Benefits enrollment guidepreston-k12.wvnet.edu/.../2020/05/2020_Preston_OE_Guide.pdfYour eyewear...

BENEFITS ENROLLMENT GUIDE

Benefits Effective:

July 1, 2020 – June 30, 2021

Open Enrollment:

May 28, 2020 – June 12, 2020

2020

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BENEFITS ENROLLMENT WE ARE PLEASED TO PRESENT THIS GUIDE WHICH HIGHLIGHTS THE COMPREHENSIVE COVERAGE AVAILABLE TO YOU.

This booklet has been created to help you understand the benefit plans that are being offered to you. benefits program is designed to offer employees substantial coverage to meet both individual and family needs. Please take the time to review the information in this guide. We want you to be fully informed of the benefits available to you and your family. This guide also incorporates information on when you may change your benefit elections.

This guide includes only highlights. The specific terms of coverage, exclusions & limitations are contained in the plan documents and insurance certificates. All coverage and coverage costs are subject to change at any time in the future. If you have any questions about a specific service or treatment, please contact the appropriate insurance carrier.

A MESSAGE FROM TAWNEY INSURANCE & SAFETY SOLUTIONS Tawney Insurance & Safety Solutions is committed to serving the wonderful staff of Preston County Schools. We have worked closely with the administrative team to deliver an exceptional benefits package to you and your loved ones.

Tawney Insurance works tirelessly on behalf of the administrative team to best provide you the service you deserve.

Our pledge to all of you in the Preston County Schools family is to always be . . .

• Objective • Informed • Reliable • Responsive

This year we will be rolling out a new electronical enrollment system, which will be provided by UZIO. No changes have been made to this year’s benefit options. All plans and pricing have remained the same. Your prior elections have been imported into UZIO for your convenience. If you plan to make not changes to your elections, then you do not need to do anything. However, if you wish to make changes to your elections please log into the system.

Instead of completing a variety of paper forms, you will be able to make all your benefit elections through the UZIO enrollment platform. You will be receiving an email from UZIO, with your private login and password information. At that time, you will be able to login and make your benefit elections and designate your beneficiaries.

All the best in the coming plan year and if you have any questions about this process, please let us know.

Sincerely,

Kris Tawney

President and CEO Tawney Insurance & Consulting LLC

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WHAT’S INSIDE… BENEFITS ENROLLMENT ............................................................................................................. 1

A MESSAGE FROM TAWNEY INSURANCE & SAFETY SOLUTIONS ................................................ 1

ELIGIBILITY & ENROLLMENT ....................................................................................................... 3

WHO IS ELIGIBLE? ................................................................................................................... 3

WHEN COVERAGE BEGINS ...................................................................................................... 3

WHAT CHANGES CAN I MAKE DURING OPEN ENROLLMENT? ................................................. 3

ELIGIBLE DEPENDENTS ............................................................................................................ 3

HOW TO ENROLL .................................................................................................................... 3

WHEN COVERAGE ENDS ......................................................................................................... 3

WHAT HAPPENS IF YOU DON’T ENROLL? ................................................................................ 3

QUALIFYING EVENTS .................................................................................................................. 3

UZIO Enrollment Platform ......................................................................................................... 4

DENTAL COVERAGE ................................................................................................................... 5

VISION COVERAGE .................................................................................................................. 10 LIFE INSURANCE COVERAGE.................................................................................................... 12

SHORT TERM DISABILITY COVERAGE ...................................................................................... 13

LONG TERM DISABILITY COVERAGE ........................................................................................ 14

SUPPLEMENTAL HEALTH COVERAGE – ACCIDENT INSURANCE OPTIONS ............................... 15

ACCIDENT PLAN A ................................................................................................................ 15

ACCIDENT PLAN B................................................................................................................. 17

ACCIDENT PLAN C ................................................................................................................. 19

SUPPLEMENTAL HEALTH COVERAGE – CRITICAL ILLNESS INSURANCE ................................... 21

SUPPLEMENTAL HEALTH COVERAGE – HOSPITAL INDEMNITY ............................................... 23

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ELIGIBILITY & ENROLLMENT WHO IS ELIGIBLE? All employees who work at least 30 hours per week and their eligible dependents, are eligible for the benefits outlined in this guide. WHEN COVERAGE BEGINS Coverage will begin on July 1, 2020 provided you have enrolled and provided all necessary information in a timely fashion. After your initial enrollment, you will have the opportunity to re-enroll in the Benefits Program each year during the Annual Open Enrollment period. WHAT CHANGES CAN I MAKE DURING OPEN ENROLLMENT?

• Enroll if not currently on the plan • Waive if you have coverage elsewhere • Add/drop dependents

ELIGIBLE DEPENDENTS Your eligible dependents include:

• Your spouse (unless you are legally separated) • Your dependent children who are under age 26

HOW TO ENROLL Simply follow the instructions from the UZIO welcome email, click through the information and benefits pages and submit your elections. WHEN COVERAGE ENDS If your employment ends, your coverage will end on the last day of the month of your termination. Depending upon the circumstances of your termination, you may be able to continue coverage under COBRA (refer to your COBRA notice). WHAT HAPPENS IF YOU DON’T ENROLL? For New Hires and Newly Eligible Employees If you are a new hire or become eligible for benefits, and do not enroll when you are first eligible, you will not receive any benefits and must wait until the next Annual Open Enrollment period to enroll for the coverage you want and need.

QUALIFYING EVENTS During the annual open enrollment period, you can change coverage for the next plan year. After the annual enrollment period, you generally will only be able to change your coverage if you have a qualifying event.

Qualifying events include, but are not limited to:

• Change in marital status (marriage, death of spouse, divorce, legal separation); • Change in number of dependents (birth, death, adoption, eligibility status, child support order); • Change in employment status for you or your spouse (commencement, termination, leave of absence, full-time

to part-time or vice versa); • Special enrollment rights under HIPAA; or • You, your spouse or child gains or loses Medical coverage.

Generally, changes in your coverage elections must be made within 30 days of the qualifying event. YOU are responsible for notifying the Human Resources Department of any qualifying event and for requesting information on changing your elections.

For further information on eligible qualifying events, please contact the Human Resources Department and also please see the attached Special Enrollment Notice for qualifying events.

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UZIO Enrollment Platform

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DENTAL COVERAGE

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VISION COVERAGE

Preston County Schools Welcome to Davis Vision!

We are pleased to provide you with information on your vision benefit to help you care for your vision and eye health - a key part of overall health and wellness!

If you are not currently enrolled, please visit our member site at davisvision.com or call 1.877.923.2847 and enter client code 3806 to locate providers or for additional information.

Significant savings on optional frames, lens types and coatings! Member Price Davis Vision Collection Frames: Fashion | Designer | Premier ................................. $0 | $0 | $25 Tinting of Plastic Lenses ............................................................................................................$0 Oversize Lenses ........................................................................................................................$0 Scratch-Resistant Coating ........................................................................................................ $0 Ultraviolet Coating ...................................................................................................................$12 Anti-Reflective Coating: Standard | Premium | Ultra ............................................. $35 | $48 | $60 Polycarbonate Lenses ...................................................................................................... $0/4-$30 High-Index Lenses................................................................................................................... $55 Progressive Lenses: Standard | Premium | Ultra ................................................ $50 | $90 | $140 Polarized Lenses .....................................................................................................................$75 Photochromic Lenses (i.e. Transitions®, etc.)/5 ........................................................................................................................ $65 Scratch Protection Plan: Single Vision | Multifocal Lenses ............................................. $20 | $40

Using your benefits is easy! Just log on to our Member site at davisvision.com and click “Find a Provider,” or call us at 1.800.999.5431.

Make an appointment. Tell your provider you are a Davis Vision member with coverage through Preston County Schools. Provide your member ID number, name and date of birth, and do the same for your covered dependents seeking vision services. Your provider will take care of the rest!

1/ Additional discounts not applicable at Walmart, Sam’s Club or Costco locations 2/ The Davis Vision Collection is available at most participating independent provider

locations. Collection is subject to change. Collection is inclusive of select toric and multifocal contacts.

3/ Including, but not limited to toric, multifocal and gas permeable contact lenses. 4/ For dependent children, monocular patients and patients with prescriptions of

+/- 6.00 diopters or greater. 5/Transitions® is a registered trademark of Transitions Optical Inc.

Please note: Your provider reserves the right to not dispense materials until all applicable member costs, fees and copayments have been collected. Contact lenses: Routine eye examinations do not include professional services for contact lens evaluations. Any applicable fees above the evaluation and fitting allowance are the responsibility of the member. If contact lenses are selected and fitted, they may not be exchanged for eyeglasses. Progressive lenses: If you are unable to adapt to progressive addition lenses you have purchased, conventional bifocals will be supplied at no additional cost; however, your copayment is nonrefundable. May not be combined with other discounts or offers. Please be advised these lens options and copayments apply to in-network benefits.

Your Davis Vision Designer Plan Benefits Benefit Frequency

Once every - In-network

Copay In-network Coverage

Eye Examination 12 months $10 Covered in full. Includes dilation when professionally indicated.

Spectacle Lenses 12 months $25 Clear plastic lenses in any single vision, bifocal, trifocal or lenticular prescription. Covered in full. (See below for additional lens options and coatings.)

Frame

24 months

$0

Covered in Full Frames: Any Fashion or Designer level frame from Davis Vision’s Collection/2 (retail value, up to $160).

OR, Frame Allowance: $130 toward any frame from provider plus 20% off any

balance./1 No copay required.

Contact Lens Evaluation, Fitting & Follow Up Care

12 months

$25

Davis Vision Collection Contacts: After copay, covered in full. Standard, Soft Contacts: After copay, covered in full.

Specialty Contacts/3: $60 allowance less copay plus 15% off balance/1.

Contact Lenses (in lieu of eyeglasses)

12 months

$0

Covered in Full Contacts: From Davis Vision’s Collection/2, up to: Planned Replacement Four boxes/multi-packs*

Disposable Eight boxes/multi-packs* OR, Contact Lens Allowance: $130 allowance toward any contacts from provider’s

supply plus 15% off balance./1 No copay required. OR, Medically Necessary Contacts: Covered in full with prior approval.

*Number of contact lens boxes may vary based on manufacturer’s packaging.

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Frequently Asked Questions How can I contact Member Services? Call 1.800.999.5431 for automated help 24/7. Live help is also available seven days a week: Monday-Friday, 8 a.m.-11 p.m. | Saturday, 9 a.m.-4 p.m. | Sunday, 12 p.m.-4 p.m. (Eastern Time). (TTY services: 1.800.523.2847.)

What frames are in Davis Vision’s Collection? Our Collection offers a great selection of fashionable and designer frames, most of which are covered in full. No wonder 8 out of 10 members select a Collection frame. Log on to our member Web site at davisvision.com and take a look!

When will I receive my eyewear? Your eyewear will be delivered to your network provider generally within five business days of order receipt. Special prescriptions, lens coatings, provider frames or out-of-stock frames may delay the standard turnaround time.

Do I need a claim form? Claim forms are only required if you visit an out-of-network provider. Claim forms are available on our member Web site.

Can I split my benefits? You may split your benefits by receiving your eye examination and eyeglasses or contact lenses on different dates or through different provider locations. To maximize your benefit value we recommend that all services be obtained from a network provider. Can I use an out-of-network provider? Yes; however, you receive the greatest value by staying in-network. If you go out-of-network, pay the provider at the time of service, then submit a claim to Davis Vision for reimbursement, up to the following amounts: eye exam - $40 | single vision lenses - $40 | bifocal - $60 | trifocal - $80 | lenticular - $100 | frame - $50 | elective contacts - $105 | medically necessary contacts - $225.

Are there any exclusions to the vision benefits? Your vision plan does not cover medical treatment of eye disease or injury; vision therapy; special lens designs or coatings, other than those described herein; replacement of lost eyewear; non- prescription (plano) lenses; contact lenses and eyeglasses in the same benefit cycle; services not performed by licensed personnel; two pair of eyeglasses in lieu of bifocals.

DAVIS VISION EXTRAS! One Year Breakage Warranty Repair or replacement of your plan covered spectacle lenses, Collection frame or frame from a network retail location where the Collection is not displayed.

Additional Savings At most participating network locations, members receive up to 20% off additional eyeglasses, sunglasses and items not covered by the benefit and 10% off disposable contact lenses./6

Mail Order Contact Lenses Replacement contacts (after initial benefit) through www.DavisVisionContacts.com mail-order service ensures easy, convenient, purchasing online and quick, direct shipping to your door. Log on to our member Web site for details.

Laser Vision Correction Up to 25% discount off participating provider’s U&C or 5% off advertised special (whichever is lower). Log on to our member Web site for details and to locate a provider.

Low Vision Services Comprehensive low vision evaluation once every five years and low vision aids up to the plan maximum. Covers up to four follow-up visits in five years.

Eye Health & Wellness Log on and learn more about your eyes, health and wellness; common eye conditions that can impair vision; and what you can do to ensure healthy eyes and a healthier life. For more details… about your vision benefits, patient rights and responsibilities about Davis Vision or to obtain a copy of Davis Vision’s Privacy Practices Notice, please log on to our member Web site or contact us at 1.800.999.5431.

Davis Vision has made every effort to correctly summarize your vision plan features herein. In the event of a conflict between this information and your organization’s contract with Davis Vision, the terms of the contract will prevail.

6/Additional discounts not applicable at Walmart, Sam’s Club or Costco locations.

Fully insured product Underwritten by HM Life Insurance Company. Administered by Davis Vision, which may operate as Davis Vision Insurance Administrators in California.

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LIFE INSURANCE COVERAGE

Preston County Board of Education

ELIGIBILITY Employees: Each Active, Full‐time employee working 30 or more hours per week, except any person working on a temporary or seasonal basis.

Dependents: You must be insured in order for Dependents to be covered. Dependents are:

your legal spouse not legally separated or divorced from you

your unmarried financially dependent children* age 14 days to 20 years (to 26 years if full‐time student). *natural and adopted children; stepchildren and foster children in your custody. Age limit does not apply to handicapped children.

A person may not have coverage as both an Employee and Dependent.

Only one insured spouse may cover Dependent children.

BENEFIT AMOUNT Supplemental Life Choose from a minimum of $10,000 to a maximum of $500,000 in $10,000 increments Amounts of life insurance equal to $150,000 or more may be subject to an earnings cap. Dependent Life Spouse Choose from a minimum of $5,000 to a maximum of $250,000 in $5,000 increments (not to exceed 5 times Earnings) (spouse amount may not exceed 50% of employee amount)

Dependent Child(ren) 14 days to age 19 : Options of $5,000, $10,000 or $25,000 (up to age 26 if a full‐time student)

GUARANTEED ISSUE (INITIAL ELIGIBILITY PERIOD ONLY) Employee: $150,000 Spouse: $50,000 Child: all child amounts are guaranteed issue

BENEFIT REDUCTION DUE TO AGE (applicable to employee/spouse coverage)

Age Original Benefit

Reduced To 70 50%

RATE See attached Rate Sheet.

CONTRIBUTION REQUIREMENTS

Supplemental Life:

Coverage is 100% employee paid.

EXCLUSIONS For a comprehensive list of exclusions and limitations, please refer to the Certificate of Insurance. The Certificate also provides all requirements necessary to be eligible for coverage and benefits.

This Plan Highlights is a brief description of the key features of the RSL insurance plan. The availability of the benefits and features described may vary by state. It is not a certificate of insurance or evidence of coverage. Insurance is provided under group policy form LRS‐6422, et al.

Plan Highlights

Group Supplemental and Dependent Life Insurance

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SHORT TERM DISABILITY COVERAGE


COVERAGE Disability income protection insurance provides a benefit for “short term” disability resulting from a covered injury or sickness. Benefits begin at the end of the elimination period and continue while you are disabled up to the maximum benefit duration.

ELIGIBILITY Each Active, Full‐time employee working 30 or more hours per week, and earning an annual salary of at least $15,000, except any person working on a temporary or seasonal basis.

BENEFIT AMOUNT The weekly benefit is an amount equal to 60% of covered earnings, up to a maximum benefit of $1,000 per week. DAY BENEFITS

BEGIN Injury (accident): Benefits begin on the 8th consecutive day of disability; Sickness (illness): Benefits begin on the 8th consecutive day of disability;

or the day following the number of accumulated sick days applicable to the employee.

MAXIMUM BENEFIT DURATION Benefits for one period of disability, will be paid up to a maximum of 25 weeks.

CONTRIBUTION REQUIREMENTS Coverage is 100% employee paid.

Plan Highlights

Voluntary Group Short Term Disability Insurance

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LONG TERM DISABILITY COVERAGE


COVERAGE Disability income protection insurance provides a benefit for “long term” disability resulting from a covered injury or sickness. Benefits begin at the end of the elimination period and continue while you are disabled up to the maximum benefit duration.

ELIGIBILITY Each Active, Full‐time employee working 30 or more hours per week, and earning an annual salary of at least $15,000, except any person working on a temporary or seasonal basis.

BENEFIT AMOUNT The monthly benefit is an amount equal to 60% of covered earnings, up to a maximum benefit of $5,000 per month.

ELIMINATION PERIOD 180 consecutive days of total disability

MAXIMUM BENEFIT DURATION Benefits will not extend beyond the longer of: Social Security Normal Retirement Age or Duration of Benefits below:

Age at Disablement Duration of Benefits 61 or less to age 65

62 3 ½ years

63 3 years

64 2 ½ years

65 2 years

66 1 ¾ years

67 1 ½ years

68 1 ¼ years

69 or more 1 year


Plan Highlights

Voluntary Group Long Term Disability Insurance

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SUPPLEMENTAL HEALTH COVERAGE – ACCIDENT INSURANCE OPTIONS ACCIDENT PLAN A

Preston Country Board of Education

COVERAGE CONTRIBUTION REQUIREMENTS Voluntary accident insurance provides a range of fixed, lump- sum benefits for injuries resulting from a covered accident, or for accidental death and dismemberment (if included). These benefits are paid directly to the insured and may be used for any reason, from deductibles and prescriptions to transportation and childcare.

ELIGIBILITY Employees: Each Active Full-Time Employee working 30 or more hours per week, except any person working on a temporary or seasonal basis. Employee must be under age 70 at date of application. Dependents: You must be insured in order for Dependents to be covered. Dependents are: • Your legal spouse. Spouse must be under age 70 at date of

application. • Your children from birth to 26 years while attending

college or other school on a full-time basis * includes natural children, legally adopted children,

children dependent on you during the waiting period before adoption, stepchildren, and foster children. Foster children must be in your custody to be considered a Dependent.

• Your child(ren) who is incapable of self-sustaining employment by reason of intellectual disability or physical handicap and who is chiefly dependent upon you for support and maintenance

BENEFITAMOUNT See Full Schedule of Benefits on next page

BENEFITREDUCTION DUE TO AGE (Applicable to employee/spouse coverage) Age Original Benefit Reduced to: 65 50% 70 25%


MONTHLY RATES

Coverage Premiums A Employee $13.29 Employee and Spouse $20.17 Employee & Children $24.22 Employee & Family $31.80

FEATURES

• Portability to employee age 70 • FMLA/MSLA Continuation

EXCLUSIONS Benefits will not be paid for any loss caused by: suicide; war; air travel (except as a passenger on commercial flights); assault/felony; acute or chronic intoxication; voluntary consumption of illegal or controlled substance or prescribed narcotic or drug.

For a comprehensive list of exclusions and limitations, please refer to the Certificate of Insurance. The Certificate also provides all requirements necessary to be eligible for benefits.

This Plan Highlights is a brief description of the key features of the RSL insurance plan. The availability of the benefits and features described may vary by state. It is not a certificate of insurance or evidence of coverage. Insurance is provided under group policy form LRS-9547-0318, et al.

Plan Highlights

Voluntary Group

Accident Insurance

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Benefits Plan A

Ambulance $100 Ground, $500 Air

Blood, Plasma and Platelets $200

Burns To $800 for 2nd degree burns; To $6,400 for 3rd degree burns; Skin Graft - 25% of benefit payable for Burns

Coma $5,000

Concussion $100

Confinement Maximum

Dental Injury $150 for Crown; $50 for Extraction

Diagnostic Exams $100 per CT/MRI scan

Initial Physician Office Visit $50

Dislocation To $1,600 for Non-surgical; To $3,200 for Surgical; Partial - 25% of full dislocation; Multiple - 100% of highest dislocation benefit

Emergency Treatment $150

Epidural Anesthesia Injection (Per Injection) $100, 2 maximum

Eye Injury $100 for removal of foreign object, $200 for surgical repair

Fractures To $2,500 for Non-surgical; To $5,000 for Surgical repair; Chip fracture: 25% of non-surgical benefit; Multiple fractures: 100% of highest sustained fracture

Hospital Confinement (Per Day) $200, 365 days maximum

Intensive Care Unit (ICU) Confinement per Day $400, 30 days maximum

Initial Intensive Care Unit (ICU) Hospital Admission $1,000

Initial Hospital Admission $500

Lacerations To $400

Lodging (Per Day) $100 per day up to 30 days if more than 100 miles from residence

MedicalAppliances $100

Paralysis $10,000 quadriplegia; $5,000 paraplegia/hemiplegia

Physical Therapy (Per Session) $25, 6 sessions maximum

Physician Visit $50 Initial, $50 Follow-up

Prosthesis $500 for one, $1,000 for two or more

Rehabilitation Facility Confinement per Day) $50, 30 days maximum

Surgery $100 for Exploratory; $300 for Knee Cartilage; $1,000 for Abdominal or Thoracic; $500 for Ruptured Disc; to $600 Tendon, Ligament, or Rotator cuff

Transportation $300, if more than 100 miles from residence

Accidental Death Benefits Employee AD&D $25,000

Spouse AD&D $12,500

Child AD&D $5,000

Common Carrier 100%

Accidental Dismemberment Benefits Single Loss 50%

Multiple Loss (Catastrophic) 100%

Thumb/Finger/Toe 1%

2 + Thumb/Finger/Toe 3%

Speech 100%

Wellness (Health Screening) $50

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ACCIDENT PLAN B









BENEFITREDUCTION DUE TO AGE (Applicable to employee/spouse coverage) Age Original Benefit Reduced to: 65-69 50% 70+ 25%


MONTHLY RATES

Coverage Premiums B Employee $19.22 Employee and Spouse $29.18 Employee & Children $34.85 Employee & Family $45.78

FEATURES • Portability to employee age 70 • FMLA/MSLA Continuation

EXCLUSIONS Benefits will not be paid for any loss caused by: suicide; war; air travel (except as a passenger on commercial flights); assault/felony; acute or chronic intoxication; voluntary consumption of illegal or controlled substance or prescribed narcotic or drug; or injuries arising out of or in the course of employment for wage or profit.



Plan Highlights

Voluntary Group

Accident Insurance

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Benefits Amount Ambulance $150 Ground, $750 Air Blood, Plasma and Platelets $300 Burns To $1,600 for 2nd degree burns; To $12,800 for 3rd degree burns; Skin Graft -

25% of benefit payable for Burns Coma $7,500 Concussion $150 Confinement Maximum Dental Injury $300 for Crown; $100 for Extraction Diagnostic Exams $200 per CT/MRI scan Dislocation To $2,400 for Non-surgical; To $4,800 for Surgical; Partial - 25% of full

dislocation; Multiple - 100% of highest dislocation benefit Emergency Treatment $225 Epidural Anesthesia Injection (Per Injection) $200, 2 maximum Eye Injury $150 for removal of foreign object, $ 300 for surgical repair Fractures To $3,750 for Non-surgical; To $7,500 for Surgical repair; Chip fracture: 25% of

non-surgical benefit; Multiple fractures: 100% of highest sustained fracture Hospital Confinement (Per Day) $300, 365 days maximum Intensive Care Unit (ICU) Confinement (Per $600, 30 days maximum Initial Intensive Care Unit (ICU) Hospital $1,500 Initial Hospital Admission $1,000 Lacerations To $800 Lodging (Per Day) $150 per day up to 30 days if more than 100 miles from residence Medical Appliances $150 Paralysis $15,000 quadriplegia; $7,500 paraplegia/hemiplegia Physical Therapy (Per Session) $35, 6 sessions maximum Physician Visit $75 Initial, $75 Follow-up Prosthesis $ 750 for one, $1,500 for two or more Rehabilitation Facility Confinement (Per Day) $100, 30 days maximum Surgery $150 for Exploratory; $450 for Knee Cartilage; $1,500 for Abdominal or

Thoracic; $750 for Ruptured Disc; to $900 Tendon, Ligament, or Rotator cuff

Transportation $450, if more than 100 miles from residence Accidental Death Benefits Amount Employee AD&D $50,000 Spouse AD&D $25,000 Child AD&D $12,500 Common Carrier 100% Accidental Dismemberment Benefits % of AD Benefit Single Loss 50% Multiple Loss (Catastrophic) 100% Thumb/Finger/Toe 1% 2 + Thumb/Finger/Toe 3% Speech 100% Wellness (Health Screening) Benefit Amount Wellness (Health Screening) $75

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ACCIDENT PLAN C

Heritage Hotels & Resorts








BENEFITREDUCTION DUE TO AGE (Applicable to employee/spouse coverage) Age Original Benefit Reduced to: 65 50% 70 25%


MONTHLY RATES

Coverage Premiums C Employee $11.24 Employee and Spouse $19.61 Employee & Children $28.48 Employee & Family $36.85

FEATURES

• Portability to employee age 70 • FMLA/MSLA Continuation

EXCLUSIONS Benefits will not be paid for any loss caused by: suicide; war; air travel (except as a passenger on commercial flights); assault/felony; acute or chronic intoxication; voluntary consumption of illegal or controlled substance or prescribed narcotic or drug.



Plan Highlights

Voluntary Group

Accident Insurance

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Benefits Plan C

Ambulance $200 Ground, $1,000 Air

Blood, Plasma and Platelets $400

Burns To $3,200 for 2nd degree burns; To $25,600 for 3rd degree burns; Skin Graft - 25% of benefit payable for Burns

Coma $10,000

Concussion $200

Dental Injury $400 for Crown; $100 for Extraction

Diagnostic Exams $400 per CT/MRI scan

Dislocation To $3,200 for Non-surgical; To $6,400 for Surgical; Partial - 25% of full dislocation; Multiple - 100% of highest dislocation benefit

Emergency Treatment $250

Eye Injury $200 for removal of foreign object, $400 for surgical repair

Fractures To $5,000 for Non-surgical; To $10,000 for Surgical repair; Chip fracture: 25% of non-surgical benefit; Multiple fractures: 100% of highest sustained fracture

Hospital Confinement (Per Day) $350, 365 days maximum

Intensive Care Unit (ICU) Confinement per Day $700, 30 days maximum

Initial Intensive Care Unit (ICU) Hospital Admission $2,250

Initial Hospital Admission $1,500

Lacerations To $800

Lodging (Per Day) $200 per day up to 30 days if more than 100 miles from residence

MedicalAppliances $200

Paralysis $20,000 quadriplegia; $10,000 paraplegia/hemiplegia

Physical Therapy (Per Session) $50, 6 sessions maximum

Physician Visit $100 Initial, $100 Follow-up

Prosthesis $1,000 for one, $2,000 for two or more

Rehabilitation Facility Confinement per Day) $150, 30 days maximum

Surgery $200 for Exploratory; $800 for Knee Cartilage; $2,000 for Abdominal or Thoracic; $1,000 for Ruptured Disc; to $1,500 Tendon, Ligament, or Rotator cuff

Transportation $600, if more than 100 miles from residence

Accidental Death Benefits Employee AD&D $25,000

Spouse AD&D $12,500

Child AD&D $5,000

Common Carrier 100%

Accidental Dismemberment Benefits Single Loss 50%

Multiple Loss (Catastrophic) 100%

Thumb/Finger/Toe 1%

2 + Thumb/Finger/Toe 3%

Speech 100%

Wellness (Health Screening) $50

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SUPPLEMENTAL HEALTH COVERAGE – CRITICAL ILLNESS INSURANCE


Coverage

Voluntary critical illness insurance provides a fixed, lump- sum benefit upon diagnosis of a critical illness, which can include heart attack, stroke, paralysis and more. These benefits are paid directly to the insured and may be used for any reason, from deductibles and prescriptions to transportation and child care.

Eligibility

Employees: Each Active Full-Time Employee working 30 or more hours per week, except any person working on a temporary or seasonal basis.

Dependents: You must be insured in order for Dependents to be covered.

Dependents are: Your legal spouse or your domestic partner.

Spouse must be under age 70 at date of application. Coverage terminates at age 75.

Your dependent children* from birth to 26 years. *An eligible employee’s child(ren) from birth to 26 years, including natural children, legally adopted children, children who are dependent on the eligible employee during the waiting period before adoption, stepchildren, and foster children. Foster children must be in the custody of the eligible employee to be considered a Dependent; and an eligible employee's child(ren) beyond the limiting age who is incapable of self-sustaining employment by reason of intellectual disability or physical handicap and who is chiefly dependent on the eligible employee for support and maintenance.

A person may not have coverage as both an Employee and Dependent.

Benefit Amount Employee: Choose from a minimum $5,000 to a maximum of $50,000 in $1,000 increments. Spouse: Choose from a minimum of $5,000 to a maximum of $50,000 in $1,000 increments, not to exceed 100% of approved employee amount. Dependent child(ren): 25% of approved employee amount up to a maximum of $12,500

Guaranteed Issue

Employee: $10,000 Spouse: $10,000 Child: All child amounts are guaranteed issue

Benefit Reduction Due to Age (applicable to employee/spouse coverage)

Age Original Benefit Reduced to: 70 50%

Contribution Requirements


www.reliancestandard.com

Plan Highlights

Voluntary Group

Critical Illness Insurance

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Features

DIAGNOSIS ADULT BENEFIT Carcinoma in Situ – Partial Benefit 25% Coma 100% Coronary Disease – Partial Benefit 25% Heart Attack 100% Life Threatening Cancer 100% Loss of Sight 100% Major Organ Failure 100% Motor Neuron Disease (ALS; Lou Gehrig’s)

100%

Paralysis 100% Ruptured Cerebral; Carotid or Aortic Aneurysm

100%

Severe Brain Damage 100% Stroke 100%

Lifetime Maximum Benefit – 1,000% of Insurance Amount Subsequent Occurrence Benefit – 100% of benefit if

diagnosed 3 months or later Recurrence Benefit (Same Illness) – 50% if diagnosed

6 months or later FMLA / MSLA Continuation Portability to employee age 70 Wellness (Health Screening) Benefit - $50

Benefit Waiting Period – 30 Days Pre-Existing Condition Limitation – A pre- existing condition is any sickness or injury, whether specifically diagnosed or not, for which an insured received treatment, consultation, care or services, including diagnostic procedures, or for which he/she took prescription drugs or medicines, during the look back period (12 months) before the individual effective date of coverage (or the effective date of an increased in coverage).Benefits (or an increased benefit) would not be payable due to a pre-existing condition unless the Critical Illnesses diagnosed after the coverage period (12 months) from the Insured’s effective date of coverage ( or effective date of an increase).

Exclusions

A benefit will not be paid if the Critical Illness is caused by or contributed to by one of the following: an act of war, declared or undeclared; intentionally self-inflicted Injury; commission or attempted commission of a felony; the use of alcohol or drugs unless taken as prescribed by a Physician; a Sickness or Injury that occurs while confined in a penal or correctional institution; cosmetic or elective surgery that is not medically necessary; committing or attempting to commit suicide while sane or insane; participation in a riot or insurrection; for a Critical Illness Diagnosed outside of the US unless confirmed within the US; for a Critical Illness which is Diagnosed during the Benefit Waiting Period; for a Critical Illness that follows a different Critical Illness Diagnosis for which a benefit has been paid, within a shorter time period than reflected under Features. (Subsequent Occurrence); and for the same Critical Illness for which a benefit has been paid, if it is Diagnosed within a shorter time period than reflected under Features. (Recurrence).

For a comprehensive list of exclusions and limitations, please refer to the Certificate of Insurance, which also provides all requirements necessary to be eligible for benefits.


www.reliancestandard.com

23

SUPPLEMENTAL HEALTH COVERAGE – HOSPITAL INDEMNITY

COVERAGE

Preston County Board of Education FEATURES

Voluntary hospital indemnity insurance provides a range of fixed, lump-sum daily benefits to help cover costs associated with a hospital admission, including room and board costs. These benefits are paid directly to the insured following a hospitalization that meets the criteria for benefit payment.

ELIGIBILITY Employees: Each Active Full-Time Employee working 30 or more hours per week, except any person working on a temporary or seasonal basis. Dependents: You must be insured in order for Dependents to be covered. Dependents are: • the Insured’s lawful spouse; and • the Insured’s children who are less than age 26


BENEFITS PLAN 1

• Guaranteed issue; no medical questions • No pre-existing conditions exclusions • Mental & Nervous and Substance Abuse treated same as any

other hospital admission • No deductibles • Eligible for continuation of coverage • HIPAA privacy compliant • Overlying Major Medical Plan NOT Required* • Coverage Offered on a Voluntary Basis * Overlying major medical plan is required for all California

residents.

EXCLUSIONS Benefits will not be paid for any loss caused by: suicide; war; assault/felony; dental care except hospitalizations for the care of sound, natural teeth and gums required on account of accidental injury that happens while covered, and that occur within 6 months of the accident; injuries arising out of or in the course of employment for wage or profit; hospitalizations that occur while outside the United States of America; or care or treatment rendered in connection with cosmetic surgery, except hospitalizations for cosmetic surgery needed for breast

Room & Board Benefit per Day (180 Daily Benefits per Coverage Year)*

Critical Care Unit Benefits per Day (30 Daily Benefits per Coverage Year)

$100

$100

reconstruction following a mastectomy or for an accident that happens while covered. The cosmetic surgery needed for an accidental injury must be performed within 90 days of the accident. For a comprehensive list of exclusions and limitations, please refer to the Certificate of Insurance. The Certificate also provides all requirements necessary to be eligible for benefits.

One Daily Benefit per Coverage Year $500



Non-Insurance Services OnCall Travel Assistance Included

* In no event will the Daily Benefits exceed 180 daily benefits per Coverage Year. ** Wellness Care means medical examinations and procedures that are preventive in nature and not for the treatment of Injury or Sickness.

This Plan Highlights is a brief description of the key features of the RSL insurance plan. The availability of the benefits and features described may vary by state. It is not a certificate of insurance or evidence of coverage.

SEMI-MONTHLY PAYROLL DEDUCTION Employee Only $7.88

Employee + Spouse $16.62 Employee + Children $11.82 Employee + Family $20.57

Wellness Care**

Hospital Critical Care Admission Benefit

Hospital Room & Board Benefits

Plan Highlights

Voluntary Hospital IndemnityInsurance

Hospital Admission Benefit

Hospital Critical Care Unit Benefits (Paid in addition to Room & Board Benefit)

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