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3. insurance

2015
Monroe County School District
Employee Benefit Guide
Monroe County School District
Dear Monroe County School District Employee,
It’s benefit enrollment time once again and we have some exciting changes for the coming year. We have partnered
with new providers for 2015 which means new opportunities for you and your family.
The School District recognizes the importance of benefits for you and your family, that’s why we take the time
to carefully select providers that can best serve our employees. We know you don’t make your benefit decisions
lightly, which is why we are dedicated to partnering with providers who offer quality benefits.
Your benefit enrollment will be for all core (Medical/Dental/Vision/Disability Income Protection/Life/Medical
Flexible Spending Account and Dependent Flexible Spending Account) plus supplementary benefits. This year
we have a new life insurance carrier, Minnesota Life. Minnesota Life is offering up to $100,000 guaranteed
issuance on life insurance for the employee, guaranteed issuance up to $25,000 for Spouse and $10,000 for
Children.
For 2015, we are proud to partner with American Fidelity Assurance Company for the following supplementary
benefits:
Disability Income Insurance
Term Life Insurance
Accident Insurance
Cancer Insurance
Critical Illness Insurance
Keep in mind that the supplementary benefits that are being offered by American Fidelity Assurance Company is
not a mandatory enrollment. These benefits are being offered to you at your discretion and you are not obligated
to enroll.
Enrollment counselors will be available throughout the open enrollment process to assist you in enrolling in all of
your benefits and to answer any questions you may have. To see a complete schedule of this year’s open enrollment
sessions, please see page 6.
The Employee Benefits Department developed the following benefit guide to provide you with information about
your benefit options for the new plan year, explain the enrollment and change process, and serve as a valuable
resource for information about all the benefits available to you. It’s a good idea to take some time to read this guide
before attending open enrollment and/or completing your enrollment forms.
Thank you in advance for taking the time to review this benefit guide and we look forward to seeing you during
open enrollment.
Sincerely,
Wanda Menendez
Employee Benefits & Risk Management Specialist
Table of Contents
2015 Benefits Enrollment
Annual Enrollment........................................................................................................5
Section 125 Cafeteria Plan .........................................................................................5
How to Enroll ..................................................................................................................6
Enrollment Schedule....................................................................................................6
Insurance Plans
SMART................................................................................................................................8
Eligibility Requirements..............................................................................................9
Prescription Plans........................................................................................................11
Medical Benefit Summaries.....................................................................................12
Dental/Vision Rates.....................................................................................................16
Dental Plan.....................................................................................................................17
Vision Plan......................................................................................................................25
Group Term Life Insurance........................................................................................28
Disability Income Protection ..................................................................................30
Critical Illness/Disability Income Insurance........................................................33
Accident Only/Hospital GAP Insurance ..............................................................34
Cancer/Permanent Portable Life Insurance ......................................................35
Life Insurance................................................................................................................36
Flexible Spending Accounts (FSA)
Health Flexible Spending Account (FSA)............................................................38
Flex Debit Card.............................................................................................................39
Dependent Care FSA..................................................................................................40
Filing a Flex Claim........................................................................................................41
Accessing Your FSA.....................................................................................................41
Other Information
Cigna Will Center..........................................................................................................43
Vista 401(k).....................................................................................................................45
COBRA Q&A ..................................................................................................................47
Beyond Your Benefits.................................................................................................48
Marketplace Notice.....................................................................................................49
Benefits Directory........................................................................................................52
2015
BENEFITS
ENROLLMENT
Annual Enrollment
Section 125 Cafeteria Plan
How to Enroll
Enrollment Schedule
Your Annual Enrollment
Important Dates to Remember
Your Open Enrollment Dates are:
November 12, 2014 - December 6, 2014
Your Plan Year is:
January 1, 2015 - December 31, 2015
Note: Changes to insurance plans will go into effect January 1st.
Annual Open Enrollment
Before you meet with your American Fidelity Representative, take time
to evaluate your current coverage and decide how well it serves the
needs of you and your family.
Important Points To Consider
•
Figure an estimate of child care expenses.
•
Review your beneficiaries.
•
Review American Fidelity’s options of portable insurance plans
that you can keep if your employment changes.
•
Evaluate your need for life insurance.
•
Consider increasing your Disability Income Insurance policy
amount to match your current salary.
Each year Open Enrollment provides you an opportunity to change
plans and modify dependent coverage. Your election deductions
begin in June and will remain in effect through the plan year (January
1, 2015 - December 31, 2015) for your Voluntary benefits.
NOTE: If eligibility changes during the year you must notify Human
Resources within 31 days of the qualifying event.
Your Section 125 Plan
Save Money With Section 125
If there was a program available that could dramatically save money
on your taxes, would you take advantage of it? That’s exactly what
the Section 125 Plan does—reduces your taxes and increases your
spendable income! Plus, the Plan is available to you at no cost* and
you’re already eligible, all you have to do is enroll.
The Plan works like this: You are allowed to deduct needed benefits
from gross earnings before taxes are computed. This means that
current after-tax expenses, such as insurance products and benefits,
can be paid for with pre-tax dollars.
The advantage of this Plan is simple: The eligible premiums you pay
under the Plan are paid on a pre-tax basis. You could be on your way to
increased savings, just by signing up and taking advantage of this Plan!
Benefits Eligible For The Section 125 Cafeteria
Plan
•
Group Medical, Dental and Vision Insurance
•
Accident Insurance
•
Cancer Insurance
•
Flexible Spending Accounts
5
How Can This Plan Help Me?
The sample paycheck below shows the benefits under the Section
125 Plan compared to benefits outside of the Plan. In this example,
the employee gained $55 more spendable income per month!
Pre-Tax Example
After-Tax
Example
$1,500.00
Monthly Gross Salary
$1,500.00
- $150.00
Pre-Tax Medical Insurance
$0.00
- $25.00
Pre-Tax Disability Insurance
$0.00
- $25.00
Pre-Tax Accident Insurance
$0.00
$1,300.00
Adjusted Monthly Gross Salary
$1,500.00
- $260.00
Estimated Federal Tax (20%)
- $300.00
- $99.45
Estimated FICA (7.65%)
- $114.75
$0.00
After-Tax Medical Insurance
- $150.00
$0.00
After-Tax Disability Insurance
- $25.00
$0.00
After-Tax Accident Insurance
- $25.00
Take-Home Pay
$885.25
$940.55
* Taxes are a sample average of State, Federal and FICA taxes. Your own
average tax rate may vary.
How to Enroll
Monroe County makes it easy for you to enroll in your 2015
benefits. Employees can enroll on-site with your American Fidelity
representative.
Don’t Miss It!
•
Have you recently received a pay increase?
•
Have you or are you planning on getting married, having children,
or buying a home?
•
What would happen if you were suddenly ill or disabled?
Enroll On-site
See your American Fidelity’s Representative during your enrollment to
complete your benefit election form and discuss the options that are
available to you.
What To Bring To Your Appointment
•
Driver’s license.
•
Bank account information (to sign up for direct deposit)
•
Spouse and children’s DOB and Social Security number if
considering coverage for them.
•
Beneficiary information, including (if a trust) full name and date
of trust.
These questions and others will be addressed during your benefit
consultation to make sure you are properly covered. It takes just a few
moments to review your coverage and protect the welfare of you and
your family.
By enrolling on-site you can enroll in:
• Dental Insurance
• Accident Only Insurance
• Vision Insurance
• Life Insurance
• Group Life Insurance
• Health Flex Spending Account
• Disability Income Insurance
• Dependent Care FSA
• Cancer Insurance
6
INSURANCE
PLANS
SMART Choices
Eligiblity Requirements
Prescription Plans
Florida Blue
Dental
Vision
Group Life Insurance
Disability Insurance
Term Life Insurance
Long-Term Disability
Insurance
Accident Insurance
Hospital GAP PLAN Insurance
Cancer Insurance
Texas Life Insurance
Critical Illness Insurance
AF Permanent Life Insurance
Life Insurance
The SMART Choices Plan Advantage
The SMART Choices Plan Advantage
TheMonroeCountySchoolDistrictprovidesallemployeeswith:
• $10,000 Life and AD&D Insurance
• Partially paid medical coverage for employees who choose medical
insurance and
• $450 a year contribution, which is applied to your medical
coverage. If you do not have medical insurance through the
school board, the contribution may be used to purchase voluntary
benefits,excluding401(k).Anyunusedbalances will revert back to
the school board.
DualSpouseProvision:TheDualSpouseEnrollmentOptionisavailable
for both instructional and non-instructional employees. Employees
shouldcalltheEmployeeBenefitsandRiskManagementDepartmentat
(305)293-1400,ext.53342,orseeWandaMenendezduringenrollment
for details.
HowDoestheSMARTChoicesPlanWork?
1. The $450 a year contribution is applied to your school board
medical coverage. If you do not have medical insurance through
the school board, the contribution may be used to purchase
voluntary benefits, excluding 401(k). Any unused balances will
revert back to the school board.
2. Youchooseanyvoluntarybenefitsyouandyourfamilyneedand
the premium costs are deducted tax free from your gross pay before
incomeandSocialSecuritytaxesarecalculated.
3. Taxes are calculated on the amount of your salary remaining after
allpremiumshavebeendeducted.Then,anyotherafter-taxpayroll
deductions you may have are taken out of your paycheck.
4. Theamountremaininginyourpaycheckisyourtake-homepayfor
eachpayperiod.Sinceyouhavepaidlesstax,youhavemoreincome
to spend.
Appeals Process
If you have a request for a mid-plan year election change, FSA
reimbursement claim or other similar request denied, in full or in part,
you have the right to appeal the decision by sending a written request
within 180 days of the denial for review
Your appeal must include:
• the name of your employer
• the date of the services for which your request was denied
• a copy of the denied request
• the denial letter you received
• why you think your request should not have been denied and
• any additional documents, information or comments you think may
have a bearing on your appeal.
Your appeal will be reviewed upon receipt and its supporting
documentation. You will be notified of the results of this review within 60
business days from receipt of your appeal. In unusual cases, such as when
appeals require additional documentation, the review period may then be
extended by an additional 30 days. We will notify you in writing if an
extension is necessary. If we request additional information, you will
have 45 days to respond. If you do not respond within 45 days, we may
conclude our review of your claim based on the information we have
received. If your claim is denied on appeal, you have the right to bring a
civil action for benefits under Section 502(a) of ERISA. If your appeal is
approved, additional processing time is required to modify your benefit
elections.
Note: Appeals are approved only if the extenuating
circumstances and supporting documentation are within your
employer’s, insurance provider’s and IRS regulations governing the
plan.
American Fidelity believes in making it easy for you. You can call our Flex
Department Colleagues to speak with a live representative for claim
questions or status. Our customer service representatives are ready to assist
you from 7:00 a.m. – 6:00 p.m. CST with any questions you may have. Call
us today at 1-800-325-0654.
8
Eligiblity Requirements
Eligibility Requirements
WhenDoesMyPeriodofCoverageBegin?
Current Employees: Your period of coverage is January 1, 2015
through December31,2015.
New Employees: Ifyouareanewfull-timeemployee,youareeligible
fortheSMARTChoicesPlanonthefirstdayofthemonthfollowing
15calendar days of active employment. If you do not enroll before
your period of coverage begins, you will not be able to do so until
the next plan year or until you experience a valid change in status.
If you enroll during open enrollment, your period of coverage is
the sameastheplanyear (January1,2015throughDecember31,
2015).
WhoIsEligibletoEnrollintheFlexible
BenefitsPlan?
Ifyouareafull-timeinstructionalornon-instructionalemployeeofthe
school board who works at least 51 percent of the average time required
foryourposition,youareeligibletoenrollintheSMARTChoicesPlan.
Upon certain triggering events, spouses, ex-spouses, children and
employeesgoingfromfull-timetopart-timestatusmaybeeligiblefor
coverageundertheConsolidatedOmnibusBudgetReconciliationAct
(COBRA).PleasecontactyourEmployeeBenefitsandRiskManagement
Department for additional information.
WhoAreEligibleDependents?
Eligible dependents are:
• your legal spouse
• your own unmarried children
• children for whom you have been appointed legal guardian; and
• stepchildrenandlegallyadoptedchildren(providedtheyresidein
yourhouseholdandprimarilydependonyouforsupport).
IntheStateofFloridaanyoneuptotheageof30maybeconsidereda
dependent for the purposes of health insurance eligibility and access.
Forallhealthcoverageofferedunderyouremployer’splan,youmay
continue to cover your dependent child until the end of the calendar
year in which the child reaches the age of 30 if the child:
• is unmarried and does not have a dependent of his or her own
• isaresidentofFloridaorafull-timeorpart-timestudentand
• is not provided coverage as a named subscriber, insured, enrollee, or
covered person under any other group, blanket, or franchise health
insurancepolicyorindividualhealthbenefitsplan,orisnotentitled
tobenefitsunderTitleXVIIIoftheSocialSecurityAct.
WhatBenefitsAmIEligibleforIfI
TerminateEmployment?
During the plan year, except as otherwise provided by law and in
accordance with your employer’s plan(s), terminating employees
are covered until the last day of the month following 31 days after
termination, provided you make necessary contributions. If termination
occurs in the month of December, then coverage will cease no later than
December31,2015.Youcancontinuecertainbenefitsbycontacting
thefollowing within 30 days of your termination of employment*:
• EmployeeBenefitsandRiskManagementDepartmentforbenefits
continuationandtoobtaininformationontheFamilyMedicalLeave
Act(FMLA).
HowWillRetiringAffectmyEligibility?
During the plan year, except as otherwise provided by law and
in accordancewithyouremployer’splan(s),anemployeewho
retiresiscovered until the last day of the month following 31 days of
retirement. Someplansmaybecontinuedatthesamepremiumrates
whileothersrequire conversion to an individual policy and may have
an increase in premiumrates.Duringthe90daysprecedingyour
scheduledretirement,it’simportantthatyoucontactcustomercarefor
continuationofflexiblebenefits.You may not continue disability
income protection or adependentcareFSAuponretirement.
A retiree is a former full-time employee of the school board who
iscurrentlyreceivingincomeundertheFloridaRetirementSystem
(FRS).
Note: In order to continue medical coverage for dependents between the
pages 27-30, additional contribution is required, as set forth by Monroe
County School District.
Note: The extension of coverage up to age 30 does not apply to accident
only, specified disease, disability income, Medicare supplement, or
long-termcareinsurancepolicies.Thepremiumsforsuchcontinued
coveragemustbeonapost-taxbasis.Youremployerisresponsiblefor
ensuring the proper tax treatment for any dependent coverage elected
under these provisions.
* Youremployer’smedicalexpenseFSAplanisnotsubjecttoCOBRAcontinuationbeyondtheend
of the plan year in which a COBRA-qualifying event occurs. Disability income protection and
dependentcareFSAsmaynotbecontinued.
9
Eligiblity Requirements
Eligibility Requirements
How Does Employee Leave Affect My
Eligibility?
Employees on leave of absence are eligible for certain types of coverage
depending on the type of leave (A or B).
A. Board-Approved Paid Leave–Theschoolboardcontinuestopay
the $450 a year contribution up to one year if you go on medical
leavebecauseofyourowndisability(whichincludespregnancyand
disabilitiesresultingfrompregnancycomplications).Yourpremium
deductionswillcontinuethroughtheSMARTChoicesPlanaslong
asyoureceiveasalary.TheFamilyMedicalLeaveActmayaffect
yourrightsconcerningthecontinuationofyourhealthbenefitswhile
on unpaid leave. Consult with your Employee Benefits and Risk
Management Department for further information.
B. Board-Approved Nonpaid Leave–Theschoolboarddoesnotpay
foryourbenefits.Youcancontinuetoreceivecoverageunderyour
benefitsforuptooneyearifyoupaytheschoolboardcontribution
and your premiums directly to the school board.The Family and
Medical Leave Act may affect your rights concerning the continuation
of your health benefits while on unpaid leave. Consult with your
Employee Benefits and Risk Management Department for further
information.
Ifyougoonboard-approvedleaveforanyreason,youmaypayyour
premiumstotheschoolboardtomaintainyourbenefitsexceptforVISTA
401(k).Ifyouhavenotmaintainedacurrentpremiumstatuswhileon
leave,youwillberequiredtore-satisfyeligibilityrequirementswhen
you return to active status, except as otherwise provided by law.
HowDoestheFlexibleBenefitsPlanAffect
OtherBenefits?
Yourcontributionstotheflexiblebenefitsplandonotreduceyourfuture
Florida Retirement System (FRS) benefits or current contributions to
FRS.Anysalarydirectedtoyourflexiblebenefitsplanisincludedinthe
compensationreportedtotheFloridaRetirementSystem.
10
Prescription Plans
Prescription Plans
The Monroe County School District Prescription Benefit Program
providesoutpatientprescriptiondrugbenefitsforitsmembersandis
administered by Envision Rx. Covered services include prescription
drugs purchased from a participating pharmacy pursuant to a prescription
orderfromaphysicianorotherlicensedpractitioner.Effective8/1/12
theMonroeCountySchoolDistrictofferstwo(2)healthinsuranceplans,
thecurrentplanwhichisnowcalledthe“TheBuyUpPlan”andan
optionalplanwhichiscalledthe“CorePlan.”Thefollowingarethe
benefitsforeachplan:
Quantity Allowed: 30-daysupplyatretail,90-daysupplyatmailorder
Generic Substitution: Patientwillpaythebrandco-paymentplusthe
cost difference between the branded product and the generic if they
receivethebrandedproductwhenanFDAapprovedgenericisavailable.
Prior Authorizations:Certainproductsarecoveredonlywhendefined
conditions have been met. Products requiring prior approval include:
• injectablemedications
• MultipleSclerosismedications
• growth hormone.
Mail Order Program: The mail order program is designed for those
who take maintenance medications on a long term basis. Prescriptions
are triple checked and screened by licensed pharmacists with personal
medical history for quick, reliable, and safe dispensing. This program
will provide the following:
•
•
•
•
firsttimeprescriptionsandrefills
90 day supply
delivery to the member’s home
nocomplicatedclaimformtofile.
Exclusions
• Non-prescriptionmedications(overthecounter“OTC”products)
• AnymedicationthathasnotbeenapprovedbytheFoodandDrug
Administration(FDA)
• Bloodandplasmarelatedproducts
• Oxygen
• Immunization agents or biological sera
• Allergy desensitization agents or allergy serum
• MedicationsobtainedoutsidetheU.S.
• Professional charges in connection with compounding, administering,
orinjectingmedications
• Durable or disposable medical equipment, devices, appliances and
supplies
• Emergency contraceptive kits/diaphragms and other intrauterine
devicesimplants/other
• Infertility medications
• Impotencemedications/allforms
• Appetite suppressants
• Nicotinereplacements/smokingcessationproducts
• Medications for cosmetic purposes
• Prescriptionmulti-vitamins/prescriptionmultivitaminswithfluoride
• Medications for foreign travel
• Influenzamedications
Customer Service:ContactEnvisionRxCustomerServiceHelpDesk
at1-800-361-4542withquestionsregardingyourprescriptionbenefit.
The website is www.envisionrx.com
Shouldyouhaveanyfurtherquestions,pleasedonothesitatetocontact
theEmployeeBenefitsDepartment,MonroeCountySchoolDistrict,at
305-293-1400,ext.53340.
Buy-up Plan - Deductible: $100/individual, $200/family
Co-payment
Retail:
Mail order:
Generic
$10
$20
Preferred Brands
$35
$70
Non-preferred brand
$50
$100
Core Plan - Deductible: $100/individual, $200/family
Co-payment
Retail:
Mail order:
Generic
$15
$30
Preferred Brands
$45
$90
Non-preferred brand
$65
$130
High Deductible Plan - Deductible: $100/individual, $200/family
Co-payment
Retail:
Mail order:
Generic
$15
$30
Preferred Brands
$50
$100
Non-preferred brand
$75
$150
11
12
Allergy Injections
In-Network Family Physician
In-Network Specialist
Out-of-Network
E-Office Visit Services
In-Network Family Physician
In-Network Specialist
Out-of-Network
Office Services
In-Network Family Physician
In-Network Specialist
Out-of-Network Family Physician
Out-of-Network Specialist
Provider Services at Hospital
In-Network Family Physician
In-Network Specialist
Out-of-Network Family Physician
Out-of-Network Specialist
Provider Services at ER
In-Network Family Physician
In-Network Specialist
Out-of-Network Family Physician
Out-of-Network Specialist
Provider Services at Other Locations
In-Network Family Physician
In-Network Specialist
Out-of-Network Family Physician
Out-of-Network Specialist
Radiology, Pathology and Anesthesiology
Provider Services at Ambulatory Surgical
Center
In-Network Specialist
Out-of-Network
COST SHARING
Maximums shown are Per Benefit Period
(BPM) unless noted
Deductible (DED) (Per Person/Family Agg)
In-Network
Out-of-Network
Coinsurance (Member Responsibility)
In-Network
Out-of-Network
Out of Pocket Maximum (Per Person/Family
Agg)
In-Network
Out-of-Network
Lifetime Maximum
Predictable Cost 03559
CORE PLAN
$1,000 / $2,000
Combined with In-Network
Predictable Cost 03768
BUY UP PLAN
$500 / $1,000
Combined with In-Network
$10
$10
$10
$10
$10
DED + 40%
$40
$50
$50
$70
$50
$50
$50
$50
$50
$50
$50
$50
$40
$50
DED + 40%
DED + 40%
$75
$75
$10
$10
$10
$10
$10
DED + 40%
$30
$30
$40
$40
$50
$50
$50
$50
$50
$50
$50
$50
$30
$30
DED + 40%
DED + 40%
$45
$45
1
25%
25%
40%
40%
Includes DED, Coins and all Copays
Includes DED, Coins and all Copays
(Excludes Rx)
(Excludes Rx)
$6,350 /$12,700
$6,350 /$12,700
Combined with In-Network
Combined with In-Network
No Maximum
No Maximum
PROFESSIONAL PROVIDER SERVICES
BlueOptions
BlueOptions
Benefit Summaries
Monroe County School District -1/1/2015
DED + 25%
DED + 40%
DED + 25%
DED + 25%
DED + 40%
DED + 40%
DED + 25%
DED + 25%
In-Ntwk DED + 25%
In-Ntwk DED + 25%
DED + 25%
DED + 25%
DED + 40%
DED + 40%
$50
DED + 25%
$60
DED + 40%
$10
$10
DED + 40%
$10
$10
$10
25%
40%
Includes DED, Coins, &
Copays(Excludes Rx)
$6,350 / $12,700
Combined with In-Network
No Maximum
$1,500 / $3,000
Combined with In-Network
Plan 05360
HIGH DEDUCTIBLE
BlueOptions
Medical Benefit Summaries
Florida Blue
$0
$0
$0
$0
$0 / $0
$0 / $0
$40
$50
$40
$70
EMERGENCY / URGENT / CONVENIENT CARE
No per Day Maximum
No per Day Maximum
DED + 25%
DED + 25%
In-Ntwk DED + 25%
In-Ntwk DED + 25%
$0 / $0
$50
$70
Age 50+ then Frequency Schedule
Applies
$0
$0
Predictable Cost 03559
CORE PLAN
BlueOptions
$0 / $0
$40
$40
Age 50+ then Frequency Schedule
Applies
$0
$0
PREVENTIVE CARE
Predictable Cost 03768
BUY UP PLAN
BlueOptions
2
Plan 05360
HIGH DEDUCTIBLE
BlueOptions
DED + 25%
DED + 25%
DED + 40%
DED + 40%
DED + 25%
DED + 40%
DED + 25%
DED + 40%
DED + 25%
DED + 40%
DED + 25%
In-Ntwk DED + 25%
DED + 25%
DED + 40%
No per Day Maximum
DED + 25%
In-Ntwk DED + 25%
$0 / $0
DED + 40%
DED + 40%
$0
$0
$0 / $0
DED + 40%
DED + 40%
Age 50+ then Frequency Schedule
Applies
$0
$0
Ambulance Maximum (per day)
In-Network
Out-of-Network
Convenient Care Centers (CCC)
In-Network
$20
$20
Out-of-Network
DED + 40%
DED + 40%
Emergency Room Facility Services
In-Network
$100
$200
Out-of-Network
$100
$200
Urgent Care Centers (UCC)
In-Network
$50
$50
Out-of-Network
DED + 40%
DED + 40%
FACILITY SERVICES – HOSPITAL / SURGICAL / LAB / INDEPENDENT DIAGNOSTIC TESTING FACILITY
Ambulatory Surgical Center
In-Network
$200
$250
Out-of-Network
DED + 40%
DED + 40%
Independent Clinical Lab
In-Network
$0
$0
Out-of-Network
DED + 40%
DED + 40%
Independent Diagnostic Testing Facility Xrays and AIS (Includes Physician Services)
In-Network - Advanced Imaging Services (AIS)
$200
$200
In-Network - Other Diagnostic Services
$50
$50
Out-of-Network-Advanced Imaging (AIS)
$200
$200
Out-of-Network-Other Diagnostic Services
DED + 40%
DED + 40%
In-Network
Out-of-Network
Mammograms (Routine )
In-Network
Out-of-Network
Well Child Office Visits (No BPM)
In-Network Family Physician / Specialist
Out-of-Network Family Physician
Out-of-Network Specialist
Adult Wellness Office Services
In-Network Family Physician / Specialist
Out-of-Network Family Physician
Out-of-Network Specialist
Colonoscopies (Routine)
COST SHARING
MAXIMUMS SHOWN ARE PER BENEFIT
PERIOD (BPM) UNLESS NOTED
Medical Benefit Summaries
Florida Blue
13
14
Out-of-Network
Provider Services at Hospital
In-Network Family Physician
In-Network-Specialist
Out-of-Network Family Physician
Out-of-Network-Specialist
Provider Services at ER
In-Network Family Physician
In-Network-Specialist
Out-of-Network Family Physician
Out-of-Network-Specialist
Physician Office Visit
In-Network Family Physician
In-Network-Specialist
Out-of-Network Family Physician
Out-of-Network Specialist
Emergency Room Facility Services (per visit)
In-Network
Out-of-Network
Provider Services at Locations other than
Hospital and ER
In-Network Family Physician / Specialist
Out-of-Network Family Physician
Out-of-Network Specialist
Out-of-Network
Outpatient Hospitalization (per visit)
In-Network
Inpatient Hospitalization
In-Network
Out-of-Network
Out-of-Network
Therapy at Outpatient Hospital
In-Network
Out-of-Network
Inpatient Rehab Maximum
Outpatient Hospital (per visit)
In-Network
Cost Sharing
Maximums shown are Per Benefit Period
(BPM) unless noted
Inpatient Hospital (per admit)
In-Network
Option 1 – DED + 25%
Option 2 – DED + 25%
DED + 40%
30 Days
Option 1 – DED + 25%
Option 2 – DED + 25%
DED + 40%
Option 1 – DED + 25%
Option 2 – DED + 25%
DED + 40%
30 Days
Option 1 – DED + 25%
Option 2 – DED + 25%
DED + 40%
Option 1 – DED + 25%
Option 2 – DED + 25%
DED + 40%
$40
$50
$50
$70
$40
$50
$50
$70
$40
$50
$50
$70
$200
$200
$40/ $50
$50
$70
Option 1 – DED + 25%
Option 2 – DED + 25%
DED + 40%
$30
$30
$40
$40
$30
$30
$40
$40
$30
$30
$40
$40
$100
$100
$30 / $30
$40
$40
3
Option 1 – DED + 25%
Option 2 – DED + 25%
DED + 40%
Option 1 – DED + 25%
Option 2 – DED + 25%
DED + 40%
Option 1 – $45
Option 1 – $50
Option 2 -- $60
Option 2 -- $70
DED + 40%
DED + 40%
MENTAL HEALTH AND SUBSTANCE ABUSE
BlueOptions
Predictable Cost 03559
CORE PLAN
BlueOptions
Predictable Cost 03768
BUY UP PLAN
DED + 25%/DED + 25%
DED + 40%
DED + 40%
DED + 25%
In-Ntwk DED + 25%
$50
DED + 25%
$60
DED + 40%
DED + 25%
DED + 25%
In-Ntwk DED + 25%
In-Ntwk DED + 25%
DED + 25%
DED + 25%
DED + 40%
DED + 40%
Option 1 - DED + 25%
Option 2 - DED + 25%
DED + 40%
Option 1 - DED + 25%
Option 2 - DED + 25%
DED + 40%
Option 1 - DED + 25%
Option 2 - DED + 25%
DED + 40%
Option 1 - DED + 25%
Option 2 - DED + 25%
DED + 40%
Option 1 - DED + 25%
Option 2 - DED + 25%
DED + 40%
30 Days
Plan 05360
HIGH DEDUCTIBLE
BlueOptions
Medical Benefit Summaries
Florida Blue
BlueOptions
BlueOptions
Predictable Cost 03559
CORE PLAN
$50
$70
Covered
Covered
$30
$40
Covered
Covered
DED + 25%
DED + 40%
$2,500 Maximum
DED + 25%
DED + 40%
30 visits
DED + 25%
DED + 40%
No Maximum
DED + 25%
DED + 40%
122 Visits (Includes up to 26 Spinal
Manipulations)
DED + 25%
DED + 40%
$2,500 Maximum
DED + 25%
DED + 40%
30 visits
DED + 25%
DED + 40%
No Maximum
DED + 25%
DED + 40%
122 Visits (Includes up to 26 Spinal
Manipulations)
$50
$40/ $50
$50 / $70
DED + 40%
60 days
DED + 25%
DED + 40%
DED + 25%
DED + 40%
No Maximum
DED + 25%
DED + 40%
No Maximum
$30
$30 / $30
$40 / $40
DED + 40%
60days
DED + 25%
DED + 40%
$200
$200
$200
$200
$200
$200
OTHER SPECIAL SERVICES AND LOCATIONS
Predictable Cost 03768
BUY UP PLAN
DED + 25%
DED + 40%
Covered
Covered
DED + 25%
DED + 25%
DED + 40%
DED + 40%
60 Days
DED + 25%
DED + 40%
DED + 25%
DED + 40%
$2,500 Maximum
DED + 25%
DED + 40%
30 Visits
DED + 25%
DED + 40%
No Maximum
DED + 25%
DED + 40%
122 Visits (Includes up to 26 Spinal
Manipulations)
DED + 25%
DED + 40%
No Maximum
DED + 25%
DED + 25%
DED + 40%
Plan 05360
HIGH DEDUCTIBLE
BlueOptions
4
The information contained in this Summary of Benefits includes benefit changes required as a result of the Patient Protection And Affordable Care Act
(PPACA), otherwise known as Health Care Reform (HCR). Please note that plan benefits are subject to change and may be revised based on guidance and
regulations issued by the Secretary of Health and Human Services (HHS) or other applicable federal agency. Additionally, Interim rules released by the
Federal Government February 2, 2010 require BCBSF to test all benefit plans to ensure compliance with the Mental Health Parity and Addiction Equity Act
(MHPAE).
Diabetic Supplies (lancets, strips, etc.) are available through DME. Diabetic Equipment (insulin pumps, tubing) are covered under the medical benefits.
In-Network Free Standing Rehabs
In-Network Family Physician / Specialist
Out-of-Network Family Physician / Specialist
Out-of-Network-All Other Locations
Skilled Nursing Facility BPM
In-Network
Out-of-Network
Acupuncture (Cover up to 28 visits per CYM)
In-Network
Out-of-Network
Bariatric Surgery
Removal of Impacted Wisdom Teeth
Advanced Imaging Services in Physician's
Office
In-Network Family Physician
In-Network Specialist
Out-of-Network
Birthing Center
In-Network
Out-of-Network
Durable Medical Equipment, Prosthetics,
Orthotics BPM
In-Network
Out-of-Network
Enteral Formulas
In-Network
Out-of-Network
Home Health Care BPM
In-Network
Out-of-Network
Hospice (In-Patient, Out-Patient & Home)
In-Network
Out-of-Network
Outpatient Therapy (PT, OT, ST, Cardiac and
Spinal Manipulations)
Cost Sharing
Maximums shown are Per Benefit Period
(BPM) unless noted
Medical Benefit Summaries
Florida Blue
15
Dental/Vision Rates
Dental Plans
Managed Care
Elite Preferred 605 PPO
(DHMO) Plan C150
Dental Plan
Coverage 20 pay periods
20 pay periods
Employee$11.32 $12.38
Employee + 1
Employee & family
$21.28
$29.33
$24.61
$36.62
Vison Plan
Coverage20 pay periods
Employee$2.99
Employee + 1$5.98
Employee + 2$8.97
Employee + 3$11.96
Employee + 4 or more
$14.95
16
Dental Plan Summary
Save Money with Elite Preferred 605.
Because we specialize in dental, we can bring you benefits and service that other
companies can’t match!
Quick Claims Turnaround
CompBenefits’ state of the art claims center provides fast reimbursement of your
claims.
Access To Information
Our toll-free customer service number at 1-(800)-342-5209 has Member Services
Representatives who can provide the answers you need quickly
and thoroughly.
Total Freedom Of Choice
The plan provides you with total freedom of choice by allowing you to use any
licensed dentist for treatment. The plan reimburses a percentage of eligible
expenses based on the plan you have chosen.
Any way you add it up, CompBenefits really is the benefits company of choice!
MAJOR RESTORATIVE LIMITATIONS
The charges for Major Restorative services will be Covered Dental Expenses
subject to the following:
1. the denture or partial denture must replace a Natural Tooth extracted
while insured for Dental Benefits under this policy;
2. the fixed bridge (including a resin bonded fixed bridge) must replace
a Natural Tooth extracted while insured for Dental Benefits under this
policy;
3. the replacement of a partial denture, full denture, or fixed partial denture
(including a resin bonded bridge), or the addition of teeth to a partial
denture if: (a) replacement occurs at least five years after the initial date
of insertion of the current full or partial denture or resin bonded bridge;
(b) replacement occurs at least five years after the initial date of insertion
of an existing implant or fixed bridge; (c) replacement prosthesis or the
addition of a tooth to a partial denture is required by the necessary
extraction of a Functioning Natural Tooth while insured for Dental
Benefits under this policy; or (d) replacement is made necessary by a
Covered Dental Injury to a partial denture, full denture, or fixed partial
denture (including a resin bonded bridge) provided the replacement is
completed within 12 months of the injury;
4. the replacement of crowns, cast restorations, inlays, onlays or other
laboratory prepared restorations if: (a) replacement occurs at least five
years after the initial date of insertion; and (b) they are not serviceable
and cannot be restored to function;
5. the replacement of an existing partial denture with fixed bridgework,
only if upgrading to fixed bridgework is essential to the correction of the
person’s dental condition; and
6. the replacement of teeth up to the normal complement of 32.
EXCLUSIONS
Benefits will not be paid for:
1. procedures which are not included in the Schedule of Benefits; which are not
medically necessary; which do not have uniform professional endorsement;
are experimental or investigational in nature; for which the patient has no
legal obligation to pay; or for which a charge would not have been made in
the absence of insurance;
2. any procedure, service, or supply which may not reasonably be expected to
successfully correct the patient’s dental condition for a period of at least three
years, as determined by CompBenefits Insurance Company;
3. crowns, inlays, cast restorations, or other laboratory prepared restorations on
teeth which may be restored with an amalgam or composite resin filling;
CompBenefits Insurance Company
Voluntary+ PPO – Ortho
4. appliances, inlays, cast restorations or other laboratory prepared restorations
used primarily for the purpose of splinting;
5. any procedure, service, supply or appliance, the sole or primary purpose
of which relates to the change or maintenance of vertical dimension; the
alteration or restoration of occlusion including occlusal adjustment, bite
registration, or bite analysis;
6. pulp caps, adult fluoride treatments, athletic mouthguards; myofunctional
therapy; infection control; precision or semi-precision attachments; denture
duplication; oral hygiene instruction; separate charges for acid etch; broken
appointments; treatment of jaw fractures; orthognathic surgery; completion
of claim forms; exams required by third party; personal supplies (e.g. water
pik, toothbrush, floss holder, etc.); or replacement of lost or stolen appliances;
7. charges for travel time; transportation costs; or professional advice given on
the phone;
8. procedures performed by a Dentist who is a member of Your immediate
family;
9. any charges, including ancillary charges, made by a hospital,ambulatory
surgical center, or similar facility;
10. charges for treatment rendered: (a) in a clinic, dental or medical facility
sponsored or maintained by the employer of any member of Your family; or
(b) by an employee of the employer of any member of Your family;
11. any procedure, service or supply required directly or indirectly to diagnose
or treat a muscular, neural, or skeletal disorder, dysfunction, or disease of the
temporomandibular joints or their associated structures;
12. charges for treatment performed outside of the United States other than for
emergency treatment. Benefits for emergency treatment which is performed
outside of the United States are limited to a maximum of $100 (US dollars)
per year;
13. the care or treatment of an injury or sickness due to war or an act of war,
declared or undeclared;
14. treatment for cosmetic purposes. Facings on crowns or bridge units on
molar teeth will always be considered cosmetic;
15. any services or supplies which do not meet the standards set by the
American Dental Association or which are not reasonably necessary, or
customarily used, for dental care;
16. procedures that are a covered expense under any other medical plan
(established by the employer) which provides group hospital, surgical, or
medical benefits whether or not on an insured basis;
17. a sickness for which the patient can receive benefits under a workers’
compensation act or similar law;
18. an injury that arises out of or in the course of a job or employment for pay
or profit;
19. charges to the extent that they are more than the Prevailing Fee. If the
amount of the Prevailing Fee for a service cannot be determined due to
the unusual nature of the service, CompBenefits Insurance Company will
determine the amount. CompBenefits Insurance Company will take into
account: (a) the complexity involved; (b) the degree of professional skill
required; and (c) other pertinent factors; or
20. orthodontic plan benefits for persons 19 years of age or older.
PREDETERMININATION
If Covered Dental Expenses for a procedure are expected to be more than
$200 it is recommended that you send a Dental Treatment Plan in prior to
beginning treatment, send preauthorization to CompBenefits, P.O. Box 8236
Chicago, IL 60680–8236. You and/or your dentist will be notified of the benefits
payable based upon the Dental Treatment Plan. This brochure contains a brief
description of the plan. A complete description of the coverage, including
limitations on certain procedures is found in the Schedule of Benefits and
Certificate of Group Dental Insurance.
17
Dental Plan Summary
CompBenefits Insurance Company
Voluntary+ PPO – Ortho
Summary of Benefits
In Network Reimbursements
Out-of- Network Reimbursements
Type I Diagnostic & Preventive
Oral Examination (once per six months)
Prophylaxis (cleaning, once per six months)
Topical Fluoride (children under 16, once per
12 months
X-Rays (limitations may apply)
Sealants (once per 3 years for children under
age 16, for non carious molars only)
Partial Listing of Covered Services*
100% No Deductible
75%
Type II Basic Services
Simple Restorative (amalgam, synthetic, or
composite fillings)
Space Maintainers (for children under age 16)
Non-Surgical Tooth Extractions
Non-Surgical Periodontics
75% After Deductible
50% After Deductible
Type III Major Services
(12 month waiting period**)
Major Restorative (crowns/inlays/onlays)
Bridge, Denture Repair
Prosthetics (bridges and dentures)
Emergency Palliative Treatment
Endodontics (root canals)
Surgical Tooth Extractions
Surgical Periodontics
50% After Deductible
25% After Deductible
Group’s plan may include Orthodontics
Coverage for an additional fee. Not all plans have Type IV coverage.
Type IV Orthodontics (Optional)
(12 month waiting period**)
Dependent children 18 years of age or younger
MAXIMUM BENEFITS
Insured Individual and Dependents
Lifetime
Type I, II and III
Type IV
Calendar Year
Type I, II and III
Type IV
Deductible***
Type I
Type II, III and IV
50%
50%
Unlimited
Unlimited
$1,000
$1,000
$1,500
$1,500
$500
$500
None
$50
None
$50
*Coverage based on contracted fees for the Preferred Provider Network.
**Time served on the employer’s immediately preceding group dental plan may be credited towards this plan’s waiting periods, subject to Underwriting approval.
***Maximum of 3 per family.
18
Dental Plan Summary
150
CompBenefits InsuranceC
Company
Voluntary+ PPO – Ortho
CompBenefits Family of Companies
schedule of benefits and subscriber copayments
ADA
CODE
PROCEDURE
PATIENT
PAYS
ADA
CODE
PROCEDURE
APPOINTMENTS
PREVENTIVE CARE (cont.)
9310
1510
9430
9440
9999
9999
Consultation (diagnostic service
provided by dentist other than
practitioner providing treatment) ................$15.00
Office Visit (normal hours) ..........................$5.00
Office Visit (after regularly
scheduled hours) ....................................$35.00
Emergency visit during regularly
scheduled hours, by report .......................$20.00
Broken appointments (without 24 hr notice,
per 15 min) Maximum $40 per broken
appointment. No charge will be made
due to emergencies ................................$10.00
DIAGNOSTIC
120
Periodic oral evaluation ..................NO CHARGE
140/150/160
Limited/Comprehensive
oral evaluation ..............................NO CHARGE
180
Comprehensive periodontal
evaluation .............................................$10.00
210
X-Ray Intraoral - complete series
including bitewings ........................NO CHARGE
220
X-Ray Intraoral - periapical first film ........................................NO CHARGE
230
X-Ray Intraoral - periapical each additional film .......................NO CHARGE
270
X-Ray Bitewing single film .....................................NO CHARGE
272
X-Ray Bitewings two films ......................................NO CHARGE
274
Bitewings - four films .......................NO CHARGE
330
Panoramic film ..............................NO CHARGE
460
Pulp vitality tests .............................NO CHARGE
470
Diagnostic casts .............................NO CHARGE
PREVENTIVE CARE
1110/1120
Prophylaxis-adult/child-routine
(once every 6 months) ....................NO CHARGE
1110/1120
Prophylaxis-adult/child- (additional) ...........$20.00
1201
Topical application of fluoride
(including prophylaxis) child
(up to 16 years of age) ..................NO CHARGE
1203
Topical application of fluoride
(not including prophylaxis) child
(up to 16 years of age) ..................NO CHARGE
1330
Oral hygiene instruction ..................NO CHARGE
1351
Sealant - per tooth ..................................$10.00
C150 03/03
005C1504
1515
1520
1525
1550
PATIENT
PAYS
Space Maintainer - fixed unilateral .....................................$45.00 + LAB
Space Maintainer - fixed bilateral ......................................$45.00 + LAB
Space Maintainer - removable unilateral .....................................$85.00 + LAB
Space Maintainer - removable bilateral ......................................$85.00 + LAB
Recementation of space maintainer ...........$10.00
RESTORATIVE
2140
2150
2160
2161
2940
2999
Amalgam - one surface,
primary or permanent .....................NO CHARGE
Amalgam - two surfaces,
primary or permanent .....................NO CHARGE
Amalgam - three surfaces,
primary or permanent .....................NO CHARGE
Amalgam - four or more surfaces,
primary or permanent .....................NO CHARGE
Sedative filling .......................................$15.00
Sedative base (under fillings),
by report ......................................NO CHARGE
RESIN RESTORATION
2330
2331
2332
2391
2392
2393
2394
2510
2520
2530
Resin - one surface, anterior .....................$35.00
Resin - two surfaces, anterior ....................$40.00
Resin - three surfaces, anterior ..................$50.00
Resin - based composite one surface, posterior .............................$60.00
Resin - based composite two surfaces, posterior ............................$80.00
Resin - based composite three surfaces, posterior .........................$100.00
Resin - based composite four or more surfaces, posterior ...............$120.00
Inlay - metallic - one surface .....................$95.00
Inlay - metallic - two surfaces ..................$105.00
Inlay - metallic - three or
more surfaces ......................................$130.00
CROWN & BRIDGE
2740
2750*
2751
2752*
Crown - porcelain/ceramic substrate ...$280 + LAB
Crown - porcelain fused to
high noble metal ..................................$280.00
Crown - porcelain fused to
predominantly base metal ......................$280.00
Crown - porcelain fused to
noble metal .........................................$280.00
Current Dental Terminology © 2004 American Dental Association. All rights reserved.
19
Dental Plan Summary
C 150
CompBenefits Insurance Company
Voluntary+ PPO – Ortho
CompBenefits Family of Companies
schedule of benefits and subscriber copayments
ADA
CODE
PROCEDURE
PATIENT
PAYS
ADA
CODE
CROWN & BRIDGE (cont.)
PROSTHODONTICS
2790*
2791
5110
5120
5130
5140
5211
2792*
2910
2920
2930
2950
2951
2952
2953
2954
2962
Crown - full cast high noble metal ...........$280.00
Crown - full cast predominantly
base metal ..........................................$280.00
Crown - full cast noble metal ..................$280.00
Recement inlay ......................................$15.00
Recement crown ....................................$15.00
Prefabricated stainless steel crown primary tooth .........................................$75.00
Core buildup, including any pins ..............$45.00
Pin retention - per tooth ...........................$15.00
Cast post and core in addition
to crown .....................................$90.00 + LAB
Each additional cast post same tooth ...................................$90.00 + LAB
Prefabricated post and core in
addition to crown ..................................$90.00
Labial veneer (porcelain laminate) laboratory ......................................$280 + LAB
5212
5213
5214
5410
5411
5421
5422
REPAIRS TO PROSTHETICS
3220
3221
5510
3320
3330
3410
Therapeutic pulpotomy ............................$35.00
Pulpal debridement, primary and
permanent teeth ...................................$100.00
Root canal therapy - anterior
(excluding final restoration) .....................$100.00
Root canal therapy - bicuspid
(excluding final restoration) .....................$200.00
Root canal therapy - molar
(excluding final restoration) .....................$250.00
Apicoectomy/periradicular surgery anterior ..............................................$125.00
5520
5610
5630
5640
5650
5730
5731
PERIODONTICS (Gum treatment)
4210
4211
4341
4342
4355
4381
4910
Gingivectomy/gingivoplasty
4+ teeth per quad ...............................$125.00
Gingivectomy/gingivoplasty
1-3 teeth per quad .................................$40.00
Periodontal scaling and root planing
4+ teeth per quad .................................$50.00
Periodontal scaling and root planing
1-3 teeth per quad .................................$50.00
Full mouth debridement to enable
eval and diagnosis .................................$45.00
Localized delivery of chemotherapeutic
agents (per tooth) ...................................$45.00
Periodontal maintenance .........................$50.00
C150 03/03
005C1504
5740
5741
5750
5751
5760
5761
5850
5851
PATIENT
PAYS
Complete denture - maxillary .........$300.00 + LAB
Complete denture - mandibular ......$300.00 + LAB
Immediate denture - maxillary ........$300.00 + LAB
Immediate denture - mandibular .....$300.00 + LAB
Maxillary partial denture resin base .................................$300.00 + LAB
Mandibular partial denture resin base .................................$300.00 + LAB
Maxillary partial denture cast metal framework,
resin denture bases .....................$300.00 + LAB
Mandibular partial denture cast metal framework,
resin denture bases .....................$300.00 + LAB
Adjust complete denture - maxillary ...........$15.00
Adjust complete denture - mandibular ........$15.00
Adjust partial denture - maxillary ...............$15.00
Adjust partial denture - mandibular ............$15.00
ENDODONTICS
3310
20
PROCEDURE
Repair broken complete
denture base ................................$15.00 + LAB
Replace missing or broken teeth complete denture (each tooth) .........$15.00 + LAB
Repair resin denture base ...............$15.00 + LAB
Repair or replace broken clasp ........$15.00 + LAB
Replace broken teeth - per tooth ......$15.00 + LAB
Add tooth to existing
partial denture ..............................$30.00 + LAB
Reline complete maxillary denture
(chairside) .............................................$50.00
Reline complete mandibular denture
(chairside) .............................................$50.00
Reline maxillary partial denture
(chairside) .............................................$50.00
Reline mandibular partial denture
(chairside) .............................................$50.00
Reline complete maxillary denture
(laboratory) ..................................$35.00 + LAB
Reline complete mandibular denture
(laboratory) ..................................$35.00 + LAB
Reline maxillary partial denture
(laboratory) ..................................$35.00 + LAB
Reline mandibular partial denture
(laboratory) ..................................$35.00 + LAB
Tissue conditioning - maxillary ..................$30.00
Tissue conditioning - mandibular ...............$30.00
Current Dental Terminology © 2004 American Dental Association. All rights reserved.
Dental Plan Summary
C 150
CompBenefits Insurance Company
Voluntary+ PPO – Ortho
CompBenefits Family of Companies
schedule of benefits and subscriber copayments
ADA
CODE
PROCEDURE
PATIENT
PAYS
ADA
CODE
PROCEDURE
PROSTHODONTICS (Fixed)
ADJUNCTIVE GENERAL SERVICES
6210*
6211
6212*
6240*
9215
9230
6241
6242*
6750*
6751
6752*
6790*
6791
6792*
6930
Pontic - cast high noble metal .................$280.00
Pontic - cast predominantly base metal .....$280.00
Pontic - cast noble metal ........................$280.00
Pontic - porcelain fused to
high noble metal ..................................$280.00
Pontic - porcelain fused to
predominantly base metal ......................$280.00
Pontic - porcelain fused to
noble metal .........................................$280.00
Crown - porcelain fused to
high noble metal ..................................$280.00
Crown - porcelain fused to
predominantly base metal ......................$280.00
Crown - porcelain fused to
noble metal .........................................$280.00
Crown - full cast high noble metal ...........$280.00
Crown - full cast predominantly
base metal ..........................................$280.00
Crown - full cast noble metal ..................$280.00
Recement fixed partial denture (per unit) .....$10.00
EXTRACTIONS/ORAL AND MAXILLOFACIAL
SURGERY
7111
7140
7210
7220
7230
7240
7250
7310
7311
7320
7321
7510
Coronal remnants, deciduous tooth ...NO CHARGE
Extraction, erupted tooth or
exposed root .................................NO CHARGE
Surgical removal of erupted tooth ..............$40.00
Removal of impacted tooth - soft tissue .......$50.00
Removal of impacted tooth partially bony ........................................$70.00
Removal of impacted tooth completely bony ....................................$85.00
Surgical removal of residual tooth roots ......$35.00
Alveoloplasty in conjunction with
extractions - per quadrant ........................$35.00
Alveoplasty in conjunction with
extractions - one to three teeth or
tooth spaces, per quadrant .......................$35.00
Alveoloplasty not in conjunction
with extractions - per quadrant ..................$70.00
Alveoplasty not in conjunction with
extractions - one to three teeth or
tooth spaces, per quadrant .......................$70.00
Incision and drainage of abscess intraoral ...............................................$25.00
C150 03/03
005C1504
9450
9951
9952
PATIENT
PAYS
Local anesthesia ............................NO CHARGE
Analgesia (nitrous oxide per 15 minutes) .....................................$15.00
Case presentation, detailed and
extensive treatment planning ............NO CHARGE
Occlusal adjustment - limited ....................$25.00
Occlusal adjustment - complete ...............$150.00
* THE ABOVE COPAYMENTS DO NOT INCLUDE THE
ADDITIONAL COST OF PRECIOUS (HIGH NOBLE) AND
SEMI-PRECIOUS (NOBLE) METAL. THE ADDITIONAL COST
OF PRECIOUS METAL SHALL NOT EXCEED $125 PER UNIT
AND $75 PER UNIT FOR SEMI-PRECIOUS METAL.
NOTE:
1. NOT ALL PARTICIPATING DENTISTS PERFORM ALL LISTED
PROCEDURES, INCLUDING AMALGAMS. PLEASE
CONSULT YOUR DENTIST PRIOR TO TREATMENT FOR
AVAILABILITY OF SERVICES.
2. UNLISTED PROCEDURES ARE AT THE DENTIST’S USUAL
FEE LESS 25%.
3. WHEN CROWN AND/OR BRIDGEWORK EXCEEDS SIX
UNITS IN THE SAME TREATMENT PLAN, THE PATIENT
MAY BE CHARGED AN ADDITIONAL $50.00 PER UNIT.
SPECIALIST SERVICES
Should you need a specialist, (i.e., Endodontist, Orthodontist,
Oral Surgeon, Periodontist, Pediatric Dentist), you may be
referred by your Participating General Dentist, or you may refer
yourself to any Participating Specialist. Upon identification of
yourself as a CompBenefits member, you will receive a 25%
reduction from usual and customary fees for services performed.
Specialist services are available only in areas where the dental
plan has a Participating Specialist.
Current Dental Terminology © 2004 American Dental Association. All rights reserved.
21
Dental Plan Summary
150
CompBenefits InsuranceC
Company
Voluntary+ PPO – Ortho
CompBenefits Family of Companies
schedule of benefits and subscriber copayments
LIMITATIONS AND EXCLUSIONS
1.
2.
3.
No service of any dentist other than a Participating
General Dentist or Participating Specialist will be covered
by Company, except out-of-area emergency care as
provided in Section VIII, Paragraph C of the Certificate.
Whenever any Contributions or Copayments are
delinquent, Member will not be entitled to receive Benefits,
transfer Dental Facilities, or enjoy any of the other
privileges of a Member in good standing.
Company does not provide coverage for the following
services:
a) Cost of hospitalization and pharmaceuticals, drugs or
medications.
b) Services which in the opinion of the Participating
General Dentist or Participating Specialist are not
Necessary Treatment to establish and/or maintain the
Member’s oral health.
CompBenefits
CompBenefits Company
CompBenefits Insurance Company
CompBenefits of Georgia, Inc.
22
C150 03/03
005C1504
c) Any service that is not consistent with the normal and/or
usual services provided by the Participating General
Dentist or Participating Specialist or which in the
opinion of the Participating General Dentist or
Participating Specialist would endanger the health of
the Member.
d) Any service or procedure which the Participating
General Dentist or Participating Specialist is unable to
perform because of the general health or physical
limitations of the Member.
e) Any dental treatment started prior to the Member’s
effective date for eligibility of benefits.
f) Services for injuries and conditions which are paid or
payable under Workers’ Compensation or Employers’
Liability laws.
g) Treatment for cysts, neoplasms and malignancies.
h) General anesthesia.
CompBenefits Dental, Inc.
CompBenefits of Alabama, Inc.
American Dental Plan of North Carolina, Inc.
Current Dental Terminology © 2004 American Dental Association. All rights reserved.
Dental Plan Summary
Insurance Company
Dental PlansCompBenefits
Voluntary+ PPO – Ortho
Foranupdatedlistofproviders,pleaseregisteratmycompbenefits.comorcallmemberservicesat1-800-342-5209formoreinformation.
PPO Provider Directory
GENERAL DENTISTS
MONROE COUNTY
ISLAMORADA
Jeffers, Janis, DMD PA
81990OverseasHwy
33040(305)664-4282
KEY WEST
Backer,Abraham
802TrumanAve
33040(305)293-1660
#183699
Ong, DMD, James N
KeyWestDentalAssociates
3146NorthsideDrSte101
33040-8014(305)293-9490
#193826
Lindner, DMD, George W
Old Town Dental Group, PA
1215SimontonSt
33040-3158(305)296-8541
Weith,CarolC,DDS
1010KennedyDr.Ste.307
33040-4134(305)292-6422
MARATHON
#31507
Buitrago,DDS,JuanC
SmilePlusoftheKeys
11399OverseasHwy
33050-3403(305)743-0401
#31507
Gil,DDS,Lester
SmilePlusoftheKeys
11399OverseasHwy
33050-3403(305)743-0401
Rangel,DeniseV.
(Pedodontist)
9713OverseasHwy
33050(305)743-4670
Tinsley,LeanneK,DMD
2901OverseasHwySte.2
33050-2235(305)289-8915
KEY LARGO
#452702
Gonzalez,DDS,MariaF
Tooth Place
99105OverseasHwy
33037-4254(305)451-2616
Hayes, Norys, DMD
103400OverseasHwy.Ste.234
33037-2849(305)453-9105
#191312
Bennett,DMD,TravisW
Everyone Loves a Gentle Dentis
102965OverseasHwy
33037-4690(305)451-2616
Lesperance,DDS,Lawrence
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
Azar,Francisco
Gomara, Luis
Salcines,Damaris
Martinez, Milton
Blanco,Diana
Davis,Stephanie
DeVera,Vanessa
Jaramillo, Gabriel
Delgado, Ligming
Saladriga,Lisa
Valdes,Marylin
Shayan,Maria
Cruz,Karen
Morgado, Aracello
Knopf,Kenneth
100750OverseasHwy
33037(305)460-7060
Rodriguez,DMD,AdrianaM
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
Soleymani,DMD,Kameran
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
Ruiz,DMD,Eliseo
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
Chiu,DDS,GordonB
Dental Associates of Homestead
925NE30thTerSte118
33033-7614(305)247-0910
#3920
Plasky,DDS,PaulE.
KeyLargoDentalAssociates
99198OverseasHwySte12
33037-2437(305)451-3204
Vazquez,DMD,JorgeE
Dental Associates of Homestead
925NE30thTerSte118
33033-7614(305)247-0910
SUMMERLAND KEY
#995507
TycolizJr.,DDS,WilliamL.
SummerlandDental
24986OverseasHwy
33042(305)745-1522
Silvestry,DDS,Elvin
Dental Associates of Homestead
925NE30thTerSte118
33033-7614(305)247-0910
Sander,Michael
(orthodonticonly)
SummerlandDental
24986OverseasHwy
33042(305)745-1522
#17655
GarciaCastellos,DMD,Jacqueline
Dental Associates of Homestead
925NE30thTerSte118
33033-7614(305)247-0910
TAVERNIER
Green,Anne,DDS
91555OverseasHwy
33070(305)735-4218
#17655
Guilarte,DMD,RhonaE
Dental Associates of Homestead
925NE30thTerSte118
33033-7614(305)247-0910
MIAMI-DADE
HOMESTEAD
Chiu,DDS,GordonB
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
#17655
Gurreonero,DMD,CarlosJ
Dental Associates of Homestead
925NE30thTerSte118
33033-7614(305)247-0910
Silvestry,DDS,Elvin
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
#17655
Lesperance,DDS,Lawrence
Dental Associates of Homestead
925NE30thTerSte118
33033-7614(305)247-0910
Rodriguez,DMD,EstebanJ
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
#17655
Rodriguez,DMD,EstebanJ
Dental Associates of Homestead
925NE30thTerSte118
33033-7614(305)247-0910
Felipe,DMD,Veronica
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
#17655
Landa, DMD, Jorge E
Dental Associates of Homestead
925NE30thTerSte118
33033-7614(305)247-0910
#183574
Sanchez,DDS,ZoraidaT
Sanchez,DDS,PA,ZoraidaT.
1619NE8thSt
33033-4603(305)247-9292
#995548
Muro Jr., DMD, Thomas
Muro Jr., DMD, PA, Thomas
311NE8thStSte204AB
33030-4738(305)242-5336
#183953
Azar,DDS,FranciscoJ
Family&CosmeticDentistry
125NE8thStSte1
33030-4676(786)243-2438
#183953
Gomara, DMD, Luis A
Family&CosmeticDentistry
125NE8thStSte1
33030-4676(786)243-2438
#183953
Salcines,DMD,DamarisG
Family&CosmeticDentistry
125NE8thStSte1
33030-4676(786)243-2438
#29103
Paz,DDS,LidiaM
Paz,DDS,LidiaM
950NKromeAve
33030-4400(305)247-5264
#25848
Gil,DDS,Lester
SmilePlus
963NKromeAve
Homestead,FL33030-4408
(305)247-5161
#191452
Buitrago,DDS,JuanC
SmilePlus
963NKromeAve
33030-4408(305)247-5161
#183887
Puente,DMD,Katia
The Tooth Place
8PalmPlz
33030-6046(305)245-7974
# 426413
Buitrago,DDS,JuanC
Tooth Place
8PalmPlz
33030-6046(305)245-7974
* Not accepting new patients.
13
23
www.myFBMC.com
Dental Plan Summary
Insurance Company
Dental PlansCompBenefits
Voluntary+ PPO – Ortho
# 426413
Saenz,DDS,ReginaH
Tooth Place
8PalmPlz
33030-6046(305)245-7974
# 426413
Gonzalez,DDS,MariaF
Tooth Place
8PalmPlz
33030-6046(305)245-7974
# 426413
Barrera,DDS,MarthaE
Tooth Place
8PalmPlz
33030-6046(305)245-7974
#5079
Rosen,DDS,HowardB.
Rosen,DDS,Howard
30NW15thSt
33030-4262(305)245-9691
#183888
Molina,DDS,RolandoJ.
Molina,DDS,PA,RolandoJ.
45NW8thStSte101
33030-4452(305)242-5223
#995577
Senk,DDS,GaryP*
Senk,DDS,PA,GaryP.*
381NKromeAveSte209
33030-6047(305)247-2143
# 32343
Chakalov,DMD,BoyanB
Homestead Dental Inc
83NW8thSt
33030-4404(305)248-0027
FLORIDA CITY
#994658
Estrada,DDS,Javier
TheFamilyDentalCareInc
646WPalmDrSte200
33034-3210(305)242-1200
#994658
DeLacruz,DDS,Alejandro
TheFamilyDentalCareInc
646WPalmDrSte200
33034-3210(305)242-1200
#994658
GonzalezRubio,DMD,Eduardo
TheFamilyDentalCareInc
646WPalmDrSte200
33034-3210(305)242-1200
* Not accepting new patients.
24
www.myFBMC.com
Managed Care Provider Directory
GENERAL DENTISTS
MONROE COUNTY
KEY LARGO
#3920
Plasky,DDS,PaulE.
KeyLargoDentalAssociates
99198OverseasHwySte12
33037-2437(305)451-3204
Hayes, Norys, DMD
103400OverseasHwy.Ste.234
33037-2849(305)453-9105
Azar,Francisco
Gomara, Luis
Salcines,Damaris
Martinez, Milton
Blanco,Diana
Davis,Stephanie
DeVera,Vanessa
Jaramillo, Gabriel
Delgado, Ligming
Saladriga,Lisa
Valdes,Marylin
Shayan,Maria
Cruz,Karen
Morgado, Aracello
Knopf,Kenneth
100750OverseasHwy
33037(305)460-7060
Dieudonne,DDS,Stephanie
SouthDadeFamilyDentistry
18435SDixieHwy
33157-6815(305)259-9130
Kablawi,DMD,FadiM
Kablawi,DMD,FadiY
27501SDixieHwySte300
33032-8219(305)245-7733
Nguyen, DMD, Diep H
SouthDadeFamilyDentistry
18435SDixieHwy
33157-6815(305)259-9130
Azar,DDS,FranciscoJ
Family&CosmeticDentistry
125NE8thStSte1
33030-4676(786)243-2438
Gonzalez-Zamora,DDS,Maria
SouthDadeFamilyDentistry
18435SDixieHwy
33157-6815(305)259-9130
Gomara, DMD, Luis A
Family&CosmeticDentistry
125NE8thStSte1
33030-4676(786)243-2438
Mendoza,DDS,Irenia
SouthDadeFamilyDentistry
18435SDixieHwy
33157-6815(305)259-9130
Salcines,DMD,DamarisG
Family&CosmeticDentistry
125NE8thStSte1
33030-4676(786)243-2438
HOMESTEAD
Chiu,DDS,GordonB
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
Vazquez,DMD,GeorgeA
GeorgeAVazquezDMD
127NE8thSt
33030-4607(305)245-0306
Vazquez,DMD,JorgeE
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
KEY WEST
#183699
Ong, DMD, James N
KeyWestDentalAssociates
3146NorthsideDrSte101
33040-8014(305)293-9490
Silvestry,DDS,Elvin
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
Rodriguez,DMD,EstebanJ
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
Stone,Ira
(oralsurgeon)
3146NorthsideDr.#B
33040(305)294-4661
Felipe,DMD,Veronica
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
SUMMERLAND KEY
#995507
TycolizJr.,DDS,WilliamL.
SummerlandDental
24986OverseasHwy
33042(305)745-1522
Lesperance,DDS,Lawrence
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
Sander,Michael
(orthodonticonly)
SummerlandDental
24986OverseasHwy
33042(305)745-1522
MARATHON
Rangel,DeniseV.
(Pedodontist)
9713OverseasHwy
33050(305)743-4670
MIAMI-DADE
CUTLER BAY
Alvarez,DMD,NolyrisK
SouthDadeFamilyDentistry
18435SDixieHwy
33157-6815(305)259-9130
Buitrago,DDS,JuanC
SmilePlus
963NKromeAve
33030-4408(305)247-5161
Gil,DDS,LesterO
SmilePlus
963NKromeAve
33030-4408(305)247-5161
Puente,DMD,Katia
The Tooth Place
8PalmPlz
33030-6046(305)245-7974
Rosen,DDS,HowardB.
Rosen,DDS,Howard
30NW15thSt
33030-4262(305)245-9691
Molina,DDS,RolandoJ.
Molina,DDS,PA,RolandoJ.
45NW8thStSte101
33030-4452(305)242-5223
Rodriguez,DMD,AdrianaM
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
FLORIDA CITY
Estrada,DDS,Javier
TheFamilyDentalCareInc
646WPalmDrSte200
33034-3210(305)242-1200
Soleymani,DMD,Kameran
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
DeLacruz,DDS,Alejandro
TheFamilyDentalCareInc
646WPalmDrSte200
33034-3210(305)242-1200
Ruiz,DMD,Eliseo
Dental Assoc. of Homestead Inc
925NE30thTerSte118
33033-7614(305)247-0910
GonzalezRubio,DMD,Eduardo
TheFamilyDentalCareInc
646WPalmDrSte200
33034-3210(305)242-1200
* Not accepting new patients.
14
Vision Plan
HumanaVision
HumanaVision
Florida
Vision Care Plan
Monroe County School Board
See a participating provider
See a nonparticipating provider
Exam with dilation as necessary
Lenses
100% after $10 copay
$35 allowance
• Single
• Bifocal
• Trifocal
100% after $15 copay
100% after $15 copay
100% after $15 copay
$25 allowance
$40 allowance
$60 allowance
Frames
Contact lenses2
$35 wholesale allowance
$45 retail allowance
$100 allowance
100%
$100 allowance
$210 allowance
Once every 12 months
Once every 12 months
Once every 24 months
Once every 12 months
Once every 12 months
Once every 24 months
1
3
• Elective (conventional and disposable)
4
• Medically necessary (limit one pair)
Frequency (based on date of service)
• Examination
• Lenses or contact lenses
• Frame
Additional plan discounts
• Members may benefit with fixed pricing for most lens options including anti-reflective and scratch-resistant
coatings.
• Members may also be eligible to receive up to a 20 percent retail discount on a second pair of eyeglasses, which is
available for 12 months after the covered eye exam through the participating provider who sold the initial pair of
eyeglasses.
• After copay, standard polycarbonate available at no charge for dependents less than 19 years old.
1
2
3
4
Material copay is required for a complete pair of eyeglasses, lenses or frames.
If a member prefers contact lenses, the plan provides an allowance for contacts in lieu of all other benefits
(including frames) (Vision Care Plan only).
The contact lens allowance applies to professional services (evaluation and fitting fee) and materials. Members
may be eligible to receive up to a 15 percent discount on in-network professional services, which is available for 12
months after the covered eye exam.
Benefit provides coverage for professional services and one pair of medically necessary contact lenses with prior
plan authorization.
25
Vision Plan
HumanaVision
Vision Care Plan
HumanaVision Lasik discount
We have contracted with many well-known facilities and eye doctors to offer Lasik procedures at substantially reduced
fees. You can take advantage of these low fees when procedures are done by network providers. The network locations
listed below offer the following prices (per eye):
Conventional / Traditional**
Custom**
TLC
888-358-3937
(designated
locations only)
LasikPlus
866-757-8082
QualSight
LASIK
855-456-2020
$895
$695*
LasikPlus free
enhancements
for 1 year
$1,395*
LasikPlus free
enhancements
for life
$895
QualSight free
enhancements
for 1 year
$1,295
with QualSight
Lifetime
Assurance Plan
$1,295
$1,895*
$1,895*
LasikPlus free enhancements for
life
You may receive a 10% discount
from retail prices at certain
independent Lasik participating
providers and pay no more than
$1,800 per eye for Conventional
Lasik and $2,300 per eye for
Custom Lasik.
$1,995*
with QualSight
Lifetime
Assurance Plan
$1,320
*with IntraLaseTM
**Pricing varies by section procedure offered by the provider you choose and options in your area. Not all locations offer fixed
pricing. Please call the provider for details
How does the wholesale frame allowance work?
Benefits include a wholesale frame allowance. If the wholesale cost exceeds the frame allowance, members pay twice
the wholesale difference. They never pay full retail.
Retail price*
Wholesale price
Wholesale allowance
Member pays
Savings
$125
$50
$50
$0
$125
$187.50
$75
$50
$50 ($75-$50=$25x2=$50)
$137.50
*
Retail costs may differ and are based on 2½ times the wholesale cost. Actual savings may vary.
Use your HumanaVision benefits
How it Works
HumanaVision options have you covered and make eye
care affordable. You have access to one of the largest
vision networks in the United States, with more than
35,000 participating optometrist, ophthalmologists, and
national retail locations, including LensCrafters®, Pearle
Vision®, Sears® Optical, Target® Optical, and JCPenney®
Optical. In addition you’ll enjoy:
1. After signing up for your vision plan, you will receive an
ID card in the mail
2. Prior to scheduling your appointment, select a network
provider through the Customer Care Center, automated
information line, or www.HumanaVisionCare.com
HumanaVisionCare.com
3. Schedule an appointment, providing your name, the
patient’s name and employer
4. Sign your provider’s form after your exam, you’ll pay any
copayments and/or costs of any upgrades at this time
• The same benefits at all participating providers, no
matter where they’re located
• Wholesale pricing on frames, avoiding high retail markups
• Simple access to plan information, provider search,
Customer Care and other automated services at
HumanaVisionCare.com
www.HumanaVisionCare.com
JCPenney Optical
®
26
Vision Plan
HumanaVision
Know what your plan covers
Attached is a summary of HumanaVision benefits
that are described in detail in your certificate. You can
www.HumanaVisionCare.com or call
find your certificate on HumanaVisionCare.com
1-866-537-0229. Here’s what you can expect:
• Quality routine eye health care from independent eye
care professionals and national retail locations.
• Services and materials provided on a prepaid basis,
and the plan pays in-network providers directly,
you also have the freedom to use out-of-network
providers if you prefer
• Life without claim forms! With HumanaVision,
you pay your eye care professional directly for
copayments and any extra cosmetic options selected
at the time of service
• Select a vision provider from our network simply by
visiting www.HumanaVisionCare.com
HumanaVisionCare.com, if you prefer, call us
at 1-866-537-0229
Vision health impacts
overall health
Routine eye exams can lead to early
detection of vision problems and
other diseases such as diabetes,
hypertension, multiple sclerosis, high
blood pressure, osteoporosis, and
rheumatoid arthritis.1
Know what your plan doesn’t cover
Some items and services not included in HumanaVision are:
• Orthoptics or vision training, subnormal vision aids or
Plano (non-prescription) lenses
• Replacement of lost or broken lenses, except at the
regularly-scheduled plan intervals
• Medical or surgical treatment of eyes
• Care provided through or required by any government
agency or program, including Workers’ Compensation
or a similar law
1
Thompson Media Inc.
This is not a complete disclosure of plan qualifications and limitations.
Check with your local Humana or HumanaDental sales office to verify product availability.
Insured by Humana Insurance Company or CompBenefits Insurance Company or CompBenefits Company
27
Group Term Life Insurance
Minnesota Life
Monroe County District School Board
Welcome to Minnesota Life
- Administered by Ochs, Inc.
Monroe County District School Board is pleased to
introduce Minnesota Life as the new Group Life
Insurance carrier, effective January 1, 2015.
ONE-TIME OPPORTUNITY
Nov. 12 - Dec. 5, 2014
All basic and supplemental life will be carried over to Minnesota Life.
NEW - SPOUSE AND CHILD LIFE
Benefit eligible employees now have a chance to purchase additional
Spouse Term Life and Child Life through a Supplemental Term Life
Program. This Program gives employees and their families a way to
keep their life insurance coverage in line with their changing needs.
Review your benefit plan options below and find the excellent rates,
enhanced plan features and value-added services on the reverse
side.
GUARANTEED ISSUE (GI) OPPORTUNITY
For a limited time, employees can enroll for up to $100,000 of
Supplemental Life; up to $25,000 of Spouse Life; and $10,000 of
Child Life - no health questions asked. Take advantage of this
special opportunity because enrolling at any other time will require
proof of good health. Guaranteed coverage elections will be effective
January 1, 2015.
No Health Questions

Employees - elect up to $100,000*

Spouses - elect up to $25,000

Children - elect $10,000
*GI limit includes amounts currently in force.
Amounts greater than the GI limit require
evidence of insurability.
Your plan at a glance
Coverage
Basic Term Life
Employer Paid
Amount
Additional Information
 Amount varies according to job
classification (ask your employer
or see certificate for details)
 All coverage is Guaranteed - no health questions
 Includes a matching AD&D benefit
 Age reductions apply beginning at age 65 or 70 depending on job
classification (ask your employer or see certificate for details)
Supplemental Term Life  $10,000 increments
Employee Paid
 Maximum $300,000
Spouse Term Life
Employee Paid
Child Term Life
Employee Paid
28
 $5,000 increments
 Maximum $150,000 (not to
 Up to $100,000 is Guaranteed - no health questions (GI limit
includes amounts currently in force)
 Includes a matching AD&D benefit
 Elections greater than $100,000 require evidence of insurability


ceed 100% of employee total

basic and supplemental coverage

amount)
ex-
 $10,000
 14 days to 6 months receive a
$1,000 benefit
Up to $25,000 is Guaranteed - no health questions
Includes a matching AD&D benefit
A spouse is not eligible, if also eligible as an employee
Elections greater than $25,000 required evidence of insurability
 All coverage is Guaranteed - no health questions
 Covers all eligible children from 14 days to 26 years
 A child may only be covered by one parent, if both are employees
Group Term Life Insurance
Minnesota Life
Employee or Spouse Supplemental Life
Age
Monthly Cost/$1,000
(includes AD&D)
Under 25
$0.108
25 -29
$0.108
30 - 34
$0.132
35 - 39
$0.132
40 - 44
$0.204
45 - 49
$0.324
50 - 54
$0.564
55 - 59
$0.924
60 - 64
$1.020
65 - 69
$1.980
70 - 74
$3.588
75*
$3.588
Rates increase with age each January 1st.
*Additional rates beyond age 75 are available upon request.
Child Life - Covers all eligible children
Benefit
Monthly Cost
$10,000
$ 1.60
Plan Features

Waiver of Premium - If you become totally disabled your
life insurance premiums may be waived.

Accelerated Death Benefit - If you become terminally ill
with a life expectancy of 12 months or less, you may
request early benefit payment of up to 100% of the life
insurance amount.

Accidental Death and Dismemberment (AD&D) Provides an additional insurance benefit if death results
from an accident, or pays a benefit if there is a loss from an
injury as defined in the plan.

Portability - If you leave or retire, prior to age 70, you may
be eligible to take your Term Life coverage with you and
pay premiums directly to Minnesota Life. Premiums may be
higher than those paid by active employees.

Conversion Rights - If you leave employment or retire, you
can convert existing coverage to an individual policy. No
health questions will be asked at conversion, as long as you
apply within 31 days after leaving your job. Premiums will be
higher than those paid by active employees.
Additional Services
Convenient Payroll Deductions
 Premiums are automatically deducted from your paycheck.
No Cost to Access the Following Resources:

Travel Assistance - Access to emergency travel assistance
service provided by Global Rescue. More information is
available at www.lifebenefits.com/travel or by calling 1-855516-5433.

Legal Services and Will Preparation - Services provided
by Ceridian LifeWorks. Additional information is available at
www.lifeworks.com: Username: will, Password: preparation
or by calling 1-877-849-6034.

Legacy Planning - Final arrangement resources provided
by Minnesota Life. More information available online at
www.LegacyPlanningResources.com.

Beneficiary Financial Counseling - Beneficiaries may
choose to use independent beneficiary counseling services
from PricewaterhouseCoopers LLP (PwC).
Supplemental Life Monthly
Premium Calculation Example
A 40 year old employee elects $50,000
of Supplemental Term Life Insurance:
Coverage elected:
Total number of units:
Rate per $1,000 (age 40):
Rate times # of units:
$50,000
$50,000 / 1,000 = 50
$0.204 (from table above)
$0.204 x 50 = $10.20
Monthly Cost = $10.20
Complete a Beneficiary Form
Your employer is requesting that all benefit eligible
employees update their beneficiary designations
currently on file. Please complete and turn in the
attached beneficiary designation form to your
Benefits Office.
Take Action - Enroll Now!
Be sure to take advantage of this enrollment opportunity.
Forms must be turned in to your Benefits Office by
December 5, 2014.
Questions:
Contact your Benefits Office; or call Ochs, Inc. at 1-800-3927295 M-F 9:00 am to 5:30 pm EST; or email your questions to
www.ochs@ochsinc.com
ochs@ochsinc.com. A representative is available to help you.
Services provided by Ceridian, Global Rescue LLC, and PricewaterhouseCoopers
LLP are their sole responsibility. The services are not affiliated with Minnesota Life
or its group contracts and may be discontinued at any time. Certain terms,
conditions and restrictions may apply when utilizing the services. To learn more,
visit the appropriate website.
This is a summary of plan provisions related to the insurance policy issued by
Minnesota Life to the policyholder. In the event of a conflict between this summary
and the policy and/or certificate, the policy and/or certificate shall dictate the
insurance provisions, exclusions, all limitations, and terms of coverage.
10-2014
400 Robert Street North Suite 1880
St. Paul, MN 55101
www.ochsinc.com
29
Disability Income Protection
Disability Income Protection Cigna Disability
A disability can put a lot of things in your life on hold. Unfortunately,
expenses aren’t one of those things. They keep right on coming. If you
become disabled, this insurance plan can help you keep up by providing
a stable monthly income, up to a maximum of $1,500 a month, or 60
percent of your monthly salary, whichever is less.
PlanFeatures
• Benefitsstartafteryouaredisabledfor90consecutivedays.
• For employees working 30 or more hours per week, benefits are
payable monthly up to age 65, if you are disabled before age 63. If
youbecomedisabledbetweentheagesof63and69,benefitsare
payableonadecreasingscale,withamaximumoneyearbenefit
periodfordisabilitiesthatcommenceatage69orolder.
• Foremployeesworkinglessthan30hoursperweek,benefitsare
payable monthly for a maximum period of 5 years if disabled before
age63.Ifdisabilityoccursbetweenages63and69,benefitsare
payableonadecreasingscalewithamaximumoneyearbenefitat
age69orolder.
• BenefitscoordinatewithSocialSecurityDisabilityBenefits,orany
othergroupbenefits,toensureyoureceiveupto60percentofyour
monthly income.
• Theminimummonthlybenefitforemployeesworking30ormore
hoursperweekis$300permonth.Theminimummonthlybenefitfor
employees working less than 30 hours per week is $100 per month.
Theminimummonthlybenefitistheminimumamountpayable,once
allotherincomebenefitshavebeenapplied.
• Premiums are waived while you receive payments under this plan.
Mental Illness, Alcoholism, Drug Abuse
Limitation
You can receive payments for a covered disability which does not
require hospitalization that results from mental illness, alcoholism or
drugabuseforamaximumof24months.After24months,thebenefit
willcontinueonlywhilethedisabledemployeeisconfinedforatleast
14 consecutive days in a hospital licensed to provide care and treatment
for the condition causing the disability.
WorkIncentiveBenefit
Thisbenefitoffersaneffectiveincentiveforemployeeswhoarereadyto
return to work, but not full time. If you are covered for work incentive
benefits, you may return to work while disabled and your disability
benefitswillcontinue.
Forthefirst12monthsyoureturntowork,if,foranymonthduring
thatperiod,thesumofyourdisabilitybenefit,yourincomefromthe
rehabilitativeworkandanyadditionalotherincomebenefitsexceed
100percentofyourindexedcoveredearnings,yourdisabilitybenefit
will be reduced by the excess amount.
After12months,yourdisabilitybenefitwillbereducedby50percent
of your income received during any month of rehabilitative work. If the
sumofyourdisabilitybenefit,yourincomefromtherehabilitativework
andanyadditionalotherincomebenefitsexceeds80percentofyour
earnings,yourdisabilitybenefitwillbereducedbytheexcessamount.
30
CatastrophicDisabilityBenefitRider
“CIGNA’sCatastrophicDisabilityBenefitRider”paysanadditional15
percent of your monthly salary, up to a maximum of $2,500 a month,
when CIGNA determines that the covered employee’s disability is
consideredcatastrophicandisduetothesamesicknessorinjuryfor
which long-term disability benefits are payable under the policy.A
catastrophic disability is determined by an inability to perform at least
two activities of daily living, which include bathing, dressing, continence,
toileting, feeding oneself, and the ability to transfer oneself without
substantialassistance(e.g.,movefromone’sbedtoawheelchair).This
benefitwillnotbereducedbyanyothersourceofincome.
Life Assistance Program
CIGNA’s LifeAssistance Program offers basic work/life services for
“employees and family members,” providing access to in-person
behavioral health assistance, telephonic counseling and online tools.
The program offers coverage for employees and their families.
• Professional counseling from licensed behavioral health providers
(includes 24/7 telephonic counseling, and up to 3 free in person
sessions).
• Life event referrals and research (research and up to 3 qualified
referrals within 12 business hours for services, and 30 minute free
legalconsultationsformostlegalissues).
• HealthyRewards®discountprogram(upto60percentdiscountson
healthandwellnessproductsandservices).
• Personal Stress Navigator (interactive tool to help evaluate stress
sourcesandsymptomsinordertomakeeffectivebehavioralchanges).
Eligibility Waiting Period
For employees hired after the policy effective date:
Thefirstofthemonthfollowing15calendardaysofactiveemployment.
Termination of Insurance
The insurance on an employee will end on the earliest date below:
• the date the employee is eligible for coverage under a plan intended
to replace this coverage
• the date the policy is terminated
• the date the employee is no longer in an eligible class
• the day after the period for which premiums are paid
• the date the employee is no longer in active service.
DisabilityDisability
Income Protection
Income ProtectionCigna Disability
RehabilitationDuringPeriodofDisability
A Rehabilitation Plan is a written agreement between you and the
insurance company in which the insurance company agrees to provide,
arrange or authorize vocational and physical rehabilitation services.
The Rehabilitation Plan may, at the insurance company’s discretion,
allow for payment of your medical expenses, education expenses,
moving expenses, accommodation expenses or family care expenses
while you participate in the program.
If, while you are disabled, the insurance company determines that
you are a suitable candidate for rehabilitation, you may participate in
aRehabilitationPlan.Youandtheinsurancecompanymustmutually
agreeuponthetermsandconditionsoftheRehabilitationPlan.The
insurance company may require that you participate in a rehabilitation
assessment with you, your employer, your physician and others, as
appropriate, to develop a rehabilitation plan. If you refuse to participate
intherehabilitationeffortsdisabilitybenefitswillnotbepayable.
SurvivorBenefit
If death occurs after the employee has been receiving the monthly
benefitsforatleastsixmonths,hisorhereligiblesurvivorwillreceive
sixmonthlypayments,nottoexceedatotalbenefitof$1,000.
Definitionof“Disability”
The plan considers you disabled if you:
• cannot perform all the material and substantial duties of your regular
occupation, and
• areunabletoearnmorethan80percentofyourindexedcovered
earnings,solelyduetoinjuryorsickness.
After monthly benefits have been payable for 24 months, the plan
considers you disabled if you cannot perform the material and substantial
duties of any occupation or employment for which you may reasonably
become qualified based on your education, training or experience
andareunabletoearnmorethan80percentofyourindexedcovered
earnings,solelyduetoinjuryorsickness.
Pre-ExistingConditions
Ifyourdisabilityresults,directlyorindirectly,fromapre-existingsickness
orinjuryforwhichyouincurredexpenses,receivedmedicaltreatment,
took prescribed drugs or consulted a physician in the three months before
the most recent effective date of your insurance, you will receive no
monthlybenefitsforthatcondition.However,thislimitationdoesnot
apply to a total disability which begins more than 12 months after the
most recent effective date of your insurance.
ConversionPrivilege
If you terminate employment or if your coverage ends for any reason
except non-payment of premium, you can convert this plan to an
individual policy by applying for conversion within 62 days of
termination. To be eligible for conversion, you must have been insured
for disability benefits and actively at work for at least 12 months.
Contact Fringe Benefits Management Company Customer Care at
1-855-5MYFBMC (1-855-569-3262), to request a LINA Conversion
Application.
Coverage
Employeeonly
20 pay periods
$9.87
OtherIncomeBenefits
Whenanemployeeisdisabled,heorshemaybeeligibleforbenefits
from other income sources. If so, the insurance company may reduce the
disabilitybenefitspayablebytheamountofsuchotherincomebenefits.
Theextenttowhichotherincomebenefitswillreduceanydisability
benefitspayableunderthepolicyisshowninthescheduleofbenefits.
Otherincomebenefitsinclude:
1. any amounts that the employee or any dependents, if applicable,
receive(orareassumedtoreceive)under:
• theCanadaandQuebecPensionPlans
• theRailroadRetirementAct
• any local, state, provincial or federal government disability or
retirement plan or law as it pertains to the employer
• any sick leave plan of the employer;
• anyworklossprovisioninmandatory“no-fault”autoinsurance
• any workers’ compensation, occupational disease, unemployment
compensation law or similar state or federal law, including all
permanentaswellastemporarydisabilitybenefits.Thisincludes
any damages, compromises or settlement paid in place of such
benefits,whetherornotliabilityisadmitted.
2. anySocialSecuritydisabilitybenefitstheemployeeoranythirdparty
receives(orisassumedtoreceive)ontheemployee’sbehalforfor
hisorherdependents,orthathisorherdependentsreceive(orare
assumedtoreceive)becauseoftheemployee’sentitlementtosuch
benefits.
3. anyretirementplanbenefitsfundedbytheEmployer.“Retirement
plan” means any defined benefit or defined contribution plan
sponsored or funded by an employer. It does not include an individual
deferred compensation agreement, a profit sharing or any other
retirementorsavingsplanmaintainedinadditiontoadefinedbenefit
orotherdefinedcontributionpensionplan,oranyemployeesavings
plan including a thrift, stock option or stock bonus plan, individual
retirementaccountor401(k)plan.
4. any proceeds payable under any franchise or group insurance or
similar plan. If there is other insurance that applies to the same claim
for disability and contains the same or similar provision for reduction
because of other insurance, the insurance company will pay its pro
ratashareofthetotalclaim.“Proratashare”meanstheproportionof
thetotalbenefitthattheamountpayableunderonepolicy,without
otherinsurance,bearstothetotalbenefitsunderallsuchpolicies.
5. any amounts paid on account of loss of earnings or earning capacity
throughsettlement,judgment,arbitrationorotherwise,whereathird
party may be liable, regardless of whether liability is determined.
6. any wage or salary for work performed. If an employee is covered
forworkincentivebenefits,theinsurancecompanywillonlyreduce
31
Disability Income Protection
Disability Income ProtectionCigna Disability
disabilitybenefitstotheextentprovidedundertheworkincentive
benefitinthescheduleofbenefits.
What’sNotCovered?
The plan will not pay disability benefits for a disability that results,
directly or indirectly, from:
• suicide,attemptedsuicideorwheneveranemployeeinjureshimself
or herself on purpose
• war or any act of war, whether or not declared
• servingonfull-timeactivedutyinanyarmedforces*
• active participation in a riot
• commission of a felony or
• revocation, restriction or non-renewal of an employee’s license,
permitorcertificationnecessarytoperformthedutiesofhisorher
occupation,unlessduesolelytoinjuryorsicknessotherwisecovered
by the policy.
* If the Employee sends proof of military service, the insurance company will refund the portion of
the premium paid to cover the employee during a period of such service.
The plan will not pay disability benefits for any period of disability
during which the employee:
• is incarcerated in a penal or corrections institution
• is not receiving appropriate care
• fails to cooperate with the insurance company in the administration
of the claim including, but not limited to, providing any information
ordocumentsneededtodeterminewhetherbenefitsarepayableor
theactualbenefitamountdue
• refuses to participate in rehabilitation efforts required by the insurance
company or
• refuses to participate in a work transition arrangement or other
modifiedworkarrangement.
Important Notice
This information is a brief description of the important features of this
plan. It is not a contract. Terms & conditions of the coverage are set forth
ingrouppolicyNo.LK006441,onpolicyformTL-004700,issuedin
Floridaandsubjecttoitslaws.Theavailabilityofthisoffermaychange.
Pleasekeepthismaterialasareference,andfileitwithyourcertificate,
should you become insured.
Plan Provider
CoverageunderwrittenbyLifeInsuranceCompanyofNorthAmerica.
32
Critical Illness Insurance
Disability Income Insurance
American Fidelity Assurance Company
Critical Illness Insurance*
Surviving a critical illness, such as a heart attack or stroke, can come at a high price. Even with medical
insurance, the out-of-pocket expenses associated with a critical illness can affect anyone’s finances.
American Fidelity’s Limited Benefit Critical Illness Insurance plan can assist with the expenses that may
not be covered by standard medical insurance, allowing you and your family to focus on what matters
the most – your recovery.
How tHe Plan works
If you are diagnosed with a covered Critical Illness, such as a heart attack or stroke, this plan is designed
to pay a lump sum benefit amount to help cover expenses.
Features:
• Health screening Benefit
Receive an annual benefit for undergoing one covered health screening test per year, such as a stress
test, echo cardiogram, blood glucose testing, or up to five other routine tests.
• three Benefit amount options
Choose from a coverage amount of $15,000, $20,000, or $25,000 at the time of application.
• Benefit Paid Directly to You
Use your benefit for any expense you wish.
*This product may be referred to by a different name. Limitations, exclusions, and waiting periods may apply. Not generally qualified
benefits under Section 125 Plans. This product is inappropriate for people who are eligible for Medicaid coverage.
SB-29446-0114
Disability Income Insurance
If your paycheck suddenly stopped today, could you afford to pay for your mortgage, car payments,
food, and other monthly expenses? How could you maintain your current lifestyle?
American Fidelity knows one of the most important assets a person possesses is their ability to earn an
income. Our Disability Income Insurance is a cost-effective solution designed to help protect you if you
become disabled and cannot work due to a covered injury or sickness.
How tHe Plan works
If you become disabled due to a covered injury or sickness, Disability Income Insurance will pay a
percentage of your gross monthly income once you have satisfied the elimination period. Disability
benefits will be payable up to the benefit period stated in your policy.
Features
• Multiple elimination Periods
Based on your individual need, you can select from multiple elimination periods.
• waiver of Premium Benefit
Premiums are not required while you are disabled based on the length of your disability.
• return to work Benefit
This allows you to return to work, on a part-time basis, and still receive a portion of the benefit.
• accidental Death Benefit
Your beneficiary will receive a lump sum payment if you die within the period stated in your policy
as a result of an accidental injury.
These products may contain limitations, exclusions, and waiting periods. Applicant’s eligibility for this program may be subject to
insurability.
SB-29447-0114
33
Accident Only Insurance
Hospital GAP PLAN Insurance
American Fidelity Assurance Company
Accident Only Insurance
Whether you are a weekend warrior with an active lifestyle or the stay-at-home type, accidents can happen
anytime, anywhere, without warning. Being prepared for the unexpected can make all the difference.
American Fidelity’s Limited Benefit Accident Only Insurance plan is designed to help cover some of the
expenses that can result from a covered accident, and benefit payments are made directly to you.
How tHe Plan works
This plan provides 24-hour coverage for accidents that occur both on and off the job. With more than
25 available benefits, this plan pays for a wide range of benefits and can help offset the financial cost of
medical expenses.
Features:
• Four Coverage options
Choose the coverage that best fits your lifestyle and financial needs.
• wellness Benefit
The plan pays an annual Wellness Benefit for one Covered Person to receive their routine physical
exam, including immunizations and preventive testing.
• accidental Death and Dismemberment Benefit
The plan pays a benefit when an Accidental Death or Dismemberment occurs within 90 days of a
covered accident.
104521457
Limitations, exclusions, and waiting periods may apply. Not all products and benefits may be available in all states. This product is
inappropriate for people who are eligible for Medicaid coverage.
SB-29441-0114
Hospital GAP PLAN® Insurance
Many people think that basic health insurance is enough to cover their medical needs, but the reality is
that many plans only cover a portion of overall expenses. It’s important to protect yourself in case of a
sudden hospitalization.
American Fidelity’s Hospital GAP PLAN® Insurance may help cover certain out-of-pocket costs such as
copayments, coinsurance, and deductibles not covered by traditional insurance.
How tHe Plan works
Our plan pays benefits directly to you and is specially designed to help supplement your standard
medical insurance plan and cover certain out-of-pocket expenses.
Features
• In-Patient Benefit
Benefits assist in paying for out-of-pocket expenses, such as copayments and deductibles.
• out-Patient Benefit
Benefits help pay for emergency room, out-patient surgery, and diagnostic testing expenses.
• Doctor Bill Benefit
Benefits help pay for treatment at a doctor’s office, out-patient treatment, hospital emergency room,
or clinic.
These products may contain limitations, exclusions, and waiting periods. This product is inappropriate for people who are
eligible for Medicaid coverage.
34
SB-29449-0114
Cancer Insurance
Permanent, Portable Life Insurance
American Fidelity Assurance Company
Cancer Insurance
The expenses associated with a cancer diagnosis can be overwhelming. Even with a good medical plan,
the out-of-pocket costs of cancer treatment, such as travel, child care, and loss of income, can be expensive.
American Fidelity’s Limited Benefit Cancer Insurance offers a solution to help so you can
focus your attention on your treatment and healing. We offer a plan that may assist with
out-of-pocket costs often associated with a covered cancer diagnosis, and we provide the money directly
to you, to be used however you see fit.
How tHe Plan works
This plan is specially designed to help with a portion of the costs of cancer, with more than 25 plan
benefits available for cancer treatment.
Features
• Preventative Care Benefit
Receive an annual benefit for undergoing a routine cancer screening test, which can help with
early detection.
• three Coverage options
Choose from Individual, Single Parent Family, and Family coverage. You choose the coverage that
best fits your lifestyle and financial needs.
• Plan enhancements*
You may be able to enhance your base plan by adding optional riders, such as a Critical Illness Rider.
*Not all riders may be available in every state. Limitations, exclusions, and waiting periods may apply. This product is inappropriate for
people who are eligible for Medicaid coverage.
SB-29445-0114
Permanent, Portable Life Insurance
Your employer may provide you with group life insurance, but do you have permanent portable life
insurance that you can take with you after employment? Life insurance at retirement can be very costly.
Secure your life insurance premium today with a permanent and portable plan.
How tHe Plan works
Permanent life insurance is a policy that is effective to age 121. You own the policy, so you take it with
you after your employment ends.
Features
• Minimal Cash Value
Premiums are dedicated primarily to the purchase of life insurance.
• Multiple Coverage options
Policies are available for you, your spouse/domestic partner, children, and grandchildren.1
• Portable
A policy that you own. Take it with you if you leave employment or retire.2
Policy Form: PRFNG-NI-10 / 14M020-C AF 1017 (expires 2/2016) See brochure for details.
1
Coverage and spouse/domestic partner eligibility may vary by state. Coverage not available for children and grandchildren in
Washington. Texas Life complies with all state laws regarding marriages and legally recognized familial relationships. 2 As long as you
pay the necessary premium. This policy has exclusions, limitations, and terms under which the policy may be continued in force or
discontinued. Not generally qualified benefits under Section 125 Plans. PureLife-plus not available in NJ, NY, or PA.
Underwritten by
SB-29479-0114
35
Life Insurance
American Fidelity Assurance Company
Life Insurance
It is impossible for life insurance to emotionally compensate for a loss, but it may help ease the financial
obligations placed on your loved ones.
American Fidelity’s portable, individual life insurance policies may help your family in the event of
your death. They have a simplified application process, minimal health questions*, and no required
medical exams.*
How tHe PlanS work
term life Insurance offers protection during your peak earning years and allows you choose from a 10,
20, or 30 year benefit. Permanent life Insurance provides lifelong protection and the ability to
accumulate cash values on a tax-deferred basis**.
FeatureS
• Guaranteed Death Benefit
Your death benefit is guaranteed for the life of the policy, provided premiums are paid.
• accelerated Death Benefit
You can receive a portion of the chosen death benefit if you are diagnosed with a terminal condition.
• non-taxable Death Benefit
A death benefit amount that is generally tax free.**
*Issuance of the policy may depend upon the answers to the health questions. **Please consult your tax advisor for your specific
situation. Limitations, exclusions, and waiting periods may apply. Not generally qualified benefits under Section 125 Plans.
SB-29457-0114
36
FLEXIBLE
SPENDING
ACCOUNTS
Health FSA
Debit Card
Dependent Care FSA
Filing a Claim
Accessing Your FSA
37
Flexible Spending Accounts
American Fidelity Assurance Company
American Fidelity Assurance Company
Flexible Spending Accounts are a great cost savings tool to help with
common medical and/or dependent care expenses not covered by
your insurance. You can elect a portion of your pay to be deducted,
on a pre-tax basis, from each paycheck to use for reimbursements of
qualified out-of-pocket expenses throughout the plan year.
Health Flexible Spending Account (FSA)
Flexible Spending Account Savings Example
Maximum Annual Deposit: $2,500
With FSA
Without FSA
$30,000
Annual Gross Income
- $2,400
Health FSA Deposit
$0
- $2,500
Dependent Care Account Deposit
$0
$25,100
Taxable Gross Income
$30,000
- $5,020
Estimated Federal Tax (20%)
- 6,000
- $1,920.15
Estimated FICA (7.65%)
- 2,295
$18,159.85
Annual Net Income
$21,705
Cost of Recurring Medical Expenses
- $2,400
$0
$0 Cost of Recurring Dependent Care Expenses
$18,159.85
Spendable Income
$30,000
- $2,500
$16,805
With an FSA you have a potential annual savings of: $1,354.85
By using an FSA to pay for eligible recurring expenses, you can cut down
on your taxable income which will result in additional spendable income.
A Health FSA allows you to allocate money on a pre-tax basis to
reimburse yourself for qualified medical expenses for you and your
family. Qualified expenses include anything from co-payments,
medical deductibles, prescriptions and much more.
Partial List of Eligible Expenses for Health FSA
Copays/coinsurance
Deductibles
Dental treatments
Diabetic supplies
Prescription drugs and medicines
Eye exams, eyeglasses, contact lenses, contact lens solution and enzyme
Flu shots
Immunizations
Lab fees
Laser/Lasik/RK surgery
Medical exams
Orthodontia
Psychiatric care
Wheelchair
X-rays
For a complete list of eligible expenses,
please visit www.americanfidelity.com
Carryover Provision for Health Flexible
Spending Accounts
The Internal Revenue Service (IRS) gives employers the ability to allow
Health Flexible Spending Account (Health FSA) participants to carry
over up to $500 of unused contributions from one plan year to the
next. This is called the Carryover Provision. This carryover amount may
then be used to reimburse eligible medical expenses incurred anytime
during the next plan year.
23
38
Flexible Spending Accounts
Health FSA Debit Card
American Fidelity will provide a Debit Card to all employees who
elect to participate in a Health FSA. The debit card gives immediate,
convenient access to Health FSA funds at the point of sale for
prescriptions, copays, and other common qualified medical expenses.
The card can only be used for the Health FSA and is not available for
the Dependent Care Account.
Using Your Debit Card
Simply swipe your Health FSA debit card like you would with any other
credit card. Whether at the doctor’s office or the dentist, the amount
of your eligible expenses will be automatically deducted from your
Health FSA account.
Health FSA Debit Card
Activating Your Card
You will receive your card at your home address and can begin using
your card at the beginning the first day of your plan year. Your card
will be automatically activated when you use it for the first time for an
eligible expense.
Guidelines for Your Health FSA Debit Card
• Keep your receipts. Claims not approved automatically will need
to be submitted manually.
• If a provider does not accept the Debit Card, you can request
reimbursement by completing the Health FSA Expense
Reimbursement Voucher and submit with the required
documentation. Health FSA reimbursement vouchers can be found
online at www.americanfidelity.com.
• If debit card “swipes” do not match up with pre-set benefits from
your employer, or, we do not receive all the necessary information
electronically from the debit card vendors to automatically
approve the flex debit card “swipe”, manual claims substantiation
will be requested.
• If you cannot provide the substantiation requested, that claim
will be determined to be ineligible and funds for that claim
must be reimbursed back to the plan. Acceptable substantiation
to accompany the request is a professional bill or receipt that
includes the provider of service, type of service rendered, charges
for the service, and original date of service; insurance company
explanation of benefits; pharmacy statement that includes
Prescription number and name of prescription.
Debit Cards for Health FSAs can be used at:
• Healthcare related facilities which include: hospitals, physician
offices, dental offices, vision offices; and,
• Merchants participating in the Inventory Information Approval
System (IIAS).
Your debit card claim will be automatically approved without further
information requested for:
• Copay Amounts – If your employer provides the necessary
information for your medical carrier, the copay amounts can
be automatically approved if your copay is stated as a flat dollar
amount. If your medical coverage is stated as a coinsurance
percentage, additional information will be necessary to approve
the expenses.
• Recurring expenses – You will need to submit your first claim
manually and state this will be a recurring claim from the same
provider at the same dollar amount. It will be noted on your
account that this will be a recurring expense, and additional
substantiation will not be required for that plan year.
39
Flexible Spending Accounts
Dependent Care Account
A Dependent Care Account allows you to allocate money on a pre-tax
basis to reimburse yourself for dependent care services such as after
school care and dependent daycare centers.
Maximum Annual Deposit: $5,000
Partial List of Eligible Dependent Care Expenses
After-school care or extended day programs
Nanny expenses
Baby-sitter inside or outside participant’s household
Custodial or elder care expenses if the qualifying individual still spends at
least 8 hours each day in the employee’s household
Dependent care center* expenses/pre-kindergarten/nursery school
expense if primary purpose is to care for the child so the parent can work
Expenses paid to a non-dependent relative of participant
Summer day camp if the primary purpose of the expense is custodial in
nature and not educational
For a complete list of eligible expenses,
please visit www.americanfidelity.com.
*A Dependent Care Center is a place that provides care for more than six persons
(other than persons who live there) and receives a fee, payment or grant for
providing services for any of those persons, regardless of whether the center is
run for profit.
Regardless of whether you participate in the dependent care plan
under Section 125 or claim the credit on your income tax, you must
provide the IRS with the name, address and taxpayer identification
number (TIN) or Social Security number of your dependent care
provider(s) by completing either Schedule 2 of Form 1040A or Form
2441 and attaching it to your annual income tax return. Be sure that
you follow the current instructions given by the IRS for preparing
your annual income tax return. Failure to provide this information to
the IRS could result in loss of the pre-tax exemption for your dependent
care expenses.
40
American Fidelity Assurance Company
FSA Fund Availability
Health FSA Account
Your full annual election is available to you on June 1st of the plan year.
Dependent Care Account
Unlike the Health FSA, the entire elected amount is not available on
the first day of the plan year, but rather as contributions are received
and services have been provided.
Important FSA Notes:
• Participants are allowed a 90-day run-off period after the plan year
ends in which to submit claims that occurred during the plan year
but were not yet submitted.
• If you are a new employee entering the plan during a plan year,
services must be provided after you are eligible to participate in
the plan.
• If you are enrolled in the Health FSA and take a leave of absence
during the plan year, you may:
1.Prepay the contributions pre-tax, or
2.Continue the contributions on an after-tax basis (pre-tax
contributions may continue when you return to work), or
3.Prorate the unpaid contributions over the remaining pay
periods when you return to work.
• Failure to make all elected contributions will result in termination
of your account as of the date contributions ceased.
• Health FSAs must comply with COBRA and offer COBRA continuation
rights to qualified beneficiaries who lose their Health FSA coverage
as a result of termination of employment. This may only be offered
upon termination of employment if you have a balance remaining
in your Health FSA. The balance is calculated by subtracting the
reimbursements made from the contributions received. You may
choose to continue your contributions by either sending your
contributions to your employer on an after-tax basis each pay
period, or, you can choose to pre-tax the remaining contributions
for the plan year from your severance pay. Expenses incurred while
contributions are being made are eligible for reimbursement. The
coverage may not continue beyond the current plan year. If you
do not elect to continue the contributions on an after-tax basis,
only expenses incurred during the period of employment will
be reimbursed. Coverage under the Health FSA ceases when the
contributions cease.
Flexible Spending Accounts
Filing a Claim
1. Complete an Expense Reimbursement Voucher, along with the thirdparty documentation of the expense. Health FSA and Dependent Care
vouchers can be found online at www.americanfidelity.com.
2. Submit your completed form and documentation to American
Fidelity’s Flex Department. You can either mail it to the address located
on the bottom of the voucher or fax it toll-free to 1-888-543-3539.
3. Your claim will be processed on an average of 5-7 business days
from the date all required claim information is received. The Health
FSA reimbursement check will be for the expenses claimed up to the
annual election for the plan year minus any previously reimbursed
amounts.
The Dependent Care expense reimbursement will be for the services
provided limited to the amount you have in your account. If the
Dependent Care expense claim is in excess of your account balance,
the balance of the claim will be paid to you as additional contributions
are received.
Filing a Claim
Accessing Your FSA
By visiting American Fidelity’s web site www.americanfidelity.com
you will have a wealth of information available to you without the use
of any customer IDs or passwords. Through the public site you have
access to:
• Claim forms
• Section 125 Flex Reimbursement Forms
• Customer FAQs
• Contact information
Secure Account Management Tools
American Fidelity’s Online Service Center is a convenient, secure web
site that gives you access to information regarding your American
Fidelity account. Available any time of day from home, work or any
computer with Internet access, the Online Service Center provides
valuable options.
• Check claim status
• Review detailed insurance policy information
• Access Health FSA information and balances
• Submit address changes
Direct Deposit
By selecting to have your reimbursements directly deposited to your
bank account you can get your reimbursements faster without having
to wait for the check to arrive in the mail. Each time a reimbursement is
deposited into your bank account, you will be mailed an Explanation of
Benefits that shows the deposit as well as a summary of your account.
41
OTHER
INFORMATION
Cigna Will Center
Vista 401(k)
COBRA Q&A
Beyond Your Benefits
42
Cigna Will Center
Cigna Life Insurance
Cigna will preparation program
Difficult legal
decisions
JUST GOT A
LITTLE EASIER.
Preparing a will is a critical step to protecting your family’s financial future. That’s why we offer
will preparation services at no additional cost if you have a Cigna life, accident, disability, critical
illness or accidental injury plan.
The death of a family member can be a confusing and
conflicting time. There are many tasks and decisions
to make – all when emotions and stress are high, time
limited and energy may be low. Planning in advance
helps relieve these uncertainties for family members left
behind and ensures that your wishes are known.
Not sure how to get started?
Don’t worry. Cigna’s Will Center is secure, easy to use
and available to you and your spouse seven days a week,
365 days a year. Phone representatives are also available
to assist you via a toll-free number.1
Once you’re registered on the site, you can:
• Follow an intuitive, interactive, question-and-answer
process to create state-specific legal documents
tailored to your needs
• Create and maintain your personalized legal
documents in an estate plan
• Preview, edit, download and print your legal
documents for execution
• Access resources and tools to help with the funeral
planning process
859684 12/12
Offered by: Connecticut General Life Insurance Company, Life Insurance Company of North America and Cigna Life Insurance
Company of New York.
43
Cigna Will Center
Cigna Life Insurance
CignaWillCenter.com
Visit www.CignaWillCenter.com
CignaWillCenter.com to register and
immediately start building your own personalized
estate and funeral plan, including:
Last will and testament: Determine what’s to be
done with your property when you die, and name
the executor of your estate and a guardian for your
minor children
Living will: Outline your wishes regarding the use
of extraordinary life support or other life-sustaining
medical treatment
To access all these valuable
tools and services, go to
CignaWillCenter.com
Health care power of attorney: Allow someone to
make medical decisions if you are unable
Financial power of attorney: Allow someone to make
financial decisions on your behalf if you are unable
Medical authorization for minors: Empower medical
personnel to treat your child if you are not present
Funeral planning resources:
• Informational guidebooks – in-depth, easy-tounderstand information to help you prepare your
or a loved one’s end-of-life wishes
• Personal information organizer tool – keep
important personal data, account information,
contacts, and end-of-life wishes all in one place
1. Legal advice is not provided.
Registrations and customized documents are maintained for two years, which allows individuals to easily make revisions to their legal documents as their personal
situation changes.
Will preparation services are independently administered by ARAG®. Cigna does not provide legal services and makes no representations or warranties as to the quality of
the information on the ARAG website or the services of ARAG.
“Cigna” is registered service marks, and the “Tree of Life” logo and “GO YOU” are service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and
its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including Life Insurance Company of North America, Cigna
Life Insurance Company of New York and Connecticut General Life Insurance Company, and not by Cigna Corporation. All models are used for illustrative purposes only.
859684 12/12 © 2012 Cigna. Some content provided under license.
Vista 401(k) Supplemental
Vista 401(k)Plan
Supplemental RetirementVista
Plan
401(k)
Retirement
Plan Features
WhoCanJoin?
Allfull-timeemployeesareeligibletoparticipateintheVista401(k)
SupplementalRetirementPlan.
HowDoesthePlanWork?
401(k) enrollment forms can be downloaded
from www.vista401k.com or contact.
The basic processes are simple:
• Contributions to the plan are made through regular payroll
deductions.
• Selectionsfromover30mutualfundsareavailable.
• No taxes are paid on any contributions or earnings until they are
withdrawn.
ParticipantStatement
How to Enroll
You can also obtain daily information from our website or through the
IVRat1-800-213-2310.
To enroll in yourVista 401(k) Plan simply visit our website at
www.vista401k.com or complete an enrollment form indicating:
• The per pay period amount you want to contribute.
• Howyouwantyourmoneyinvested(youmaydeferthatdecision
untilafteryouhaveenrolledbutbeforethefirstpayrolldeductions
arereceived).Ifnodecisionismade,yourcontributionswillbemade
tothetargetretirementfundclosesttoyourretirement(age62).
• Thebeneficiarywhowillreceiveyouraccountintheeventofyour
death.
MailyourcompletedformtoVista401(k)atP.O.Box1878,Tallahassee,
Florida32302-1878.
HowtoChangeYourInvestments
YoucanchangeyourinvestmentsbygoingtotheVista401(k)
websiteat www.vista401k.com
• Changehowyourfuturecontributionswillbeinvested.
• Transfer your existing account balance among the fund choices.
You will receive personal account statements on a quarterly basis.
Your statement will show activity in your account including contributions,
sharespurchased,gains/losses,fundtransfersanddistributions.Youmay
also create a statement for any time period by visiting our website at
www.vista401k.com.
Contributions
Contribution Limits
The minimum annual contribution is $500. The maximum amount is
indexedonanannualbasisbytheIRS.Pleasevisitwww.vista401k.com
for current annual amount.
Tax Savings
Each contribution defers your federal income taxes. Additionally, no
taxes are paid on any earnings in the plan until they are withdrawn.
Yourcontributionsare,however,subjecttoSocialSecuritytaxes.Visit
our website at www.vista401k.com and perform an investment analysis.
Contribution Changes
Achangeisdefinedasanincreaseordecreaseinyourcontribution
amount. You are allowed to make two changes per year. You can stop
your contributions at any time even if you have made a change during
the year.
There is no minimum time period before transfers or exchanges are
allowed.
45
Vista
401(k)
Supplemental
Vista 401(k)
Supplemental RetirementVista
Plan
401(k)
Retirement
Plan
FeesandExpenses
Vista401(k)planexpensesareasfollows:
• OverallManagement-A“wrap”feeof0.5%isassessedfromyour
assetbalances
• administration-$1.00permonthisassessedtoparticipantsnolonger
activelycontributingtotheir401(k)account
• MutualFund-Thereareinvestmentfeesthataredifferentforeach
fund as described in their prospectus. A detailed summary is available
at www.vista401k.com
• $20 check writing fee for distributions and loan checks.
• Front-endorloadingcharge-none.
• Surrendercharge-none.
• Fees and/or restrictions on transferring plan assets between
funds-none.
• Othercharges-none.
• Loanfee-$65.
Loans
Note: Some of these funds normally charge a sales charge from
contributions by individual investors. All of those charges have
beenwaivedbyeachfundfortheVista401(k)Plan.Therefore,your
contributionspurchasesharesatNetAssetValue(NAV).
Your401(k)planhasaloanprovisiontogiveyouaccesstoyourmoney
The following rules apply:
• You must have a minimum of $2,000 in your account.
• Youcanborrowupto50%ofyouraccountbalance,withamaximum
of $50,000. Employer contributions and any earnings are not eligible
for a loan.
• The minimum loan amount is $1,000.
• You have a choice of paying your loan back, with interest, in 1, 2, 3
or 4 years.
• You pay back your loan through equal payroll deductions.
• There are no penalties if you prepay your loan, but if you want to
pay it off early, you must pay it off in one lump sum.
• Youcanonlyhaveoneloanatatime;thereisa30-daywaitingperiod
between loans.
• Theinterestratewillbe2%overtheprimerate.
• Yourtotalpayment(principalandinterest)willbedepositedback
into your account.
• Thereisa$65feeforloanprocessing,whichincludesStateofFlorida
DocumentaryStamppayment.
RestrictionsonPlanDistributions
Hardship Withdrawal Provisions
Your401(k)accountisalong-terminvestment,designedspecifically
foryourretirementneeds.Becauseofthis,theIRSrestrictswhenyou
can withdraw your money. You are able to withdraw your money when
you reach age 59½, retire, terminate employment, become totally
andpermanentlydisabled,orhaveafinancialhardship(seehardship
withdrawalprovisions).Federallawimposestheselimitations.
Taxes on Distributions
YoupaytaxesonyourVista401(k)plancontributionsandyourearnings
when you withdraw them. If a check is written to you, your distribution
willhave20%federalincometaxwithheld.Ifyouwanttoavoidpaying
taxesonyourwithdrawal,youmaydoadirectrollovertoanIRAoryour
newemployer’s401(k)plan.
Anadditional10%penaltytaxwillbeimposedfordistributionsmade
beforetheageof59½exceptforthefollowingcircumstances:
• distributions if you have reached age 55 and retired early
• hardship distributions
• distributionstoanalternatepayeeunderaqualifieddomesticrelations
order, issued by the court in the divorce or dissolution of marriage
proceeding
• distributions made due to an employee’s death or disability
• adirectrollovertoanotherqualifiedplan
• purchaseofservicecreditsforadefinedbenefitplan.
TheIRSconsidersyour401(k)accounttobealast resort for money.
Youmustmeetspecificcriteriatoqualifyforafinancialhardship.The
IRSallowsthefollowingsixreasonsforhardshipwithdrawalofyour
401(k)funds.Thewithdrawalcannotexceedthecostofyourhardship.
($1,000.00minimum)
• Purchaseofaprimaryresidence(excludingmortgagepayments).
• Tuition expenses and related educational fees for you or your
dependent’snext12monthsofpost-secondaryeducation.
• Expenses incurred by you or your dependents to obtain medical
services.
• Payments to prevent eviction or foreclosure on your primary
residence.
• Payments for burial or funeral expenses for the employee's deceased
parent, spouse, children or dependents.
• Expenses for the repair of damage to the employee's principal
residencethatqualifiesforthecasualtydeductionundercodesection
165.
You must complete a hardship withdrawal application that details your
financialsituationandprovidewrittendocumentationforalleligible
expenses. Also, you may be asked to provide proof that a commercial
lender has denied you a loan and that you are ineligible for a loan from
your401(k)plan.
Your contributions to theVista 401(k) plan and any other retirement
plan,suchasa403(b)tax-deferredannuity,mustbesuspendedforsix
months after the withdrawal.
Rollovers
All investments involve risks. You should carefully
consider all of your options before investing.
46
Youmayrollover,onatax-freeexchangebasis,fundsfromaprevious
employer's 401(a), 401(k), 403(b), 457 or IRA plans into yourVista
401(k)plan.
CallVista401(k)toll-freeat1-866-325-1278forinformation.
COBRA Q&A
COBRA Q&A
WhatIsContinuationCoverage?
ForMoreInformation
Federal law requires that most group health plans, including medical flexible
spendingaccounts(medicalexpenseFSAs),giveemployeesandtheirfamiliesthe
opportunity to continue their health care coverage when there is a “qualifying
event”thatwouldresultinalossofcoverageunderanemployer’splan.
This COBRA Q&A section does not fully describe continuation coverage or other
rights under the plan. More information about continuation coverage and your
rights under the plan is available from your employer.
FormoreinformationaboutyourCOBRArights,theHealthInsurancePortability
andAccountabilityAct (HIPAA) and other laws affecting group health plans,
contacttheU.S.DepartmentofLabor’sEmployeeBenefitsSecurityAdministration
(EBSA)inyourareaorvisittheEBSAWebsiteatwww.dol.gov/ebsa.
HowLongWillContinuationCoverageLast?
For Medical Expense FSAs:
IfyoufundyourmedicalexpenseFSAentirely,youmaycontinueyourmedical
expenseFSA(onapost-taxbasis)onlyfortheremainderoftheplanyearinwhich
your qualifying event occurs, if you have not already received, as reimbursement,
themaximumbenefitavailableunderthemedicalexpenseFSAfortheyear.For
example,ifyouelectedamedicalexpenseFSAbenefitof$1,000fortheplanyear
and have received only $200 in reimbursement, you may continue your medical
expenseFSAfortheremainderoftheplanyearoruntilsuchtimethatyoureceive
themaximummedicalexpenseFSAbenefitof$1,000.
Keep Your Address Updated
In order to protect your family’s rights, you should keep AFA
informed of any changes in the addresses of family members. You
should also keep a copy, for your records, of any notices you send to
your employer and AFA.
If your employer funds all or any portion of your medical expense FSA, you may be
eligible to continue your medical expense FSA beyond the plan year in which your
qualifying event occurs and you may have Open Enrollment rights at the next
Open Enrollment period. There are special continuation rules for employer-funded
medical expense FSAs. If you have questions about your employer-funded medical
expense FSA, you should call our customer service representatives. We are ready
to assist you from 7:00 a.m. – 6:00 p.m. CST with any questions you may have. Call
us today at 1-800-325-0654
47
www.myFBMC.com
30
Beyond Your Benefits
Beyond Your Benefits
TaxableBenefitsandtheIRS
Insuranceplan(s)aresetforthfromtimetotimeinthehealthinsuranceplan(s).Allclaims
toreceivebenefitsunderthehealthinsuranceplan(s)shallbesubjecttoandgovernedby
thetermsandconditionsofthehealthinsuranceplan(s)andtherules,regulations,policies
and procedures from time to time adopted.
Certainbenefitsmaybetaxedifyoubecomedisabled,dependingonhowthepremiums
were paid during the year of the disabling event. Payments, such as disability, from
coveragespurchasedwithpre-taxpremiumsand/ornontaxableemployercredits,will
besubjecttofederalincomeandemployment(FICA)tax.Ifpremiumswerepaidwitha
combinationofpre-taxandafter-taxdollars,thenanypaymentsreceivedundertheplan
willbetaxedonaproratabasis.Ifpremiumswerepaidonapost-taxbasis,youwillnot
be taxed on the money you receive from the plan. You can elect to have federal income
taxwithheldbytheproviderjustasitiswithheldfromyourwages.Consultyourpersonal
tax adviser for additional information.
AFA Privacy Statement
As a provider of products and services that involve compiling personal—and sometimes,
sensitive—information, protecting the confidentiality of that information has been, and
will continue to be, a top priority of AFA. We collect only the customer information
necessary to consistently deliver responsive services. AFA collects information that helps
serve your needs, provide high standards of the service center and fulfill legal and
regulatory requirements. The sources and types of information collected generally varies
depending on the products or services you request and may include:
Inaddition,FICAandMedicaretaxeswillbewithheldfromanydisabilitypaymentspaid
through six calendar months following the last calendar month in which you worked prior
tobecomingdisabled.ThereafternoFICAorMedicaretaxwillbewithheld.
• Information provided on enrollment and related forms - for example, name, age,
address,SocialSecuritynumber,e-mailaddress,annualincome,healthhistory,marital
statusandspousalandbeneficiaryinformation.
YouwillberequiredbytheIRStopayFICA,Medicare,andfederalincometaxeson
certainotherbenefitpayments,suchasthosefromHospitalIndemnityInsurance,Personal
CancerExpenseInsuranceandHospitalIntensiveCareInsurance,thatexceedtheactual
Healthcaresyouincur,ifthesepremiumswerepaidwithpre-taxdollarsand/ornontaxable
employer credits. If you have questions, consult your personal tax adviser.
• Responsesfromyouandotherssuchasinformationrelatingtoyouremploymentand
insurance coverage.
• Information about your relationships with us, such as products and services purchased,
transaction history, claims history and premiums.
AccordingtoIRSregulations,youcanpaylifeinsurancepremiumstaxfreeonyourfirst
$50,000 of life insurance. You must pay tax on premiums for coverage exceeding $50,000.
• Information from hospitals, doctors, laboratories and other companies about your
health condition, used to process claims and prevent fraud.
Notice of Administrator's Capacity
This notice advises insured persons of the identity and relationship among the contract
administrator, the policyholder and the insurer:
We maintain safeguards to ensure information security and are committed to preventing
unauthorized access to personal information.
1. AFA has been authorized by your employer to provide administrative services for
your employer’s insurance plans offered herein. In some instances, AFA may also be
authorized by one or more of the insurance companies underwriting the benefits offered
herein to provide certain services, including (but not limited to) marketing, underwriting,
billing and collection of premiums, processing claims payments, and other services. AFA is
not the insurance company or the policyholder.
We limit how, and with whom, we share customer information. We do not sell lists of
our customers, and under no circumstances do we share personal health information for
marketing purposes. With the following exceptions, we will not disclose your personal
information without your written authorization. We may share your personal information
with insurance companies with whom you are applying for coverage, or to whom you are
submitting a claim. We also may disclose personal information as permitted or required by
laworregulation.Forexample,wemaydiscloseinformationtocomplywithaninquiry
by a government agency or regulator, in response to a subpoena or to prevent fraud.
2. The policyholder is the entity to whom the insurance policy has been issued. The
policyholder is identified on either the face page or schedule page of the policy or
certificate.
NotethisprivacystatementisnotmeanttobeaprivacynoticeasdefinedbytheHealth
InsurancePortabilityandAccountabilityAct(HIPAA).Youmayreceiveaprivacynotice
from your employer or from the providers of various health plans in which you enroll. You
should read these statements carefully to assure you understand your rights under HIPAA.
3. The insurance companies noted herein have been selected by your employer, and are
liable for the funds to pay your insurance claims.
If AFA is authorized to process claims for the insurance company, we will do so promptly. In
the event there are delays in claims processing, you will have no greater rights to interest or
other remedies against AFA than would otherwise be afforded to you by law. AFA is not an
insurance company.
SocialSecurity
SocialSecurityconsistsoftwotaxcomponents:theFICAorOASDIcomponent(thetax
forold-age,survivors’anddisabilityinsurance)andtheMedicarecomponent.Aseparate
maximum wage to which the tax is assessed applies to both tax components. There is
no maximum taxable annual wage for Medicare. The maximum taxable annual wage for
FICAissubjecttofederalregulatorychange.Ifyourannualsalaryaftersalaryreduction
isbelowthemaximumwagecapforFICA,youarereducingtheamountoftaxesyoupay
andyourSocialSecuritybenefitsmaybereducedatretirementtime.
However,thetaxsavingsrealizedthroughtheflexiblebenefitsplangenerallyoutweighthe
SocialSecurityreduction.Calltheservicecenterat1-855-569-3262foranapproximation.
Disclaimer - Health Insurance Benefits Provided
UnderHealthInsurancePlan(s)
HealthInsurancebenefitswillbeprovidednotbyyouremployer’sflexiblebenefitsplan,
butbythehealthinsuranceplan(s).Thetypesandamountsofhealthinsurancebenefits
availableunderthehealthinsuranceplan(s),therequirementsforparticipatinginthehealth
insuranceplan(s)andtheothertermsandconditionsofcoverageandbenefitsofthehealth
48
31
www.myFBMC.com
Members of the Board
District # 1
ROBIN SMITH-MARTIN
MARK T. PORTER
Superintendent of Schools
District # 2
ANDY GRIFFITHS
Chair
District # 3
ED DAVIDSON
New Beginnings…High
Expectations
District # 4
JOHN R. DICK
District # 5
RONALD A. MARTIN
Vice Chair
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A: General Information
When key parts of the health care law take effect in 2014, there will be a new way to buy health
insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and
your family, this notice provides some basic information about the new Marketplace and
employment-based health coverage offered by your employer.
What is the Health Insurance Marketplace?
The Marketplace is designed to help you find health insurance that meets your needs and fits
your budget. The Marketplace offers "one-stop shopping" to find and compare private health
insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly
premium right away. Open enrollment for health insurance coverage through the Marketplace
begins in October 2013 for coverage starting as early as January 1, 2014.
Can I Save Money on my Health Insurance Premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if your employer
does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on
your premium that you're eligible for depends on your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the
Marketplace?
Yes. If you have an offer of health coverage from your employer that meets certain standards,
you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your
employer's health plan. However, you may be eligible for a tax credit that lowers your monthly
premium or a reduction in certain cost-sharing if your employer does not offer coverage to you at
all or does not offer coverage that meets certain standards. If the cost of a plan from your
employer that would cover you (and not any other members of your family) is more than 9.5% of
your household income for the year, or if the coverage your employer provides does not meet the
"minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1
1
An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by
the plan is no less than 60 percent of such costs.
241 Trumbo Road  Key West, FL 33040
Tel. (305) 293-1400  Fax (305) 293-1408
www.KeysSchools.com
49
Monroe County School District
Page 2 of 3
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage
offered by your employer, then you may lose the employer contribution (if any) to the employeroffered coverage. Also, this employer contribution -as well as your employee contribution to
employer-offered coverage- is often excluded from income for Federal and State income tax
purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.
How Can I Get More Information?
For more information about your coverage offered by your employer, please check your
summary plan description or contact: ___Employee Benefits & Risk Management
Department_________________.
The Marketplace can help you evaluate your coverage options, including your eligibility for
coverage through the Marketplace and its cost. Please visit www.HealthCare.gov for more
information, including an online application for health insurance coverage and contact
information for a Health Insurance Marketplace in your area.
PART B: Information about Health Coverage Offered by Your Employer
This section contains information about any health coverage offered by your employer. If you
decide to complete an application for coverage in the Marketplace, you will be asked to provide
this information. This information is numbered to correspond to the Marketplace application.
Employer name
Employer Identification Number (EIN)
Monroe County District School Board
59-6000750
Employer Address
Employer Phone Number
241 Trumbo Road
305-293-1400, Ext. 53342
City
State
ZIP code
Key West
FLORIDA
33040
Who can we contact about employee health coverage at this job?
Wanda Menendez, Employee Benefits & Risk Management Specialist
Phone number (if different from above)
Email address
Wanda.menendez@keysschools.com
Wanda.menendez@keysschools.com
50
Monroe County School District
Page 3 of 3
Here is some basic information about health coverage offered by this employer:

As your employer, we offer a health plan to:
____
All employees.
__X__
Some employees. Eligible employees are: Employees that work at least 51%
of the average time required for the position held.

With respect to dependents:
__X__
We do offer coverage. Eligible dependents are: 1. The Covered Employee’s
spouse under a legally valid existing marriage; 2) The covered employee’s natural,
newborn, adopted, foster, or step child(ren) (or a child for whom the Covered Employee
has been court-appointed as legal guardian or legal custodian or a child that has been
placed for adoption) who has not reached the end of the Calendar Year in which he or
she reaches age 26 (or in the case of a Foster Child, is no longer eligible under the
Foster Child Program), regardless of the dependent child’s student or marital status,
financial dependency on the Covered Employee, whether the dependent child is eligible
for or enrolled in any other group health plan.; 3) The newborn child of a covered
dependent child who has not reached the end of the Calendar Year in which he or she
becomes 26. Coverage for such newborn child will automatically terminate 18 months
after the birth of the newborn child.
Children may be covered up to the end of the calendar year in which they reach 30,
subject to statutory conditions and contribution requirements.
____
We do not offer coverage
This coverage meets the minimum value standard, and the cost of this coverage to you is
intended to be affordable, based on the employee wages.
**Even though we intend your coverage to be affordable, you may still be eligible for a
premium discount through the Marketplace. The Marketplace will use your household
income, along with other factors, to determine whether you may be eligible for a premium
discount. If, for example, your wages vary from week to week (perhaps you are an hourly
employee or you work on a commission basis), if you are newly employed mid-year, or if
you have other income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you
through the process. Here’s the employer information you’ll enter when you visit
HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums
51
Benefits Directory
Medical Benefits
Florida Blue
1-888-387-4962
BCBSFL.com
Prescription Plans
Envision Rx
Customer Service Help Desk
1-800-361-4542
www.envisionrx.com
Dental Insurance
CompBenefits
(Dental Plans)
Member Services
Mon-Fri, 8 A.M. - 5 P.M. ET
1-800-432-3376
www.compbenefits.com
Vision Insurance
Humana - Vision Care Plan
(Vision Plan)
1-866-537-0229
HumanaVisionCare.com
Voluntary Insurance Benefits
American Fidelity
Assurance Company
Disability Income, Cancer, Hospital
Gap, Critical Illness, Accident, and Life
2000 N Classen
Oklahoma City, OK 73106
800-654-8489
www.americanfidelity.com
Vista 401(k) Plan
Mon-Fri, 8 A.M. - 5 P.M.
1-866-325-1278
Automated Services
1-800-213-2310
www.vista401k.com
Minnesota Life
Underwritten by: Ochs, Inc.
(Group Term Life Insurance)
Customer Service
Mon - Fri, 9 A.M. - 5:30 P.M. ET
1-800-392-7295
www.ochsinc.com
Section 125 Services &
Flexible Spending Accounts
American Fidelity
Assurance Company
2000 N Classen
Oklahoma City, OK 73106
800-654-8489
www.americanfidelity.com
Other Contact Information
Monroe County School District
School Board Office
Mon-Fri, 8 A.M. - 5 P.M. ET
(305) 293-1400
American Fidelity
Assurance Company
Mark A. Cisneros, Manager I
601 Cleveland St #501-10
Clearwater FL 33755
877-425-1104
Mark.Cisneros@americanfidelity.com
This Enrollment Benefits booklet is not a contract, is not legally binding, and does not alter any original plan documents. Rather, it is
intended to be a summary of available benefits provided through your employer. Every effort has been made to ensure the accuracy
of this information. However, the actual determination of your benefits is based solely on the plan documents and if statements
in this description differ from the applicable plan documents, coverage documents or Summary Plan Descriptions, then the terms
and conditions of those documents will prevail. Please check with your employer’s Benefit’s Office for further guidance.