). However, you must request enrollment within 30 days aer your or your dependents’ other coverage ends (or aer employer stops contribung towards the other coverage). In addion, if you have a new dependent as a result of marriage, birth, adopon, or placement for adopon, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days aer the marriage, birth, adopon, or placement for adopon. IMPORTANT NOTICE FROM Charlie’s Plumbing Inc. ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE Please read this noce carefully and keep it where you can nd it. This noce has informaon about your current prescripon drug coverage with Charlie’s Plumbing Inc. . and about your opons under Medicare’s prescripon drug coverage. This informaon can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans oering Medicare prescripon drug coverage in your area. Informaon about where you can get help to make decisions about your prescripon drug coverage is at the end of this noce. There are two important things you need to know about your current coverage and Medicare’s prescripon drug coverage: 1. Medicare prescripon drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescripon Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that oers prescripon drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also oer more coverage for a higher monthly premium. 2. Charlie’s Plumbing Inc. Services Corp. has determined that the prescripon drug coverage oered by the BlueCross BlueShield of Texas is, on average for all plan parcipants, expected to pay out as much as standard Medicare prescripon drug coverage pays and is therefore considered Creditable Coverage. Because your exisng coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you rst become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescripon drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current BlueCross BlueShield of Texas coverage will [or will not] be aected. See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at hp://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescripon drug plan provisions/opons that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current Charlie’s Plumbing Inc. coverage, be aware that you and your dependents will not be able to get this coverage back. 3 Medical Plan Options The chart below gives a summary of the 2024 plan year medical coverages provided by EMI Health. All covered services are subject to medical necessity as determined by the Plan. The informaon in this Employee Benets Communicator is presented for illustrave purposes only. The text contained in this Guide was taken from various summary plan descripons and benet informaon documents. While every eort was taken to accurately report your benets, discrepancies or errors are always possible. In case of dis-crepancy between the Benet Enrollment Guide and the actual plan document will prevail. If you have any quesons about this summary, contact Human Resources. Base Plan Mid-Plan Buy Up EMI Health T 5000 100% EMI Health T 2500 100% EMI Health T 1000 Funding Type Level Funded Level Funded Level Funded Benefit items In-network Out-of-network In-network Out-of-network In-network Out-of-network Individual Deductible $5,000 $10,000 $2,500 $5,000 $1,000 $2,000 Family Deductible $10,000 $20,000 $5,000 $10,000 $2,000 $4,000 Individual Out-of-Pocket Max $6,800 $13,600 $5,000 $10,000 $4,000 $7,000 Family Out-of-Pocket Max $13,600 $27,200 $10,000 $20,000 $8,000 $14,000 Coinsurance (Policy Holder Portion) 0% 50% 0 50% 20% 50% Primary Care/Office $35 Ded + 50% $30 Ded + 50% $30 Ded + 50% Specialist Care $70 Ded + 50% $60 Ded + 50% $60 Ded + 50% Emergency Room $300; Waived if admitted. $250; Waived if admitted. $250; Waived if admitted. Urgent Care $75 Ded + 50% $75 Ded + 50% $75 Ded + 50% In-Network Prescription Coverage Tiers $10 /$40/$150/25% up to $250 $10 /$35/$150/25% up to $250 $10 /$35/$150/25% up to $250 Rx - Mail Order / Retail 2X for 90 day supply 2X for 90 day supply 2X for 90 day supply Weekly Rates Employee $0.00 $10.56 $19.36 + Spouse $117.57 $139.73 $158.21 + Child(ren) $96.19 $116.25 $132.97 + Family $235.14 $268.91 $297.07
22 HIPAA NOTICE OF SPECIAL ENROLLMENT RIGHTS If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contribung towards your or your dependents’ other coverage). However, you must request enrollment within 30 days aer your or your dependents’ other coverage ends (or aer employer stops contribung towards the other coverage). In addion, if you have a new dependent as a result of marriage, birth, adopon, or placement for adopon, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days aer the marriage, birth, adopon, or placement for adopon. IMPORTANT NOTICE FROM Charlie’s Plumbing Inc. ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE Please read this noce carefully and keep it where you can nd it. This noce has informaon about your current prescripon drug coverage with Charlie’s Plumbing Inc. . and about your opons under Medicare’s prescripon drug coverage. This informaon can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans oering Medicare prescripon drug coverage in your area. Informaon about where you can get help to make decisions about your prescripon drug coverage is at the end of this noce. There are two important things you need to know about your current coverage and Medicare’s prescripon drug coverage: 1. Medicare prescripon drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescripon Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that oers prescripon drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also oer more coverage for a higher monthly premium. 2. Charlie’s Plumbing Inc. Services Corp. has determined that the prescripon drug coverage oered by the BlueCross BlueShield of Texas is, on average for all plan parcipants, expected to pay out as much as standard Medicare prescripon drug coverage pays and is therefore considered Creditable Coverage. Because your exisng coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you rst become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescripon drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current BlueCross BlueShield of Texas coverage will [or will not] be aected. See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at hp://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescripon drug plan provisions/opons that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current Charlie’s Plumbing Inc. coverage, be aware that you and your dependents will not be able to get this coverage back. 3 Medical Plan Options The chart below gives a summary of the 2024 plan year medical coverages provided by EMI Health. All covered services are subject to medical necessity as determined by the Plan. The informaon in this Employee Benets Communicator is presented for illustrave purposes only. The text contained in this Guide was taken from various summary plan descripons and benet informaon documents. While every eort was taken to accurately report your benets, discrepancies or errors are always possible. In case of dis-crepancy between the Benet Enrollment Guide and the actual plan document will prevail. If you have any quesons about this summary, contact Human Resources. Base Plan Mid-Plan Buy Up EMI Health T 5000 100% EMI Health T 2500 100% EMI Health T 1000 Funding Type Level Funded Level Funded Level Funded Benefit items In-network Out-of-network In-network Out-of-network In-network Out-of-network Individual Deductible $5,000 $10,000 $2,500 $5,000 $1,000 $2,000 Family Deductible $10,000 $20,000 $5,000 $10,000 $2,000 $4,000 Individual Out-of-Pocket Max $6,800 $13,600 $5,000 $10,000 $4,000 $7,000 Family Out-of-Pocket Max $13,600 $27,200 $10,000 $20,000 $8,000 $14,000 Coinsurance (Policy Holder Portion) 0% 50% 0 50% 20% 50% Primary Care/Office $35 Ded + 50% $30 Ded + 50% $30 Ded + 50% Specialist Care $70 Ded + 50% $60 Ded + 50% $60 Ded + 50% Emergency Room $300; Waived if admitted. $250; Waived if admitted. $250; Waived if admitted. Urgent Care $75 Ded + 50% $75 Ded + 50% $75 Ded + 50% In-Network Prescription Coverage Tiers $10 /$40/$150/25% up to $250 $10 /$35/$150/25% up to $250 $10 /$35/$150/25% up to $250 Rx - Mail Order / Retail 2X for 90 day supply 2X for 90 day supply 2X for 90 day supply Weekly Rates Employee $0.00 $10.56 $19.36 + Spouse $117.57 $139.73 $158.21 + Child(ren) $96.19 $116.25 $132.97 + Family $235.14 $268.91 $297.07
4 21 To see if any other states have added a premium assistance program since July 31, 2014, or for more informaon on special enrollment rights, contact either: U.S. Department of Labor Employee Benets Security Administraon www.dol.gov/ebsa U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 18 MONTANA – Medicaid NEBRASKA – Medicaid Website: http://medicaidprovider.hhs.mt.gov Phone: 1-800-694-3084 Website: www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 NEVADA – Medicaid NEW HAMPSHIRE – Medicaid Website: http://dwss.nv.gov/ Phone: 1-800-992-0900 Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY – Medicaid and CHIP NEW YORK – Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA – Medicaid NORTH DAKOTA – Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604 OKLAHOMA – Medicaid and CHIP OREGON – Medicaid Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 Website: http://www.oregonhealthykids.gov Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid RHODE ISLAND – Medicaid Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462 Website: www.ohhs.ri.gov Phone: 401-462-5300 SOUTH CAROLINA – Medicaid SOUTH DAKOTA – Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS – Medicaid UTAH – Medicaid and CHIP Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493 Website: http://health.utah.gov/upp Phone: 1-866-435-7414 VERMONT – Medicaid VIRGINA – Medicaid and CHIP Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 Website: http://www.coverva.org/programs_premium_assistance.cfm Phone: 1-800-432-5924 WASHINGTON – Medicaid WEST VIRGINA – Medicaid Website: http://www.hca.wa.gov/medicaid/ Phone: 1-800-562-3022 ext. 15473 Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN – Medicaid WYOMING – Medicaid Website: http://www.badgercareplus.org/pubs/p-10095.htm Website: http://health.wyo.gov/healthcarefin/equalitycare
4 21 To see if any other states have added a premium assistance program since July 31, 2014, or for more informaon on special enrollment rights, contact either: U.S. Department of Labor Employee Benets Security Administraon www.dol.gov/ebsa U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 18 MONTANA – Medicaid NEBRASKA – Medicaid Website: http://medicaidprovider.hhs.mt.gov Phone: 1-800-694-3084 Website: www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 NEVADA – Medicaid NEW HAMPSHIRE – Medicaid Website: http://dwss.nv.gov/ Phone: 1-800-992-0900 Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY – Medicaid and CHIP NEW YORK – Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA – Medicaid NORTH DAKOTA – Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604 OKLAHOMA – Medicaid and CHIP OREGON – Medicaid Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 Website: http://www.oregonhealthykids.gov Phone: 1-800-699-9075 PENNSYLVANIA – Medicaid RHODE ISLAND – Medicaid Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462 Website: www.ohhs.ri.gov Phone: 401-462-5300 SOUTH CAROLINA – Medicaid SOUTH DAKOTA – Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS – Medicaid UTAH – Medicaid and CHIP Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493 Website: http://health.utah.gov/upp Phone: 1-866-435-7414 VERMONT – Medicaid VIRGINA – Medicaid and CHIP Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427 Website: http://www.coverva.org/programs_premium_assistance.cfm Phone: 1-800-432-5924 WASHINGTON – Medicaid WEST VIRGINA – Medicaid Website: http://www.hca.wa.gov/medicaid/ Phone: 1-800-562-3022 ext. 15473 Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN – Medicaid WYOMING – Medicaid Website: http://www.badgercareplus.org/pubs/p-10095.htm Website: http://health.wyo.gov/healthcarefin/equalitycare
20 Medicaid and the Children’s Health Insurance Program (CHIP) Oer Free or Low-Cost Health Coverage to Children and Families If you are eligible for health coverage from your employer, but are unable to aord the premiums, many states, including Texas, have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP, you can contact the Texas State Medicaid or CHIP oce to nd out if premium assistance is available to you. 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, you can contact your State Medicaid or CHIP oce or dial 1-877-KIDS NOW or www.insurekidsnow.gov to nd out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer- sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. You may be eligible for assistance for paying your employer health plan premiums. To nd out if you are you should contact the following department for addional informaon about eligibility. If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2014. Contact your State for more informaon on eligibility. 17 ALABAMA – Medicaid ALASKA – Medicaid Website: http://www.medicaid.alabama.gov Phone: 1-855-692-5447 Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 ARIZONA – CHIP COLORADO – Medicaid Website: http://www.azahcccs.gov/applicants Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437 Website: http://www.colorado.gov/ Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943 FLORIDA – Medicaid GEORGIA – Medicaid Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268 Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150 IDAHO – Medicaid INDIANA – Medicaid Medicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/PremiumAssist ance/tabid/1510/Default.aspx Medicaid Phone: 1-800-926-2588 Website: http://www.in.gov/fssa Phone: 1-800-889-9949 IOWA – Medicaid KANSAS – Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884 KENTUCKY – Medicaid LOUISIANA – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447 MAINE – Medicaid MASSACHUSETTS – Medicaid and CHIP Website: http://www.maine.gov/dhhs/ofi/public- assistance/index.html Phone: 1-800-977-6740 Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120 MINNESOTA – Medicaid MISSOURI – Medicaid Website: http://www.dhs.state.mn.us/ Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm 5
20 Medicaid and the Children’s Health Insurance Program (CHIP) Oer Free or Low-Cost Health Coverage to Children and Families If you are eligible for health coverage from your employer, but are unable to aord the premiums, many states, including Texas, have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP, you can contact the Texas State Medicaid or CHIP oce to nd out if premium assistance is available to you. 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, you can contact your State Medicaid or CHIP oce or dial 1-877-KIDS NOW or www.insurekidsnow.gov to nd out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer- sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. You may be eligible for assistance for paying your employer health plan premiums. To nd out if you are you should contact the following department for addional informaon about eligibility. If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2014. Contact your State for more informaon on eligibility. 17 ALABAMA – Medicaid ALASKA – Medicaid Website: http://www.medicaid.alabama.gov Phone: 1-855-692-5447 Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 ARIZONA – CHIP COLORADO – Medicaid Website: http://www.azahcccs.gov/applicants Phone (Outside of Maricopa County): 1-877-764-5437 Phone (Maricopa County): 602-417-5437 Website: http://www.colorado.gov/ Medicaid Phone (In state): 1-800-866-3513 Medicaid Phone (Out of state): 1-800-221-3943 FLORIDA – Medicaid GEORGIA – Medicaid Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268 Website: http://dch.georgia.gov/ - Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-800-869-1150 IDAHO – Medicaid INDIANA – Medicaid Medicaid Website: http://healthandwelfare.idaho.gov/Medical/Medicaid/PremiumAssist ance/tabid/1510/Default.aspx Medicaid Phone: 1-800-926-2588 Website: http://www.in.gov/fssa Phone: 1-800-889-9949 IOWA – Medicaid KANSAS – Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884 KENTUCKY – Medicaid LOUISIANA – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447 MAINE – Medicaid MASSACHUSETTS – Medicaid and CHIP Website: http://www.maine.gov/dhhs/ofi/public- assistance/index.html Phone: 1-800-977-6740 Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120 MINNESOTA – Medicaid MISSOURI – Medicaid Website: http://www.dhs.state.mn.us/ Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm 5
6 19 Judicial and Administrave Proceedings: We may disclose protected health informaon in the course of any judicial or administrave pro-ceeding: 1) in response to an order of a court or administrave tribunal, or 2) in response to a subpoena, discovery request, or other lawful process. Law Enforcement Purposes: We may disclose your protected health informaon for a law enforcement purpose to a law enforcement ocial as required or permied by law. Workers’ Compensaon: We may disclose protected health informaon as authorized by and to the extent necessary to comply with laws relang to workers’ compensaon or other similar programs that provide benets for work-related injuries or illness without regard to fault. Health and Safety: We may, consistent with applicable law and standards of ethical conduct, use or disclose protected health informaon, if we, in good faith, believe the use or disclosure will avert a serious threat to health or safety of a person or the public. Plan Sponsor: We may disclose your protected health informaon to corporate ocials as needed to fulll our administrave responsibili-es relang to Charlie’s Plumbing Inc. Health Care Plan. Naonal Security: We may use and disclose the protected health informaon of individuals who are Armed Forces personnel for acvies deemed necessary by appropriate military command authories to assure the proper execuon of the military mission, if the appropriate military authority has published by noce the appropriate informaon. We may also disclose to authorized federal ocials health infor-maon required for lawful intelligence, counterintelligence, and other naonal security acvies. We may disclose to a correconal instu-on or law enforcement ocial having lawful custody of an inmate or other individual protected health informaon about such inmate or individual upon a showing of necessity. INDIVIDUAL RIGHTS Access: You have a right of access to inspect and obtain a copy of protected health informaon about you, with limited excepons, for so long as we maintain the informaon. You may request the informaon in a format other than hard copies and we will comply with your request if praccable. You must make your wrien request for a copy to the contact person listed at the end of this noce. You will be charged a reasonable cost-based fee for expenses such as copies, labor, postage, and a summary of the health informaon if you request one. You may also request access by sending wrien noce to the contact person at the end of this noce. You have a right to request a review of certain denials of access. Restricon: You have the right to request addional restricons on the use and disclosure of your protected health informaon. We are not required to agree, but if we do, we are required to abide by the restricon. We must also accommodate reasonable wrien requests to receive communicaons of protected health informaon by alternave means or at alternave locaons, if you clearly state that the disclosure of all or part of that informaon could endanger you. Amendment: You have the right to request that we amend your protected health informaon. Your request must be in wring stang the reason for your request and must be provided to the contact person listed at the end of this noce. We have the right to deny such re-quests under certain circumstances. If your request is denied, you have a right to submit a wrien statement disagreeing with the denial. Accounng: You have a right to receive an accounng of disclosures of your protected health informaon made by us or our business asso-ciates for purposes other than treatment, payment or health care operaons and certain other acvies. The request may be for disclo-sures in the six years prior to the date on which the accounng is requested, but not before April 14, 2003. The rst request for an ac-counng is provided free of charge. Addional requests within a 12-month period will be charged a reasonable cost-based fee. Authorizaon: The Plan will obtain your authorizaon for uses or disclosures that are not idened by this noce or permied by applica-ble law. You may revoke any authorizaon in wring at any me. Your revocaon will not aect any use or disclosure permied by your authorizaon while it was in eect. Electronic Noce: If you receive this noce electronically, you may sll obtain a paper copy upon request to the contact person listed at the end of this noce. QUESTIONS AND COMPLAINTS If you have quesons, concerns, or complaints about our privacy pracces please contact us. Sara Hursman 713-941-3162 If you believe that your privacy rights have been violated or you are concerned about a decision relang to access, restricon, amendment, accounng, or noce, you may le a grievance with the contact person listed below. You may also submit a wrien complaint to the Secre-tary of the U.S. Department of Health and Human Services at: Region VI, Oce for Civil Rights, U.S. Department of Health and Human Ser-vices, 1301 Young Street, Suite 1169, Dallas, Texas 75202; or by e-mail at: OCRComplaint@hhs.gov. The privacy of your health informaon is important to us. We will not retaliate against you for ling a complaint.
6 19 Judicial and Administrave Proceedings: We may disclose protected health informaon in the course of any judicial or administrave pro-ceeding: 1) in response to an order of a court or administrave tribunal, or 2) in response to a subpoena, discovery request, or other lawful process. Law Enforcement Purposes: We may disclose your protected health informaon for a law enforcement purpose to a law enforcement ocial as required or permied by law. Workers’ Compensaon: We may disclose protected health informaon as authorized by and to the extent necessary to comply with laws relang to workers’ compensaon or other similar programs that provide benets for work-related injuries or illness without regard to fault. Health and Safety: We may, consistent with applicable law and standards of ethical conduct, use or disclose protected health informaon, if we, in good faith, believe the use or disclosure will avert a serious threat to health or safety of a person or the public. Plan Sponsor: We may disclose your protected health informaon to corporate ocials as needed to fulll our administrave responsibili-es relang to Charlie’s Plumbing Inc. Health Care Plan. Naonal Security: We may use and disclose the protected health informaon of individuals who are Armed Forces personnel for acvies deemed necessary by appropriate military command authories to assure the proper execuon of the military mission, if the appropriate military authority has published by noce the appropriate informaon. We may also disclose to authorized federal ocials health infor-maon required for lawful intelligence, counterintelligence, and other naonal security acvies. We may disclose to a correconal instu-on or law enforcement ocial having lawful custody of an inmate or other individual protected health informaon about such inmate or individual upon a showing of necessity. INDIVIDUAL RIGHTS Access: You have a right of access to inspect and obtain a copy of protected health informaon about you, with limited excepons, for so long as we maintain the informaon. You may request the informaon in a format other than hard copies and we will comply with your request if praccable. You must make your wrien request for a copy to the contact person listed at the end of this noce. You will be charged a reasonable cost-based fee for expenses such as copies, labor, postage, and a summary of the health informaon if you request one. You may also request access by sending wrien noce to the contact person at the end of this noce. You have a right to request a review of certain denials of access. Restricon: You have the right to request addional restricons on the use and disclosure of your protected health informaon. We are not required to agree, but if we do, we are required to abide by the restricon. We must also accommodate reasonable wrien requests to receive communicaons of protected health informaon by alternave means or at alternave locaons, if you clearly state that the disclosure of all or part of that informaon could endanger you. Amendment: You have the right to request that we amend your protected health informaon. Your request must be in wring stang the reason for your request and must be provided to the contact person listed at the end of this noce. We have the right to deny such re-quests under certain circumstances. If your request is denied, you have a right to submit a wrien statement disagreeing with the denial. Accounng: You have a right to receive an accounng of disclosures of your protected health informaon made by us or our business asso-ciates for purposes other than treatment, payment or health care operaons and certain other acvies. The request may be for disclo-sures in the six years prior to the date on which the accounng is requested, but not before April 14, 2003. The rst request for an ac-counng is provided free of charge. Addional requests within a 12-month period will be charged a reasonable cost-based fee. Authorizaon: The Plan will obtain your authorizaon for uses or disclosures that are not idened by this noce or permied by applica-ble law. You may revoke any authorizaon in wring at any me. Your revocaon will not aect any use or disclosure permied by your authorizaon while it was in eect. Electronic Noce: If you receive this noce electronically, you may sll obtain a paper copy upon request to the contact person listed at the end of this noce. QUESTIONS AND COMPLAINTS If you have quesons, concerns, or complaints about our privacy pracces please contact us. Sara Hursman 713-941-3162 If you believe that your privacy rights have been violated or you are concerned about a decision relang to access, restricon, amendment, accounng, or noce, you may le a grievance with the contact person listed below. You may also submit a wrien complaint to the Secre-tary of the U.S. Department of Health and Human Services at: Region VI, Oce for Civil Rights, U.S. Department of Health and Human Ser-vices, 1301 Young Street, Suite 1169, Dallas, Texas 75202; or by e-mail at: OCRComplaint@hhs.gov. The privacy of your health informaon is important to us. We will not retaliate against you for ling a complaint.
18 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR LEGAL DUTIES We are required by law to reasonably safeguard the privacy of your protected health informaon. We are also required to give you this noce about our legal dues and privacy pracces relang to protected health informaon. Protected health informaon is any individually idenable health informaon, whether oral or recorded in any medium, that is created or received by enes such as health care providers, health plans, or employers, and relates to the physical or mental health or condion of an individual, or to the payment for the provision of health care to an individual and that is maintained in a designated record set(s). We are required to abide by the terms of this noce currently in eect. We reserve the right to change our privacy pracces and the terms of this noce for all protected health informaon we maintain even if it was created or received before issuing the revised noce. If a material revision is made, we will distribute a copy of the revised noce. This noce takes eect on April 14, 2003, and remains in eect unl we replace it. You may request a copy of this noce at any me. For more informaon about our privacy pracces, or for addional copies of this noce, please contact the individual designated at the end of this noce. USES AND DISCLOSURES We may use and disclose your health informaon for treatment, payment, and healthcare operaons. For example: Treatment: We may use and disclose your protected health informaon to provide, coordinate, or manage your health care and any related services with a physician or other health care provider. Payment: We may use and disclose your protected health informaon to determine and to fulll coverage responsibilies and to provide benets under Charlie’s Plumbing Inc. health plan. We may also use and disclose your protected health informaon to obtain or provide reimbursement for benets provided. Healthcare Operaons: We may use and disclose your protected health informaon for certain administrave, nancial, legal, and quality improvement acvies necessary to run our business and to support the core funcons of treatment and payment. Such acvies include, but are not limited to, underwring and other acvies relang to the creaon, renewal, or replacement of a contract for health benets. Such acvies also include sharing your protected health informaon with third party “business associates” that perform various acvies for us. In addion to treatment, payment and health care operaons purposes, we may use or disclose your protected health informaon for the following purposes: Family and Representaves: We must disclose your protected health informaon to you, as described in the Paent Rights secon of this noce. We may disclose your health informaon to a family member, friend or other person to the extent necessary for the proper provision or payment of healthcare. Persons Involved in Your Care: We may use or disclose protected health informaon to nofy, or assist in the nocaon of (including idenfying or locang) a family member, a personal representave of the individual, or another person responsible for the care of the individual of the individual’s locaon, general condion, or death. If you are present you will have the opportunity to object to such use or disclosure of your protected health informaon. If you are not present, or the opportunity to agree or object cannot be provided due to incapacity or emergency, we, in the exercise of professional judgment, may determine whether the disclosure is in your best interest. We may use professional judgment and our experience with common pracce to make reasonable inferences of your best interest in allowing a person to act on your behalf to pick up protected health informaon. Required by Law: We may use or disclose protected health informaon to the extent that such use or disclosure is required by federal, state or local law and the use or disclosure complies with & is limited to the relevant requirements of such law. Public Health Acvies and Related Purposes: We may disclose your protected health informaon to public health authories authorized by law to collect or receive such informaon for the purpose of prevenng or controlling disease, injury, disability, or child abuse or neglect. We may also disclose your protected health informaon to a person subject to the jurisdicon of the Food and Drug Administraon (FDA) with respect to an FDA-regulated product or acvity for which that person has certain responsibilies. Abuse or Neglect: We may disclose protected health informaon about an individual whom we reasonably believe to be a vicm of abuse, neglect, or domesc violence to a government authority, including a social service or protecve services agency, authorized by law to receive reports of such abuse, neglect, or domesc violence. Health Oversight Acvies: With certain excepons, we may disclose your protected health informaon to a health oversight agency for oversight acvies authorized by law, including audits; civil, administrave, or criminal invesgaons; inspecons; licensure or disciplinary acons; civil, administrave, or criminal proceedings or acons; or other acvies necessary for appropriate oversight of specied programs. 7 Dental Benefits Value Plan MAC Plus Plan / 90th Principal Principal Benefit items In-network In-network Individual Deductible Preventive: $10 / Basic & Major: %50 $50 Calendar Year Max Benefit $750 $1,500 Preventive Coinsurance 100% 100% Basic Coinsurance 70% 80% Major Coinsurance 30% 50% Waiting Period - Major (No Waiting Period) (No Waiting Period) Ortho Coinsurance N/A N/A Periodontics / Endodontics Major Basic Weekly Rates Weekly Rates Employee $0.00 $4.48 + Spouse $1.95 $11.85 + Child(ren) $5.45 $17.18 + Family $6.82 $26.49 Our Dental Plan helps you maintain good dental health through affordable options for preventive care, including regular checkups and other dental work. When you receive services from a dentist in our network, your cost may be lower. Network dentists agree to lower their fees for dental services and not charge you the difference. You’ll have access to the Principal Plan Dental network with more than 117,000 dentists nation-wide. Visit principal.com/dentist to find a dentist or call 800-247-4695
18 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR LEGAL DUTIES We are required by law to reasonably safeguard the privacy of your protected health informaon. We are also required to give you this noce about our legal dues and privacy pracces relang to protected health informaon. Protected health informaon is any individually idenable health informaon, whether oral or recorded in any medium, that is created or received by enes such as health care providers, health plans, or employers, and relates to the physical or mental health or condion of an individual, or to the payment for the provision of health care to an individual and that is maintained in a designated record set(s). We are required to abide by the terms of this noce currently in eect. We reserve the right to change our privacy pracces and the terms of this noce for all protected health informaon we maintain even if it was created or received before issuing the revised noce. If a material revision is made, we will distribute a copy of the revised noce. This noce takes eect on April 14, 2003, and remains in eect unl we replace it. You may request a copy of this noce at any me. For more informaon about our privacy pracces, or for addional copies of this noce, please contact the individual designated at the end of this noce. USES AND DISCLOSURES We may use and disclose your health informaon for treatment, payment, and healthcare operaons. For example: Treatment: We may use and disclose your protected health informaon to provide, coordinate, or manage your health care and any related services with a physician or other health care provider. Payment: We may use and disclose your protected health informaon to determine and to fulll coverage responsibilies and to provide benets under Charlie’s Plumbing Inc. health plan. We may also use and disclose your protected health informaon to obtain or provide reimbursement for benets provided. Healthcare Operaons: We may use and disclose your protected health informaon for certain administrave, nancial, legal, and quality improvement acvies necessary to run our business and to support the core funcons of treatment and payment. Such acvies include, but are not limited to, underwring and other acvies relang to the creaon, renewal, or replacement of a contract for health benets. Such acvies also include sharing your protected health informaon with third party “business associates” that perform various acvies for us. In addion to treatment, payment and health care operaons purposes, we may use or disclose your protected health informaon for the following purposes: Family and Representaves: We must disclose your protected health informaon to you, as described in the Paent Rights secon of this noce. We may disclose your health informaon to a family member, friend or other person to the extent necessary for the proper provision or payment of healthcare. Persons Involved in Your Care: We may use or disclose protected health informaon to nofy, or assist in the nocaon of (including idenfying or locang) a family member, a personal representave of the individual, or another person responsible for the care of the individual of the individual’s locaon, general condion, or death. If you are present you will have the opportunity to object to such use or disclosure of your protected health informaon. If you are not present, or the opportunity to agree or object cannot be provided due to incapacity or emergency, we, in the exercise of professional judgment, may determine whether the disclosure is in your best interest. We may use professional judgment and our experience with common pracce to make reasonable inferences of your best interest in allowing a person to act on your behalf to pick up protected health informaon. Required by Law: We may use or disclose protected health informaon to the extent that such use or disclosure is required by federal, state or local law and the use or disclosure complies with & is limited to the relevant requirements of such law. Public Health Acvies and Related Purposes: We may disclose your protected health informaon to public health authories authorized by law to collect or receive such informaon for the purpose of prevenng or controlling disease, injury, disability, or child abuse or neglect. We may also disclose your protected health informaon to a person subject to the jurisdicon of the Food and Drug Administraon (FDA) with respect to an FDA-regulated product or acvity for which that person has certain responsibilies. Abuse or Neglect: We may disclose protected health informaon about an individual whom we reasonably believe to be a vicm of abuse, neglect, or domesc violence to a government authority, including a social service or protecve services agency, authorized by law to receive reports of such abuse, neglect, or domesc violence. Health Oversight Acvies: With certain excepons, we may disclose your protected health informaon to a health oversight agency for oversight acvies authorized by law, including audits; civil, administrave, or criminal invesgaons; inspecons; licensure or disciplinary acons; civil, administrave, or criminal proceedings or acons; or other acvies necessary for appropriate oversight of specied programs. 7 Dental Benefits Value Plan MAC Plus Plan / 90th Principal Principal Benefit items In-network In-network Individual Deductible Preventive: $10 / Basic & Major: %50 $50 Calendar Year Max Benefit $750 $1,500 Preventive Coinsurance 100% 100% Basic Coinsurance 70% 80% Major Coinsurance 30% 50% Waiting Period - Major (No Waiting Period) (No Waiting Period) Ortho Coinsurance N/A N/A Periodontics / Endodontics Major Basic Weekly Rates Weekly Rates Employee $0.00 $4.48 + Spouse $1.95 $11.85 + Child(ren) $5.45 $17.18 + Family $6.82 $26.49 Our Dental Plan helps you maintain good dental health through affordable options for preventive care, including regular checkups and other dental work. When you receive services from a dentist in our network, your cost may be lower. Network dentists agree to lower their fees for dental services and not charge you the difference. You’ll have access to the Principal Plan Dental network with more than 117,000 dentists nation-wide. Visit principal.com/dentist to find a dentist or call 800-247-4695
8 Vision Benefits Vision benefits provide access to quality vision care. To ensure that you and your family get the care you need, we offer a comprehensive vision benefit provided by Principal. Visit vsp.com to locate a VSP doctor close to you Choose the “Choice” doctor network Call 800-877-7195 Current Vision Plan Principal VSP Choice Network Benefit items In-Network Out-of-Network Exam Frequency Once every 12 months Lense Frequency Once every 12 months Frame Frequency Once every 24 months Exams $10 Up to $45 Single Lenses $25 Up to $30 Bifocal Lenses $25 Up to $50 Trifocal Lenses $25 Up to $65 Frames $130 Allowance / 20% off remaining balance Up to $70 Contacts - Medically Necessary $25 Up to $210 Contacts - Elective $130 Allowance Up to $105 Current Employee $0.00 Employee + Spouse $1.48 Employee + Child(ren) $1.41 Employee + Family $3.17 17 COBRA LAW TEMPORARY EXTENSION OF HEALTH & DENTAL INSURANCE COVERAGE Pursuant to the Consolidated Omnibus Budget Reconciliaon Act (COBRA), Charlie’s Plumbing Inc. oers employees and their families the opportunity to obtain temporary extension of health coverage at the group rate in certain instances where coverage under the plan would otherwise end. An employee or an employee's dependent covered by a Charlie’s Plumbing Inc. insurance plan (medical or dental), may extend coverage for a period of eighteen (18) months if the employee’s/dependent's coverage is lost due to the occurrence of any of the following qualifying events and the employee or dependent is not covered by any other group health insurance plan: • voluntary terminaon of employment (i.e. resignaon or rerement); • involuntary terminaon of employment (other than for gross misconduct); • temporary disability leave; or • reducon in work hours. In the event of one of the above qualifying events, COBRA coverage is available for up to eighteen (18) months, but may be extended to a total of twenty-nine (29) months in certain cases of disability (see Disability Extension below). The employee and each covered dependent has an individual right to request COBRA coverage. A covered dependent may elect COBRA coverage for a period of up to thirty-six (36) months if coverage is lost due to one of the following qualifying events: • the employee's death; • divorce or legal separaon; • the employee becomes eligible for Medicare; • or the dependent child ceases to be dependent because of age, dependency status, or marriage. The cost for this extended coverage is 102% of the total premium (the amount Charlie’s Plumbing Inc. and you have been paying for health insurance coverage, plus a 2% administraon charge). If the cost for COBRA coverage changes during your parcipaon you will be noed of the new premium in wring prior to its due date. The coverage may be terminated automacally if: (1) you fail to make a monthly premium payment, (2) obtain health coverage through a new employer, (3) Medicare coverage begins for a person beneng from the extension; (4) a spouse remarries and becomes eligible for coverage under another group health plan; or, (5) the plan itself is terminated. Both you and Charlie’s Plumbing Inc. have responsibilies when certain events occur which qualify you for connued coverage. You or a covered dependent have the responsibility to inform Charlie’s Plumbing Inc. a divorce, legal separaon, or a child losing dependent status under the group health plan within sixty (60) days of the qualifying event. Charlie’s Plumbing Inc. will then nofy any other covered dependents that are aected by the event of their right to elect COBRA coverage. COBRA parcipants also have the responsibility of nofying Charlie’s Plumbing Inc. they experience addional COBRA qualifying events during their COBRA term that might qualify them for addional months of extended coverage. Legislave changes to COBRA coverage eecve January 1, 1997. Disability Extension - If you elect COBRA connuaon coverage based on terminaon of employment or reducon of hours, and you become disabled (as determined by Social Security) anyme within the rst sixty (60) days of COBRA connuaon coverage, you and your covered family members may elect a special addional eleven (11)-month extension, for a total of twenty-nine (29) months of COBRA connuaon coverage. To elect the eleven (11)-month extension, you must nofy the Plan Administrator within sixty (60) days of the date Social Security determines that you or your family member is disabled and within the rst eighteen (18) months of COBRA connuaon coverage. (The cost of COBRA coverage will increase from 102% to 150% of total premium during this addional eleven (11)-month extension period.) Newborn and Adopted Children - If you are entled to COBRA because you are a current or former employee of Charlie’s Plumbing Inc. a child is born to or adopted by you while you are on COBRA connuaon coverage, you can enroll your new child for COBRA connuaon coverage immediately. Also, your newborn or adopted child will aain "qualied beneciary" status; in other words, he/she will have independent elecon rights and second qualifying event rights. Pre-exisng Condion Limitaon - COBRA coverage may be terminated when you become covered under another group health plan, but only if the other plan does not contain an exclusion or limitaon that aects a pre-exisng condion you have. If you do become covered under another group health plan and are aected by a pre-exisng condion limitaon, COBRA coverage may be canceled as soon as that pre-exisng condion limitaon is sased due to the new plan's creding toward the limitaon any prior coverage you had. If you have any quesons about the COBRA law, need premium informaon, or need to report a qualifying event, please contact Charlie’s Plumbing Inc.
8 Vision Benefits Vision benefits provide access to quality vision care. To ensure that you and your family get the care you need, we offer a comprehensive vision benefit provided by Principal. Visit vsp.com to locate a VSP doctor close to you Choose the “Choice” doctor network Call 800-877-7195 Current Vision Plan Principal VSP Choice Network Benefit items In-Network Out-of-Network Exam Frequency Once every 12 months Lense Frequency Once every 12 months Frame Frequency Once every 24 months Exams $10 Up to $45 Single Lenses $25 Up to $30 Bifocal Lenses $25 Up to $50 Trifocal Lenses $25 Up to $65 Frames $130 Allowance / 20% off remaining balance Up to $70 Contacts - Medically Necessary $25 Up to $210 Contacts - Elective $130 Allowance Up to $105 Current Employee $0.00 Employee + Spouse $1.48 Employee + Child(ren) $1.41 Employee + Family $3.17 17 COBRA LAW TEMPORARY EXTENSION OF HEALTH & DENTAL INSURANCE COVERAGE Pursuant to the Consolidated Omnibus Budget Reconciliaon Act (COBRA), Charlie’s Plumbing Inc. oers employees and their families the opportunity to obtain temporary extension of health coverage at the group rate in certain instances where coverage under the plan would otherwise end. An employee or an employee's dependent covered by a Charlie’s Plumbing Inc. insurance plan (medical or dental), may extend coverage for a period of eighteen (18) months if the employee’s/dependent's coverage is lost due to the occurrence of any of the following qualifying events and the employee or dependent is not covered by any other group health insurance plan: • voluntary terminaon of employment (i.e. resignaon or rerement); • involuntary terminaon of employment (other than for gross misconduct); • temporary disability leave; or • reducon in work hours. In the event of one of the above qualifying events, COBRA coverage is available for up to eighteen (18) months, but may be extended to a total of twenty-nine (29) months in certain cases of disability (see Disability Extension below). The employee and each covered dependent has an individual right to request COBRA coverage. A covered dependent may elect COBRA coverage for a period of up to thirty-six (36) months if coverage is lost due to one of the following qualifying events: • the employee's death; • divorce or legal separaon; • the employee becomes eligible for Medicare; • or the dependent child ceases to be dependent because of age, dependency status, or marriage. The cost for this extended coverage is 102% of the total premium (the amount Charlie’s Plumbing Inc. and you have been paying for health insurance coverage, plus a 2% administraon charge). If the cost for COBRA coverage changes during your parcipaon you will be noed of the new premium in wring prior to its due date. The coverage may be terminated automacally if: (1) you fail to make a monthly premium payment, (2) obtain health coverage through a new employer, (3) Medicare coverage begins for a person beneng from the extension; (4) a spouse remarries and becomes eligible for coverage under another group health plan; or, (5) the plan itself is terminated. Both you and Charlie’s Plumbing Inc. have responsibilies when certain events occur which qualify you for connued coverage. You or a covered dependent have the responsibility to inform Charlie’s Plumbing Inc. a divorce, legal separaon, or a child losing dependent status under the group health plan within sixty (60) days of the qualifying event. Charlie’s Plumbing Inc. will then nofy any other covered dependents that are aected by the event of their right to elect COBRA coverage. COBRA parcipants also have the responsibility of nofying Charlie’s Plumbing Inc. they experience addional COBRA qualifying events during their COBRA term that might qualify them for addional months of extended coverage. Legislave changes to COBRA coverage eecve January 1, 1997. Disability Extension - If you elect COBRA connuaon coverage based on terminaon of employment or reducon of hours, and you become disabled (as determined by Social Security) anyme within the rst sixty (60) days of COBRA connuaon coverage, you and your covered family members may elect a special addional eleven (11)-month extension, for a total of twenty-nine (29) months of COBRA connuaon coverage. To elect the eleven (11)-month extension, you must nofy the Plan Administrator within sixty (60) days of the date Social Security determines that you or your family member is disabled and within the rst eighteen (18) months of COBRA connuaon coverage. (The cost of COBRA coverage will increase from 102% to 150% of total premium during this addional eleven (11)-month extension period.) Newborn and Adopted Children - If you are entled to COBRA because you are a current or former employee of Charlie’s Plumbing Inc. a child is born to or adopted by you while you are on COBRA connuaon coverage, you can enroll your new child for COBRA connuaon coverage immediately. Also, your newborn or adopted child will aain "qualied beneciary" status; in other words, he/she will have independent elecon rights and second qualifying event rights. Pre-exisng Condion Limitaon - COBRA coverage may be terminated when you become covered under another group health plan, but only if the other plan does not contain an exclusion or limitaon that aects a pre-exisng condion you have. If you do become covered under another group health plan and are aected by a pre-exisng condion limitaon, COBRA coverage may be canceled as soon as that pre-exisng condion limitaon is sased due to the new plan's creding toward the limitaon any prior coverage you had. If you have any quesons about the COBRA law, need premium informaon, or need to report a qualifying event, please contact Charlie’s Plumbing Inc.
16 16 IMPORTANT NOTIFICATIONS WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998 The federal law entled the Women's Health and Cancer Rights Act of 1998 requires group health plans and health insurers provide coverage for mastectomies to provide certain mastectomy-related benets or services. Charlie’s Plumbing Inc. medical plan with EMI HEALTH provides coverage for these medical services. The following informaon is being provided to you as required by law. This noce is a summary, for informaon purposes only, and is not intended to be legal advice. The Women's Health and Cancer Rights Act of 1998 (The "ACT") was enacted as part of H.R. 4328, Federal Omnibus Consolidated and Emergency Supplemental Appropriaons Bill for 1999. The Act requires that group health plans and health insurance issuers, in the group or individual markets, that provide medical and surgical benets with respect to mastectomy, must provide plan parcipants and plan beneciaries who are receiving benets in connecon with a mastectomy, and who elect breast reconstrucon in connecon with the mastectomy, coverage for the following: • reconstrucon of the breast on which the mastectomy has been performed; • surgery and reconstrucon of the other breast to produce a symmetrical appearance; • and prostheses and treatment of physical complicaon at all stages of mastectomy, including lymphedemas. Coverage for these benets or services will be provided in a manner determined in consultaon with the aending physician and the paent. Coverage for the mastectomy-related services or benets required under the Women's Health Law may be subject to the same deducbles and co-insurance or co-payment provisions that apply with respect to other established medical or surgical benets under the group health plan or coverage. Insured plans, including large and small groups, individual coverage, associaon plans and self-funded plans, are subject to the law. The Act's requirements are eecve for plan years beginning on or aer October 21, 1998. In addion to the mandated coverage, the Act requires that group plans and health insurance issuers provide wrien noce of the availability of the coverage to plan parcipants and plan beneciaries at the me of inial enrollments, and annually thereaer. The Act prohibits group health plans and health insurance issuers from: • denying eligibility or connuing eligibility; • not enrolling or non-renewing coverage under the terms of the plan solely for the purpose of avoiding compliance with the Act; • penalizing or otherwise reducing or liming the reimbursements of an aending health care provider; • providing incenves (monetary or otherwise) to an aending health care provider; or inducing a provider to provide care in a manner inconsistent with the Act. The summary above is an overview of the Women's Health and Cancer Rights Act of 1998. This is your legally required nocaon. If you have any quesons regarding the provisions of this law, please contact your plan's Member or Customer Service Department (the telephone number is on your health insurance ID card). Newborn’s & Mothers’ Protecons (Newborns’ Act) The Newborns’ and Mothers’ Health Protecon Act (Newborns’ Act) includes important protecons for mothers and their newborn children with regard to the length of the hospital stay following childbirth. The Newborns’ Act requires that group health plans that oer maternity coverage pay for at least a 48-hour hospital stay following childbirth (96-hour stay in the case of Cesarean secon). 9 Basic Life and AD&D & Term Life Plans Life insurance is very important to those who depend on you for financial security. This benefit helps support your loved ones by providing financial assistance in your absence. Basic Life and AD&D Insurance Life benefits are essential to the financial security of you and your family. As such, it is important to understand how your plan works and what benefits you will receive. The Basic Life and AD&D benefit is paid on your behalf by Charlie’s Plumbing. Voluntary Life Term Life Insurance is available to you through Principal. This benefit allows your loved ones, such as a spouse or other beneficiaries, to receive financial help in the case of your death. Your Term Life insurance benefit is available in $10,000 increments, to a maximum of $300,000. Dependent Term Life Insurance Term Life coverage is available for your spouse with the benefit of up to a max of $100,000, and for your child(ren) with a benefit of $10,000. Tip It is important that you name a primary and contingent beneficiary to receive your Life insurance benefits. Current Basic Life and Accidental Death & Dismemberment (AD&D) Principal Amount $25,000 Benet Age Reducon 35% - Age 65 / 50% - Age 70
16 16 IMPORTANT NOTIFICATIONS WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998 The federal law entled the Women's Health and Cancer Rights Act of 1998 requires group health plans and health insurers provide coverage for mastectomies to provide certain mastectomy-related benets or services. Charlie’s Plumbing Inc. medical plan with EMI HEALTH provides coverage for these medical services. The following informaon is being provided to you as required by law. This noce is a summary, for informaon purposes only, and is not intended to be legal advice. The Women's Health and Cancer Rights Act of 1998 (The "ACT") was enacted as part of H.R. 4328, Federal Omnibus Consolidated and Emergency Supplemental Appropriaons Bill for 1999. The Act requires that group health plans and health insurance issuers, in the group or individual markets, that provide medical and surgical benets with respect to mastectomy, must provide plan parcipants and plan beneciaries who are receiving benets in connecon with a mastectomy, and who elect breast reconstrucon in connecon with the mastectomy, coverage for the following: • reconstrucon of the breast on which the mastectomy has been performed; • surgery and reconstrucon of the other breast to produce a symmetrical appearance; • and prostheses and treatment of physical complicaon at all stages of mastectomy, including lymphedemas. Coverage for these benets or services will be provided in a manner determined in consultaon with the aending physician and the paent. Coverage for the mastectomy-related services or benets required under the Women's Health Law may be subject to the same deducbles and co-insurance or co-payment provisions that apply with respect to other established medical or surgical benets under the group health plan or coverage. Insured plans, including large and small groups, individual coverage, associaon plans and self-funded plans, are subject to the law. The Act's requirements are eecve for plan years beginning on or aer October 21, 1998. In addion to the mandated coverage, the Act requires that group plans and health insurance issuers provide wrien noce of the availability of the coverage to plan parcipants and plan beneciaries at the me of inial enrollments, and annually thereaer. The Act prohibits group health plans and health insurance issuers from: • denying eligibility or connuing eligibility; • not enrolling or non-renewing coverage under the terms of the plan solely for the purpose of avoiding compliance with the Act; • penalizing or otherwise reducing or liming the reimbursements of an aending health care provider; • providing incenves (monetary or otherwise) to an aending health care provider; or inducing a provider to provide care in a manner inconsistent with the Act. The summary above is an overview of the Women's Health and Cancer Rights Act of 1998. This is your legally required nocaon. If you have any quesons regarding the provisions of this law, please contact your plan's Member or Customer Service Department (the telephone number is on your health insurance ID card). Newborn’s & Mothers’ Protecons (Newborns’ Act) The Newborns’ and Mothers’ Health Protecon Act (Newborns’ Act) includes important protecons for mothers and their newborn children with regard to the length of the hospital stay following childbirth. The Newborns’ Act requires that group health plans that oer maternity coverage pay for at least a 48-hour hospital stay following childbirth (96-hour stay in the case of Cesarean secon). 9 Basic Life and AD&D & Term Life Plans Life insurance is very important to those who depend on you for financial security. This benefit helps support your loved ones by providing financial assistance in your absence. Basic Life and AD&D Insurance Life benefits are essential to the financial security of you and your family. As such, it is important to understand how your plan works and what benefits you will receive. The Basic Life and AD&D benefit is paid on your behalf by Charlie’s Plumbing. Voluntary Life Term Life Insurance is available to you through Principal. This benefit allows your loved ones, such as a spouse or other beneficiaries, to receive financial help in the case of your death. Your Term Life insurance benefit is available in $10,000 increments, to a maximum of $300,000. Dependent Term Life Insurance Term Life coverage is available for your spouse with the benefit of up to a max of $100,000, and for your child(ren) with a benefit of $10,000. Tip It is important that you name a primary and contingent beneficiary to receive your Life insurance benefits. Current Basic Life and Accidental Death & Dismemberment (AD&D) Principal Amount $25,000 Benet Age Reducon 35% - Age 65 / 50% - Age 70
10 Beneficiary Designation A beneficiary is the person designated to receive life insurance benefits in the event of the covered person’s death. It is important that your beneficiary designation is clear so that there will be no question as to your intentions. When naming your beneficiary(ies), please indicate the full name, address, Social Security number, relationship, date of birth and distribution percentage. It is also important that you name a primary and contingent beneficiary. Your Primary beneficiary(ies) will receive the benefit amount at the time of your death. If the Primary beneficiary(ies) is no longer living at that time, the benefit amount will go to your Contingent beneficiary(ies). For example: Primary Beneficiary(ies) - should total 100% » Mary J. Doe, Wife (100%) OR » Mary J. Doe, Wife (34%), Jane Doe, Daughter (33%), and John Doe, Son (33%) Contingent Beneficiary(ies) - should total 100% (receives benefit if Primary Beneficiaries are no longer living) » Joseph W. Doe, Son, and Jane Doe, Daughter (50% each) OR » Estate of the Insured (100%) If you name more than one beneficiary with unequal shares, please show the amount of insurance to be paid to each beneficiary in percentages, for example: “33% to Pauline Smith, Mother, and 67% to Mary J. Doe, Wife.” If there is insufficient space for your beneficiary designations, attach a separate sheet of paper indicating your designations and share percentages. If you need assistance, contact the Benefits Department or your own legal counsel. Current Voluntary Life Insurance / AD&D Principal Employee Minimum $10,000 Guarantee Issue $100,000 (within 31 days of initial eligibility) / Up to 2 increments @ Open Enrollment Maximium $300,000 Spouse Minimum $5,000 Guarantee Issue $25,000 (within 31 days of initial eligibility) / Up to 2 increments @ Open Enrollment Maximium $100,000 Child > 14 days old $5K or $10K Age Band Employee Spouse 0-29 $0.083 $0.109 30-34 $0.106 $0.131 35-39 $0.157 $0.180 40-44 $0.232 $0.248 45-49 $0.380 $0.376 50-54 $0.613 $0.572 55-59 $0.951 $0.866 60-64 $1.493 $1.464 65-69 $2.602 $2.484 70+ $4.657 $4.407 Child: $5k: $1.00 / $10K: $2.00 15 Group Medical Bridge insurance can help with medical costs associated with a hospital stay that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Please speak with a licensed benefit counselor for rates and see plan summary for additional details, limitations and exclusions.
10 Beneficiary Designation A beneficiary is the person designated to receive life insurance benefits in the event of the covered person’s death. It is important that your beneficiary designation is clear so that there will be no question as to your intentions. When naming your beneficiary(ies), please indicate the full name, address, Social Security number, relationship, date of birth and distribution percentage. It is also important that you name a primary and contingent beneficiary. Your Primary beneficiary(ies) will receive the benefit amount at the time of your death. If the Primary beneficiary(ies) is no longer living at that time, the benefit amount will go to your Contingent beneficiary(ies). For example: Primary Beneficiary(ies) - should total 100% » Mary J. Doe, Wife (100%) OR » Mary J. Doe, Wife (34%), Jane Doe, Daughter (33%), and John Doe, Son (33%) Contingent Beneficiary(ies) - should total 100% (receives benefit if Primary Beneficiaries are no longer living) » Joseph W. Doe, Son, and Jane Doe, Daughter (50% each) OR » Estate of the Insured (100%) If you name more than one beneficiary with unequal shares, please show the amount of insurance to be paid to each beneficiary in percentages, for example: “33% to Pauline Smith, Mother, and 67% to Mary J. Doe, Wife.” If there is insufficient space for your beneficiary designations, attach a separate sheet of paper indicating your designations and share percentages. If you need assistance, contact the Benefits Department or your own legal counsel. Current Voluntary Life Insurance / AD&D Principal Employee Minimum $10,000 Guarantee Issue $100,000 (within 31 days of initial eligibility) / Up to 2 increments @ Open Enrollment Maximium $300,000 Spouse Minimum $5,000 Guarantee Issue $25,000 (within 31 days of initial eligibility) / Up to 2 increments @ Open Enrollment Maximium $100,000 Child > 14 days old $5K or $10K Age Band Employee Spouse 0-29 $0.083 $0.109 30-34 $0.106 $0.131 35-39 $0.157 $0.180 40-44 $0.232 $0.248 45-49 $0.380 $0.376 50-54 $0.613 $0.572 55-59 $0.951 $0.866 60-64 $1.493 $1.464 65-69 $2.602 $2.484 70+ $4.657 $4.407 Child: $5k: $1.00 / $10K: $2.00 15 Group Medical Bridge insurance can help with medical costs associated with a hospital stay that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Please speak with a licensed benefit counselor for rates and see plan summary for additional details, limitations and exclusions.
14 If you’re diagnosed with a covered critical illness or cancer, group critical illness insurance from Colonial Life can help with your expenses, so you can concentrate on what’s most important—your treatment, care and recovery. *The policy name is Critical Illness and Cancer Group Specified Disease Insurance. Face Amount: $15,000 & $30,000 Please speak with a licensed benefit counselor for rates and see plan summary for additional details. 11 Income Protection If you have to miss work due to illness or an off-the-job injury, this benefit helps to ensure that at least part of your income continues. Our Disability Plans cover a portion of your income until you can return to work, or until you reach retirement age. Short Term Disability Insurance Short Term Disability (STD) benefits is provided for full time eligible employees. STD insurance protects a portion of your income if you become partially or totally disabled for a short period of time. Short Term Disability insurance replaces 60% of your income, up to a maximum of $1,000 per week. Certain exclusions as well as pre-existing condition limitations may apply. Please refer to your Summary Plan Description for details or contact the Benefits Department for specific benefits. Long Term Disability Insurance Long Term Disability (LTD) benefits is provided for full time eligible employees. LTD insurance protects a portion of your income if you become partially or totally disabled for a long period of time. This insurance replaces 60% of your income, up to a maximum of $6,000 per month, depending on your current annual earnings. Certain exclusions as well as pre-existing condition limitations may apply. Please refer to your Summary Plan Description for details or contact the Benefits Department about specific benefits. Short Term Disability Insurance Principal Elimination Period Benefit begins on the 7th day for accidents and 7th day for sickness Weekly Benefit Percentage 60% Weekly Benefit Maximum $1,000 Benefit payment period Up to 12 weeks Long Term Disability Insurance Principal Elimination Period Benefits begin after 90 days Monthly Benefit Percentage 60% Monthly Benefit Maximum $6,000 Benefit payment period Up to 24 months
14 If you’re diagnosed with a covered critical illness or cancer, group critical illness insurance from Colonial Life can help with your expenses, so you can concentrate on what’s most important—your treatment, care and recovery. *The policy name is Critical Illness and Cancer Group Specified Disease Insurance. Face Amount: $15,000 & $30,000 Please speak with a licensed benefit counselor for rates and see plan summary for additional details. 11 Income Protection If you have to miss work due to illness or an off-the-job injury, this benefit helps to ensure that at least part of your income continues. Our Disability Plans cover a portion of your income until you can return to work, or until you reach retirement age. Short Term Disability Insurance Short Term Disability (STD) benefits is provided for full time eligible employees. STD insurance protects a portion of your income if you become partially or totally disabled for a short period of time. Short Term Disability insurance replaces 60% of your income, up to a maximum of $1,000 per week. Certain exclusions as well as pre-existing condition limitations may apply. Please refer to your Summary Plan Description for details or contact the Benefits Department for specific benefits. Long Term Disability Insurance Long Term Disability (LTD) benefits is provided for full time eligible employees. LTD insurance protects a portion of your income if you become partially or totally disabled for a long period of time. This insurance replaces 60% of your income, up to a maximum of $6,000 per month, depending on your current annual earnings. Certain exclusions as well as pre-existing condition limitations may apply. Please refer to your Summary Plan Description for details or contact the Benefits Department about specific benefits. Short Term Disability Insurance Principal Elimination Period Benefit begins on the 7th day for accidents and 7th day for sickness Weekly Benefit Percentage 60% Weekly Benefit Maximum $1,000 Benefit payment period Up to 12 weeks Long Term Disability Insurance Principal Elimination Period Benefits begin after 90 days Monthly Benefit Percentage 60% Monthly Benefit Maximum $6,000 Benefit payment period Up to 24 months
12 13 Group Accident Insurance Premier Plan If you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance can pay benefits directly to you to use however you like—from medical costs to everyday expenses. Whether you’ve had a fall or a car accident, these benefits can offer financial support when you need it. Our coverage includes: Benefits payable directly to you No medical questions to qualify for coverage Coverage for simple and complex injuries Benefits payable regardless of other insurance Worldwide coverage Works alongside your Health Savings Account Please speak with a licensed benefit counselor for rates and see plan summary for additional details.
12 13 Group Accident Insurance Premier Plan If you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance can pay benefits directly to you to use however you like—from medical costs to everyday expenses. Whether you’ve had a fall or a car accident, these benefits can offer financial support when you need it. Our coverage includes: Benefits payable directly to you No medical questions to qualify for coverage Coverage for simple and complex injuries Benefits payable regardless of other insurance Worldwide coverage Works alongside your Health Savings Account Please speak with a licensed benefit counselor for rates and see plan summary for additional details.