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The benefits plan year runs fromJanuary 1st through December 31st. Unless you have a qualified change-in-status event that impacts your eligibility and the change is allowed under the terms of the insurance contract or plan document, you cannot make changes to your benefits until the next Open Enrollment period.Benefit changes must be consistent with your qualified change-in-status event.Mid year changes must be submitted to Human Resources within 30 days of the event; documentation supporting the change will be required.Who is eligible for benefits?All full-time employees who work a minimum of 32-hours per week are eligible for benefits. For new hires, benefits are effective on the first of the month following 60 days of employment.In addition to enrolling yourself, you may also enroll any eligible dependents. Eligible dependents are defined below:• Spouse: a person to whom you are legally married by ceremony• Child(ren): Your biological, adopted, or legal dependents up to age 26 regardless of student, financial, and marital status; coverage for a dependent child will terminate at the end of the month in which the child turns age 26Change-in-Status EventsUnless you have a qualified change-in-status event that impacts your eligibility and the change is allowed under the terms of the insurance contract or plan document, you cannot make changes to the benefits you elect until the next Open Enrollment period. Some examples of qualified change-in-status events are highlighted below:Marriage or divorceBirth, adoption, or deathChange in employment, or employment status for you, your spouse, or your dependent childChange in coverage under another employer plan, such as a change made during your spouse’s Open EnrollmentRaven Mechanical takes pride in providing a comprehensive employee benefits program, and we recognize the important role employee benefits play as a critical component of your overall compensation. We strive to maintain a benefits program that is rewarding and competitive.WHAT’S INSIDEEmployee Resources Medical Plan Highlights Benefits Concierge Health Savings Account (HSA) Dental Plan Highlights Vision Plan Highlights Life/AD&D Disability Plan Highlights Voluntary Worksite Benefits Employee Assistance Program Additional Benefits Vendor Contact Information2
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.OVERVIEW OF BENEFITS PROGRAM3Raven Mechanical provides an array of benefits that can help you enjoy increased well-being, deal with an unexpected illness or accident, build and protect your financial security, balance your personal and professional life and meet everyday needs. These benefits are affordable, comprehensive and competitive.The table below summarizes the benefits available to eligible staff and their dependents. These benefits are described in greater detail in this booklet.Benefits Funding Carrier Medical & Prescription DrugsEmployee + DependentsShared funding UltraBenefits Health Savings Account (HSA)Employee OnlyEmployee ContributionsWEXVoluntary DentalEmployee + Dependents100% Employee PaidCigna Voluntary VisionEmployee + Dependents100% Employee Paid CignaGroup Life / AD&DEmployee + Dependents100% Company PaidMutual of OmahaVoluntary Life / AD&DEmployee + Dependents100% Employee PaidMutual of OmahaVoluntary Short-Term DisabilityEmployee Only100% Employee PaidMutual of OmahaVoluntary Long-Term Disability Employee Only100% Employee PaidMutual of OmahaVoluntary Accident InsuranceEmployee + Dependents100% Employee PaidMutual of OmahaVoluntary Critical IllnessEmployee Only100% Employee PaidMutual of OmahaEmployee Assistance Program (EAP)Employee + Dependents100% Company PaidMutual of Omaha3
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.KEY TERMS TO REMEMBERANNUAL DEDUCTIBLEThe amount you must pay each year before the plan starts paying a portion of medical expenses. All family members’ expenses that count toward a health plan deductible accumulate together in the aggregate; however, each person also has a limit on their own individual accumulated expenses (the amount varies by plan).OUT-OF-POCKET MAXIMUMThis is the total amount you can pay out of pocket each calendar year before the plan pays 100 percent of covered expenses for the rest of the calendar year. Most expenses that meet provider network requirements count toward the annual out-of-pocket maximum, including expenses paid to the annual deductible, copays and coinsurance.COPAYS AND COINSURANCEThese expenses are your share of cost paid for covered health care services. Copays are a fixed dollar amount and are usually due at the time you receive care. Coinsurance is your share of the allowed amount charged for a service and is generally billed to you after the health insurance company reconciles the bill with the provider.MEDICAL TERMINOLOGY4PLAN TYPESEPO – EPO stands for exclusive provider organization. This is a network of doctors, hospitals, and other healthcare providers that offers in-network coverage only. HDHP – A plan that has higher deductibles in exchange for lower premiums. HDHPs are compatible with Health Savings Accounts (HSA).4
This booklet provides only a summary of your benefits. All services described within are subject to the definitions, limitations, and exclusions set forth in each insurance carrier or provider’s contract.MEDICAL & PRESCRIPTION INSURANCE5IN-NETWORK Base $6,900-100% HDHP EPOMiddle $5,000-80% EPO Buy-Up $2,000-80% EPO Provider Network Cigna Open Access Plus-In EPO Cigna Open Access Plus-In EPO Cigna Open Access Plus-In EPOHSA Compatible? YES NO NODeductibles$6,900 / $13,800 $5,000 / $10,000 $2,000 / $4,000(Individual / Family)Out-of-Pocket Max (Individual / Family)$6,900 / $13,800(Includes Deductible and Coinsurance)$6,600 / $13,200(Includes Deductible, Coinsurance, & Copays)$6,000 / $12,000(Includes Deductible, Coinsurance, & Copays)Coinsurance(Member Responsibility)0% after deductible 20% after deductible 20% after deductiblePreventive Care No Charge No Charge No chargePrimary Care Visit No charge after deductible $40 copay $25 copayVirtual Visits No charge after deductible $40 copay $25 copaySpecialist Visit No charge after deductible $70 copay $50 copayDiagnostic Lab & X-Ray No charge after deductible 20% after deductible 20% after deductibleComplex Imaging(MRI, CT scan, PET scan)No charge after deductible 20% after deductible 20% after deductibleOutpatient Procedure No charge after deductible 20% after deductible 20% after deductibleInpatient Stay No charge after deductible 20% after deductible 20% after deductibleEmergency Room No charge after deductible$500 copay per visit $300 copay per visit + 20% coinsurance + 20% coinsuranceUrgent Care No charge after deductible $75 copay $75 copayRetail Pharmacy / RX (30-Day Supply)No charge after deductibleRX Out-of-Pocket MaximumIndividual: $1,000 / Family: $2,000 $15 / $50 / $90 / $200$15 / $50 / $90 / $200Mail Order Pharmacy / RX (90-Day Supply)*Excludes specialty drugsNo charge after deductible $38 / $125 / $225 $38 / $125 / $225 OUT-OF-NETWORKDeductibles (Individual / Family)Not Covered Not Covered Not CoveredCoinsurance(Member Responsibility)Not Covered Not Covered Not CoveredOut-of-Pocket Max (Individual / Family)Not Covered Not Covered Not CoveredCost Per Pay Period (52) Base $6,900-100% HDHP EPO Middle $5,000-80% EPO Buy-Up $2,000-80% EPO Employee$36.45 $69.92 $88.63 Employee + Spouse$174.20 $249.02 $290.63 Employee + Child(ren)$165.25 $237.24 $277.50 Employee + Family$296.07 $407.16 $469.33
About your Rightway benefit.Rightway is a service we sponsor that makes healthcare simpler for you. With Rightway, you have a dedicated (real, live) health guide who can do all the doctor-finding, appointment-making, and price-comparing for you through a simple-to-use-app. Your health guide is there to answer all of your healthcare questions, no matter how big or how small. You can use Rightway for free. Your account is ready to go, just follow the steps below to get started.1. Activate your Rightway account.Download the Rightway app in the Apple App Store or get it on Google Play.I2. Connect with your health guide through the Rightway app to...o Find the best doctor and book your appointment.o Review your symptoms and figure out next steps.o Create a tailored care plan for ongoing conditions.o Get upfront pricing on your medical and dental visits.3. Use Rightway for everything healthcare.o Not sure what's covered? Your health guide can answer your health insurance questions.o Unexpected bill? Rightway can explain it and even dispute charges on yourbehalf.o Have a different question? Your guide is a healthcare expert who is dedicated to helping you find answers.RIGHTWAY - BENEFIT ADVOCACY6
7This chart is intended for summary purposes only. If there are any discrepancies, the official plan documents will always govern. Pre-certification may be required for certain services.HEALTH SAVINGS ACCOUNTWho Is Eligible?* All three criteria must be met:• Enrolled in an IRS “qualified” High Deductible Health Plan• Not covered by another medical plan unless the other plans is also a “qualified” HDHP• Not enrolled in Medicare coverage*It is the employee’s responsibility to notify HR if you are not eligible for HSA.How does it work? The HDHP allows employees to set aside money on a pre-tax basis into a Health Savings Account (HSA). The HSA is an account established exclusively for the purpose of paying for qualified medical expenses for you and your eligible dependents on a tax-free basis. Contributions to the HSA are funded with pre-tax deductions withheld from your paycheck. The funds are deposited into an interest-bearing account in your name. The money in the HSA can be used to reimburse eligible expenses not covered by your insurance plan, including the deductible, coinsurance, and copays. Any money not used for medical reimbursement remains in the account. In the event you leave the company, you own the account and the money therein. For a complete list of “qualified” medical expenses, please refer to Publication 502 at www.irs.gov. How much can I contribute? IRS ANNUAL LIMITS 2024 Max ContributionSingle Only$4,150 Employee + Family$8,300Catch-Up Contribution Employees Age 55+ may be eligible to contribute an additional $1,000
Dental We are pleased to offer you comprehensive dental plans. On the DPPO plan, you can visit any licensed dentist, but your costs are usually lowest with an in-network dentist. In-network dentists accept reduced fees for covered services; out-of-network dentists may balance bill you the difference between their usual fee and what the plan pays. VOLUNTARY DENTAL INSURANCEPrevention first!Make sure you take advantage of your preventive dental visits. Preventive care services are not subject to the deductible and the plan covers 100% of the cost if you visit an in-network provider!8This chart is intended for summary purposes only. If there are any discrepancies, the official plan documents will always govern.DHMO Plan FeaturesIn-Network OnlyProvider NetworkFee ScheduleAnnual Benefit Maximum (Maximum amount the plan will pay per calendar year)NoneCalendar Year Deductible Amount you must pay per calendar year before the plan begins to pay benefits. Deductible waived for preventive services.NonePreventive and Diagnostic ServicesFee ScheduleBasic ServicesFee ScheduleMajor ServicesFee ScheduleLifetime Orthodontia Maximum(Maximum amount the plan will pay per lifetime)Fee ScheduleYour Cost Per Pay Period (52)Employee$3.82Employee + Spouse$6.80Employee + Child(ren)$7.87Employee + Family$10.35DPPO FeaturesIn-Network & Out-of-NetworkNetworkTotal Cigna DPPOAnnual Benefit Maximum (Maximum amount the plan will pay per calendar year)$1,000 Calendar Year Deductible Amount you must pay per calendar year before the plan begins to pay benefits waived for preventive$50 individual$150 familyPreventive and Diagnostic ServicesNo charge—no deductibleBasic Services20% after deductibleMajor Services50% after deductibleLifetime Orthodontia Maximum(Maximum amount the plan will pay per lifetime)50% after deductible (Children to age 19 only)$1,000 lifetime maximumYour Cost Per Pay Period (52)Employee$6.57Employee + Spouse$13.90Employee + Child(ren)$17.43Employee + Family$25.56
VOLUNTARY VISION INSURANCE9VisionYour vision coverage provides a full range of vision care services. You may receive care from any provider you choose, but your benefits are greater when you see a participating provider in the network. If you choose to receive services from an out-of-network provider, you will be required to pay that provider at the time of service and submit a claim form for reimbursement.*Benefit includes coverage for contacts or glasses, not both.Plan FeaturesIn-Network Out-of-Network ReimbursementProvider NetworkVSPVision ExamOnce every 12 months$0 copay Up to $45Eyeglass Frames*Once every 24 months$130 plan allowance + 20% off balance over $130Up to $71Eyeglass Lenses Once every 12 months Single$0 copay Up to $32Lined Bifocal$0 copay up to $55Lined Trifocal$0 copayUp to $65Lenticular$0 copayUp to $80Members pay for lens enhancements as an out-of-pocket expense; discounts range from ~40-60% off retailContact Lenses*Once every 12 monthsElective: $130 allowanceNecessary: $25 copayUp to $105Up to $210Your Cost Per Pay Period (52)Employee$1.81Employee + Spouse$3.36Employee + Child(ren)$3.39Employee + Family$5.26
Basic Term Life and AD&D Insurance (Company Paid)All full-time employees working 30 or more hours per week are automatically enrolled in the basic life benefit. While coverage is automatic, is critical that you complete a beneficiary form when first enrolling in benefits. You can change your beneficiary at any time and as frequently as needed. LIFE INSURANCEDuring your benefits enrollment, don’t forget to designate a beneficiary!10Life insurance helps protect your family from financial risk and sudden loss of income in the event of your death. Accidental death and dismemberment (AD&D) insurance provides an additional benefit if you lose your life, sight, hearing, speech, or limbs in an accident. Basic Life SummaryEmployee Life and AD&D Benefit$25,000Spouse Life Benefit$5,000(Spousal coverage ends at age 70)Child Life Benefit$2,500(14 days to age 26)Employee Reduction Schedule67% at age 70; 52% at age 75Additional BenefitsConversion, Accelerated Death Benefit, Waiver of PremiumVoluntary Life SummaryLife/AD&D Benefit-Employee-Spouse-Child(ren) 5X annual salary up to $500,000 (units of $10,000)50% of employee’s benefit up to $250,000 (units of $5,000)50% of employee’s benefit up to $10,000 (units of $1,000)Guaranteed Issue (no medical questions)-Employee-Spouse5X annual salary up to $150,000100% of employee’s benefit up to $25,000Reduction Schedule67% at age 70; 52% at age 75Additional BenefitsConversion, Accelerated Death Benefit, Waiver of PremiumVoluntary Term Life and AD&D Insurance (Employee Paid)All full-time employees working 30 or more hours per week are eligible to enroll in additional voluntary life insurance above and beyond the employer paid benefits. Voluntary term life rates are offered at heavily discounted group rates. So long as you enroll when first eligible, guaranteed coverage is also available to you, regardless of your current health status.
VOLUNTARY LIFE/ AD&D RATES11To determine your weekly deduction for Employee coverage, use the chart below. First, locate the benefit amount you want along the top row. Second, find your age bracket in the far-left column. The premium amount is found in the box where the row (your age) and column (benefit amount) intersect. Example: Benefit Amount = $50,000 Age = 36 Premium = $1.80EMPLOYEE PREMIUM TABLE (52 PAYROLL DEDUCTIONS PER YEAR)Age$10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 0 - 24 $0.18 $0.36 $0.54 $0.72 $0.90 $1.08 $1.26 $1.44 $1.62 $1.80 25 - 29 $0.22 $0.44 $0.66 $0.89 $1.11 $1.33 $1.55 $1.77 $1.99 $2.22 30 - 34 $0.30 $0.60 $0.90 $1.20 $1.50 $1.80 $2.10 $2.40 $2.70 $3.00 35 - 39 $0.36 $0.72 $1.08 $1.44 $1.80 $2.16 $2.52 $2.88 $3.24 $3.60 40 - 44 $0.48 $0.96 $1.44 $1.92 $2.40 $2.88 $3.36 $3.84 $4.32 $4.80 45 - 49 $0.66 $1.32 $1.98 $2.64 $3.30 $3.96 $4.62 $5.28 $5.94 $6.60 50 - 54 $1.02 $2.04 $3.06 $4.08 $5.10 $6.12 $7.14 $8.16 $9.18 $10.20 55 - 59 $1.80 $3.60 $5.40 $7.20 $9.00 $10.80 $12.60 $14.40 $16.20 $18.00 60 - 64 $3.24 $6.48 $9.72 $12.96 $16.20 $19.44 $22.68 $25.92 $29.16 $32.40 65 - 69 $4.92 $9.84 $14.76 $19.68 $24.60 $29.52 $34.44 $39.36 $44.28 $49.20 70+ $7.80 $15.60 $23.40 $31.20 $39.00 $46.80 $54.60 $62.40 $70.20 $78.00 To determine your semi-monthly deduction for Spouse coverage, use the chart below. First, locate the benefit amount you want. Second, find your age bracket (based on employee’s age). The premium amount is found in the box where the row (age bracket) and column (election amount) intersect. Example: Benefit Amount = $25,000 Employee’s Age = 52 Premium = $2.55SPOUSE PREMIUM TABLE (52 PAYROLL DEDUCTIONS PER YEAR)Age$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 0 - 24 $0.09 $0.18 $0.27 $0.36 $0.45 $0.54 $0.63 $0.72 $0.81 $0.90 25 - 29 $0.11 $0.22 $0.33 $0.44 $0.55 $0.66 $0.78 $0.89 $1.00 $1.11 30 - 34 $0.15 $0.30 $0.45 $0.60 $0.75 $0.90 $1.05 $1.20 $1.35 $1.50 35 - 39 $0.18 $0.36 $0.54 $0.72 $0.90 $1.08 $1.26 $1.44 $1.62 $1.80 40 - 44 $0.24 $0.48 $0.72 $0.96 $1.20 $1.44 $1.68 $1.92 $2.16 $2.40 45 - 49 $0.33 $0.66 $0.99 $1.32 $1.65 $1.98 $2.31 $2.64 $2.97 $3.30 50 - 54 $0.51 $1.02 $1.53 $2.04 $2.55 $3.06 $3.57 $4.08 $4.59 $5.10 55 - 59 $0.90 $1.80 $2.70 $3.60 $4.50 $5.40 $6.30 $7.20 $8.10 $9.00 60 - 64 $1.62 $3.24 $4.86 $6.48 $8.10 $9.72 $11.34 $12.96 $14.58 $16.20 65 - 69 $2.46 $4.92 $7.38 $9.84 $12.30 $14.76 $17.22 $19.68 $22.14 $24.60 Regardless of how many children you have, they are included in the “All Children” premium amounts listed. ALL CHILDREN PREMIUM TABLE (52 PAYROLL DEDUCTIONS PER YEAR)*$1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 $0.05 $0.11 $0.16 $0.22 $0.27 $0.32 $0.38 $0.43 $0.49 $0.54 Note: This is an estimate of premium cost. Actual deductions may vary slightly due to rounding.
VOLUNTARY DISABILITY INSURANCE12Short-Term Disability Plan Features Mutual of OmahaEmployee Benefit Amount 60%Maximum Benefit Amount $1,500 per WeekElimination Period (Waiting Period) 14 DaysBenefit Duration 11 WeeksPre-Existing Condition Exclusion 3/6*Long-Term Disability Plan Features Mutual of OmahaEmployee Benefit Amount 60%Maximum Benefit Amount $8,000 per MonthOwn Occupation Period 2 YearsElimination Period (Waiting Period) 90 DaysBenefit Duration Social Security Normal Retirement AgePre-Existing Condition Exclusion 12/12*Why do you need Voluntary Long-Term Disability? (Employee Paid)A lengthy disability can be devastating and is more common than you may think. Long-term disability may lead to a loss of income, independence, and financial security. A disability insurance policy can help provide security when you need it most. It pays you cash benefits when you’re sick or hurt and can’t work. As an active, full-time employee of Raven Mechanical who works a minimum of 32-hours per week, you are eligible to elect LTD and take advantage of the group rate through Mutual of Omaha. Why do you need Voluntary Short-Term Disability? (Employee Paid)How would you pay your bills if you were sick or injured? Even a short illness or injury could seriously impact your paycheck. What happens when your sick time runs out? Disability replaces part of your income if you are unable to work due to an accident, illness, or if you are expecting a new addition to your family. Maternity Leave is one of the most common uses for disability insurance. Fortunately, all full-time employees who work a minimum of 32-hours per week are eligible to elect Short-Term benefits and take advantage of the group rate.Weekly STD Premium Calculation Example:Employee Age: 42; Annual Salary: $40,000; STD rate: $0.0049846; Employee Contribution = 100%1) Calculate Your Weekly Earnings (maximum is $2,500): $40,000 / 52 weeks = $769.23 2) Multiply by the premium factor: $769.23 x $0.0049846 = $3.83 per paycheckThis is an estimate of premium cost. Actual deductions may vary slightly due to rounding and payroll frequency. Monthly LTD Premium Calculation Example:Employee Age: 42; Annual Salary: $40,000; LTD rate: $0.00175538; Employee Contribution = 100%1) Calculate Your Monthly Earnings (maximum is $13,333.33): $40,000 / 12 months = $3,333.332) Multiply by the premium factor: $3,333.33 x $0.0017538 = $5.84 per paycheckThis is an estimate of premium cost. Actual deductions may vary slightly due to rounding and payroll frequency. *Both disability plans include a pre-existing condition exclusion. A pre-existing condition is one for which you have received medical treatment, consultation, care or services including diagnostic measures, or if you were prescribed or took prescription medications in the predetermined time frame prior to your effective date of coverage. The pre-existing condition under the STD plan is 3/6 and the LTD is 12/12. This means any condition that you receive medical attention for in the 3 (STD) or 12 (LTD) months prior to your effective date of coverage that results in a disability during the first 6 months (STD) or 12 months (LTD) of coverage, will not be covered.
VOLUNTARY ACCIDENT INSURANCE13ELIGIBILITY - ALL ELIGIBLE EMPLOYEESEligibility Requirement You must be actively working a minimum of 32 hours per week to be eligible forcoverage.Dependent Eligibility RequirementTo be eligible for coverage, your dependents must be able to perform normal activities, and not be confined (at home, in a hospital, or in any other care facility), and any child(ren) must be under age 26. In order for your spouse and/or children to be eligible for coverage, you must elect coverage for yourself.Premium Payment The premiums for this insurance are paid in full by you.PLAN INFORMATION INFORMATION / AMOUNT(S)Coverage Type Non-occupational (Off-job only)Express Benefit $75Annual Benefit Maximum(ABM)Not IncludedPortability IncludedBENEFITS AMOUNTSInitial Care & Emergency1 – Most treatment / service required within 72 hours of accident; Once per accident perinsured personEmergency Room $150Urgent Care Center $100Initial Physician Office Visit $75Ambulance Up to $1,000Specified Injuries1,2Fractures (Surgical / Non-surgical) Up to $6,000/Up to $3,000Dislocations (Surgical / Non-surgical) Up to $9,000/Up to $4,500Lacerations Up to $800Burns Up to $15,000Dental Up to $300Hospital, Surgical & DiagnosticAdmission $1,000Daily Confinement (Up to 365 days per accident) $200 per dayICU Confinement (Up to 15 days per accident) $400 per dayRehab. Facility Confinement (Up to 30 days per accident)$100 per daySurgical Up to $1,500Diagnostic Up to $200Follow-Up Care – Treatment / service required within 365 days of accident; Medical device is once per accident per insured person Physician Follow-Up Office Visit $75; Up to 6 per accidentTherapy Services $25; Up to 6 per accidentMedical Device $100Prosthetic Device(s) $750; Up to 2 per accidentAdditional Benefits – Benefits are payable within 365 days of accidentTransportation (Up to 3 trips per accident) $300 per tripLodging (Up to 30 nights per accident) $125 per night
VOLUNTARY CRITICAL ILLNESS INSURANCE14ELIGIBILITY - ALL ELIGIBLE EMPLOYEESEligibility Requirement You must be actively working a minimum of 32 hours per week to be eligible for coverage.Dependent Eligibility RequirementTo be eligible for coverage, your dependents must be able to perform normal activities, and not be confined (at home, in a hospital, or in any other care facility), and any child(ren) must be under age 26. In order for your spouse and/or children to be eligible for coverage, you must elect coverage for yourself.Premium PaymentThe premiums for this insurance are paid in full by you. Child insurance is automatic. A separate premium is not required.BENEFIT CATEGORY1 CONDITION% OF CI PRINCIPAL SUMHeart/Circulatory/Motor FunctionHeart Attack, Heart Transplant, Stroke, ALS (Lou Gehrig’s), Advanced Alzheimer's, Advanced Parkinson's100%Heart Valve Surgery, Coronary Artery Bypass, Aortic Surgery 25%OrganMajor Organ Transplant/Placement on UNOS List, End-Stage Renal Failure100%Acute Respiratory Distress Syndrome (ARDS) 25%Childhood/Developmental*benefits only available to childrenCerebral Palsy, Structural Congenital Defects, Genetic Disorders,Congenital Metabolic Disorders, Type 1 Diabetes100%CancerCancer (Invasive) 100%Bone Marrow Transplant 50%Carcinoma in Situ, Benign Brain Tumor 25%COVERAGE GUIDELINES2MINIMUM MAXIMUM GUARANTEE ISSUE3For YouElect in $10,000 increments$10,000 $10,000 $10,000SpouseElect in $10,000 increments$10,000100% of employee’s CIPrincipal Sum, up to $10,000$10,000Child(ren)*benefit for each child25% of employee’s CI Principal Sum, up to $3,000 $3,000ADDITIONAL BENEFITSPolicy Benefit MaximumThe maximum payout amount is 300% of the CI Principal Sum amount for each insured person. If the policy benefit maximum is reached for an insured person, the coverage will terminate. Dependents will remain insured if you continue to satisfy the eligibility requirements of the policy.Health Screening Benefit Pays a flat, annual benefit of $50 for a health screening test.Additional Occurrence BenefitOnce benefits have been paid for a Critical Illness, no additional benefits are payable for that same Critical Illness for each insured person. Benefits are still payable for any other Critical Illness in the same benefit category, for each insured person.Reoccurrence Benefit The reoccurrence benefit is equal to 100% of the Critical Illness principal sum.PortabilityWhen insurance ends, you have the right to continue group Critical Illness insurance for yourself and your dependents.Conditions & LimitationsAge ReductionsWhen you turn age 70, the original amount of insurance will reduce to 50% for both you and your spouse. Benefit Waiting Period There is no benefit waiting period VOLUNTARY CRITICAL ILLNESS EMPLOYEE PREMIUM RATESAge $10,000 0 - 29 $0.92 30 - 39 $1.66 40 - 49 $3.69 50 - 59 $8.15 60 - 69 $17.47 70 - 79 $32.63 80+ $44.22 1. Payment of a partial benefit reduces the remaining amount payable in a category. 2. The amount of insurance for your spouse and child(ren) will be rounded to the next higher multiple of $1,000, if not already an even multiple of $1,000.3. Subject to any reductions, Guarantee Issue is available to new hires. Amounts over the Guarantee Issue will require a health application/evidence of insurability. For late entrants, all amounts will require a health application/evidence of insurability. Amounts over the Guarantee Issue and/or not meeting minimum participation levels will require a health application/evidence of insurability.
ADDITIONAL BENEFITS15Employee Assistance Program - 100% Company PaidLife isn’t always easy. Sometimes a personal or professional issue can affect your work, health, and general well-being. During these tough times, it’s important to have someone to talk with to let you know you’re not alone. We are pleased to offer an employee assistance program (EAP) for you and your immediate family members. Our EAP is a comprehensive resource providing access to professional assistance for a wide range of personal and work-related issues. The service is provided by Raven , at no cost to you, and is available to you and your immediate family members twenty-four hours a day, 365 days a year, and provides resources to help employees find solutions to everyday issues. Services include 3 face-to-face counseling or video sessions per household, unlimited phone counseling with master’s-level consultants to help with more serious issues, and online resources. Participation is voluntary and strictly confidential.Sample topics include:✓Legal and financial matters✓Work and lifestyle✓Child / elder care resources and referrals✓Stress, anxiety, depression✓Substance abuse and addiction Travel Assistance Program - 100% Company PaidTake comfort in knowing that travel assistance travels with you worldwide, offering access to a network of professionals who can help you with local medical referrals or provide emergency assistance services in foreign locations. Travel assistance can help you avoid unexpected bumps in the road anywhere in the world for you, your spouse, and dependent children on any single trip, more than 100 miles from home.You have options! Don’t delay if you need help. To speak to a counselor, or to learn more about your EAP plan, simply:Call: 1-800-316-2796, orgo online: www.mutualofomaha.com/eap Pre-Trip Assistance ➢ Travel, health advisories, and inoculation requirements for foreign countries➢ Daily Foreign currency exchange rates➢ Consulate and embassy locations Emergency Travel Support➢ 24/7 access to telephonic translation services➢ Assistance with lost, stolen, or delayed baggage while traveling on a common carrier➢ Emergency payment and cashMedical Assistance ➢ Help locating medical providers➢ Transportation home for further treatment – in the event of death, assist in the return of mortal remains➢ Coordination with your health insurance carrier during a medical emergency
ADDITIONAL BENEFITS16Will Preparation Creating a will is an important investment in your future. It specifies how you want your possessions to be distributed after you pass away. Whether you’re single, married, have children, or you’re a grandparent, your will should be tailored for your life situation. That’s why it’s good that you have access to FREE online will preparation services provided by Epoq, Inc.Epoq provides the following FREE documents: ➢ Last Will and Testament➢ Power of Attorney➢ Healthcare Directive➢ Living Trust Here’s how it works: 1. Log onto www.willprepservices.com and use code MUTUALWILLS to register2. Answer simple questions and customize your document in real time3. Download, print, and share your documents instantly 4. Don’t forget to update your documents with any major life changes, including marriage, divorce, and birth of a child5. Make the document legally binding – check with your state for requirementsIdentity Theft Assistance helps you and your dependents understand the risks of identity theft, learn how to prevent it, and most importantly, assist you if your information is compromised. Services include: AWARENESS & EDUCATION RECOVERY ASSISTANCE→ Promoting awareness of identity theft → Connecting you to fraud departments at your bank and credit card companies→ Answering your questions about ID theft → Facilitating access to credit bureaus and obtaining a complimentary credit report→ Educating you on how to avoid having your identity stolen → Guiding you in contacting federal and local law enforcement agencies and filing reports and complaints Identity Theft Assistance
VENDOR CONTACT INFORMATION17Carrier Name Group # Website Phone NumberMedical/RXUltraBenefits557www.ultrabenefits.com(best to register)(866) 858-7223Benefits ConciergeRightway(833) 689-0569M-F: 7AM - 9PMCSTSa & Su: 8AM - 4PMCSTHealth Savings Account (HSA)WEXwww.wex.com (866) 451-3399DentalCigna631941www.cigna.com1.Find doctor, dentist, or facility2.Log-in, or search ‘plans through employer’3.Select a dental plan4.DPPO = Total Cigna DPPO5.Enter search criteria(800) 244-6224VisionCigna631941www.cigna.com1.Find a doctor, dentist, or facility2.Select Cigna Vision Directory under‘Additional Directories’3.Enter search criteria(800) 244-6224Group Life and AD&DMutual of OmahaG000BP4B www.mutualofomaha.com (800) 877-5176Voluntary Life and AD&DMutual of OmahaG000BP4B www.mutualofomaha.com (800) 877-5176Voluntary DisabilityMutual of OmahaG000BP4B www.mutualofomaha.com (800) 877-5176Voluntary Worksite Benefits(Critical Illness & Hospital)Mutual of OmahaG000BP4B www.mutualofomaha.com (800) 877-5176Employee
Assistance Program (EAP)Mutual of OmahaG000BP4B www.mutualofomaha.com/eap (800) 316-2796Human ResourcesAnn MintonHR Managerann.minton@ravenmechanical.com(281) 987-1618, ext. 6138
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