Summary of Benefits and Rate Guide - LISI Broker | … of Benefits and Rate Guide For plans...

Summary of Benefits and Rate Guide

For plans effective January 1, 2011

Table of Contents

CoPower ONE™

About CoPower ONE 3–6CoPower ONE Dental: Delta Dental of California 4CoPower ONE Vision: VSP 5CoPower ONE Basic Life: Unum 6

Plan Benefits and Enrollment Guidelines 7–9CoPower ONE 7–8Buy-up Option: Unum Voluntary Life 9

Rates 9–10CoPower ONE 9Buy-up Option: Unum Voluntary Life 10

Delta Dental SIC Codes 10–11

Contact Information 12

While the information and rates provided in this guide are believed to be accurate as of the print date, they are subject to change without notice. For the most up-to-date information, contact CoPower or your local LISI representative.

The benefit information contained in this booklet is summary in nature. It does not include all services, limitations or exclusions. Please refer to the carrier’s Evidence of Coverage or Certificate of Insurance documents for terms and conditions of coverage.

3CoPower ONE Summary of Benefits & Rate Guide:

Good:

• Delta Dental PPO with $1,000 In-network Max

• VSP Choice Network with 12/24/24 Frequency

• Unum Basic Group Term Life with $15,000 Policy, AD&D, and EAP

Better:

• Delta Dental PPO with $1,500 In-network Max + Ortho



Best:

• Delta Dental PPO+Premier with $2,000 In-network Max + Ortho



CoPower ONE

The Easiest Way to Have Dental, Vision, and Life

About CoPower ONE

CoPower ONE™

One application. One bill. One price.

A Simple, Comprehensive Solution for Small BusinessesCoPower ONE is a simplified package of the most popular ancillary offerings for small businesses. Dental, vision, and life coverages are bundled together in one package that makes it easy to explain and even easier to sell. And the consolidated customer interface through CoPower makes it even easier for your clients to administer.

• Top quality coverage from recognized ancillary carriers. In CoPower ONE, your clients get first-in-class coverage from carriers they trust: Delta Dental of California, VSP, and Unum.

• Custom-tailored sets of benefits, networks, and pricing. Your clients just choose the option that works best for them: Good, Better or Best. The ‘Good’ package is the most economical plan, while the ‘Better’ and ‘Best’ plans feature increased benefits and orthodontia.

These bundled benefit packages consist of the Delta Dental PPO and PPO+Premier plans, VSP Choice plans, and Group Term Life from Unum. All three packages have family tiers, industry loads (some exempt industries), and two rating regions.

• Effortless administration. When signing up for CoPower ONE, your clients only need to fill out one application, have one point of contact, and get only one bill every month. It is easy to administer and simple to use.

Delta Dental PPO and Delta Dental PPO+Premier are underwritten by Delta Dental of California; VSP Choice is underwritten by VSP; and Unum Basic Group Term Life is underwritten by Unum Life Insurance Company of America. These companies are financially responsible for their own products.

4 CoPower ONE Summary of Benefits & Rate Guide:

Why do 54 million enrollees trust their smiles to Delta Dental?Most enrollees stay with Delta Dental year after year, and it’s no wonder. Delta Dental sets the industry standard by delivering:• More savings. The Delta Dental Difference® saves clients and

enrollees billions of dollars a year.1 Because Delta Dental dentists agree to Delta Dental’s determination of fees, clients enjoy extensive cost controls and enrollees pay less out-of-pocket.

• More dentists. Three out of four dentists nationwide are contracted with Delta Dental, so enrollees have convenient access and quality assurance through the nation’s largest dentist network.

• More satisfaction. Clients and enrollees rate Delta Dental more favorably on reputation, value, quality of care, and customer service than any other brand.2 Delta Dental delivers an exceptional customer experience with their fast and accurate claims processing, ease of use and administration, and personalized service. This means employees will have:

• No waiting periods for any procedures.• No need to fill out any claim forms since Delta Dental directly

reimburses dentists.• Access to online services, such as eligibility, benefits, claim

status, and dentist directories, at www.deltadentalins.com.

About the Delta Dental Classic Plans

CoPower ONE offers the PPO and PPO+Premier plans from Delta Dental’s Classic portfolio. For the Better and Best plans, orthodontics is available to groups as small as five enrolled.

1. Savings due to reduction of premiums or claims liability and patient out-of-pocket costs, as reported by the Delta Dental Plans Association.

2. Based on a nationwide survey, ‘Brand Awareness and Perception Survey,’ by The Long Group for Delta Dental Plans Association (2008).

• Outstanding provider access in California: over 54% dentists are in the PPO network and over 92% in the Premier network.

• Stable network with 98% dentist retention minimizes disruption in service.

• Unlike many other dental carriers, Delta Dental covers dental implants under their Major Services.

Great Reasons to Choose CoPower ONE

Delta Dental PPO

• Proactively promotes oral health among pregnant women.

• Can benefit both the mother and child, and thus, improve their overall health.

Third Cleaning for Pregnant Women

CoPower ONE Dental: Delta Dental of California

CoPower ONE Dental: Delta Dental of California


Why Choose VSP?VSP’s vision plans are good for your clients’ eyes as well as their wallets! Members don’t have to cut coupons or wait for a sale like with retail chains; the savings are already built into the VSP plans. Plus, employees can use their flexible savings account for any out-of-pocket costs, including copays, at a VSP doctor’s office.• Personalized Care. Establishing a relationship with an eye

doctor is important—members receive personalized care from a doctor they trust. Since all VSP doctors are private-practice doctors and they stay in their practices year after year, members don’t have to worry at their annual eye exam about seeing a new unfamiliar doctor.

• Diverse Selection and Services. Members can experience the private-practice difference with a VSP doctor. Products and services from a retail chain are also available from a VSP doctor’s office, such as a diverse selection of eyewear, including designer brands, and weekend and evening appointments.

• Everyone Needs an Annual Eye Exam. Think eye exams aren’t necessary because one has 20/20 vision or have had laser vision surgery? Think again. Annual eye exams are important to one’s overall health.

During a WellVision Exam®, a VSP doctor can see differences in their patient’s vision and overall eye health. The doctor is also qualified to detect problems and signs of other health conditions, such as diabetes, high blood pressure, and high cholesterol.

About the VSP Choice Plans

VSP Choice is the portfolio of choice in CoPower ONE. These are full-service plans that offer comprehensive coverage, choices, and value with competitive rates to members. This network has 24,000 doctors with 35,000 access points nationwide.

CoPower ONE Vision: VSP

• VSP members have 35,000 access points in more than 18,000 locations, including suburban and rural locations.

• VSP provides members with lower out-of-pocket costs through additional discounts, as well as one of the industry’s most comprehensive lists of cost-controlled patient options.

• VSP has approximately 500 staff members dedicated to customer service with 350 serving as Customer Service Representatives.

Great Reasons to Choose CoPower ONE

VSP Choice

CoPower ONE Vision: VSP


Unum Group Term Life Offers Peace of Mind and Helps Protect FamiliesUnum group term life coverage through CoPower ONE enables employers to provide a basic level of life insurance to their employees with the opportunity to purchase higher levels of coverage at an affordable price. To enroll, members are not required to undergo a physical exam. This benefit is even portable—it gives employees coverage they can keep if they ever leave their employer.

Unum group term life plans sold through CoPower ONE are accompanied by these value-added coverage and services:

• Accidental Death and Dismemberment (AD&D). This coverage provides additional benefits to the covered member or their beneficiary in the event of a fatal accident or an accident that results in the loss of their eyesight, speech, hearing, or a limb.

• Work-Life Balance Employee Assistance Program (EAP). Members have access to master-level consultants who can help with all of life’s challenges, including work and personal issues by phone, web, or through face-to-face sessions.

• Life Planning Financial and Legal Resources. Financial and legal resources, as well as emotional counseling and support are available at no charge to the spouse and beneficiaries if the covered employee is terminally ill or dies.

• Worldwide Emergency Travel Assistance. Whether traveling for business or pleasure, covered members can get help—from guaranteed hospital admission to assistance with prescription replacement—with just one phone call in the event of a medical emergency.

CoPower ONE Basic Life: Unum

• Voluntary life coverage can be offered by your clients as a buy-up option to their employees, allowing them to obtain additional protection for themselves or their family members.

• It is available with scaled Guarantee Issue and no participation requirements.

Group Lifestyle Protection Life (Voluntary Life)

CoPower ONE Basic Life: Unum

AD&D • 100% benefit for loss of life/

dismemberment, loss of sight/speech/hearing, quadriplegia

• Education, repatriation, exposure/disappearance, and seatbelt/airbag benefits

EAP• Childcare/eldercare referrals• Financial planning assistance

Life Planning Financial and Legal Resources• Impartial, accurate advice• Customized service

Worldwide Emergency Travel Assistance• Emergency medical evacuation• Medically supervised

transportation home

Great Reasons to Choose CoPower ONEHighlights of Unum’s Benefits

7CoPower ONE Summary of Benefits & Rate Guide: Plan Benefits

Plan Benefits

For groups of 5–99 employees

CoPower ONE Good CoPower ONE Better CoPower ONE Best

In-network Delta Dental PPO Dentists

Out-of-network Delta Dental Premier and

Non-Delta Dental Dentists

In-network Delta Dental PPO Dentists

Out-of-network Delta Dental Premier and


In-networkDelta Dental PPO

Dentists

Out-of-networkDelta Dental Premier and


Dental Delta Dental PPO Delta Dental PPO+Premier

Reimbursement Basis All dentists (in- and out-of-network) are reimbursed at the lesser of the submitted charge or the PPO provider allowed fee.

Delta Dental PPO dentists are reimbursed at the lesser of the submitted charge or the PPO provider allowed fee. Delta Dental Premier dentists are reimbursed at the lesser of the submitted charge or the Premier provider allowed fee. Non-contracted dentists are reimbursed at the lesser of the submitted charge or the fee that satisfies the majority of dentists with the same training and geographical area.

Calendar Year Max $1,000 $750 $1,500 $1,250 $2,000 $1,500

Deductible• $50• For D&P:

Waived

• $75• For D&P:

Not waived

• $50• For D&P:

Waived

• $75• For D&P:

Not waived

• $50• For D&P: Waived

• $75• For D&P: Not waived

Diagnostic & Preventive Services (D&P)

100% 50% 100% 80% 100% 80%

Basic, Oral Surgery, Endodontics, and Periodontics

80% 50% 80% 80%

Major Services 50% 50% 50%

Orthodontics— Children Only (Available to groups 5+ enrolled)

Not available 50% lifetime max $1,000 50% lifetime max $1,000

Vision VSP Choice Network

Annual Copayment $25 exam/$25 prescription glasses $10 exam/$25 prescription glasses $10 exam/$25 prescription glasses

Eye Exam Covered after copayment

Reimbursed up to $45

Covered after copayment


Covered after copayment


Single-vision Lenses Covered in fullReimbursed

up to $30Covered in full


Covered in fullReimbursed

up to $30

Bifocal Lenses Covered in fullReimbursed




up to $50

Trifocal Lenses Covered in fullReimbursed




up to $65

Frames $150 allowanceReimbursed

up to $70$150

allowanceReimbursed

up to $70$150 allowance


Contact Lenses $150 allowanceReimbursed up to $105

$150 allowance


$150 allowanceReimbursed up to $105

Frequency

• Eye Exam 12 months 12 months 12 months

• Lenses 24 months 12 months 12 months

• Frames 24 months 24 months 12 months

• Contact Lenses (in lieu of lenses and a frame)

24 months 12 months 12 months

8 CoPower ONE Summary of Benefits & Rate Guide: Plan Benefits and Enrollment Guidelines

Plan Benefits (continued)CoPower ONE Good CoPower ONE Better CoPower ONE Best

Life Unum Basic Group Term Life with AD&D and EAP

Policy $15,000 $20,000 $25,000

Voluntary Term Life Insurance. Employers can also offer Unum’s Group Lifestyle Protection Life as a buy-up option to their employees. For more information, please refer to the plan benefits, enrollment guidelines, and rates in the following pages.

Enrollment GuidelinesCoPower ONE Good CoPower ONE Better CoPower ONE Best

Group Size/Eligibility

• Groups with 5–99 employees• Minimum of 5 enrolled• DE-9C is required.• Groups currently enrolled with Delta Dental or Unum are not eligible for coverage in CoPower ONE.• In order to maintain enrollment in the CoPower ONE program, groups must continue coverage in all three lines

of coverage.

Employer Contribution • 75% minimum for employees• No minimum for dependents

Participation

• Non-voluntary• Minimum of 85% enrollment• If employer contributes 100%, 100% participation is required.• Employees with dental coverage from another employer’s plan can waive CoPower ONE coverage even if they

do not have other vision coverage.

Rate Guarantee 12 months

Industry Loads Yes. Some industries are ineligible.

Waiting Period for Services None

Out-of-State No more than 50% of primary enrollees may reside outside of California.

Overage Dependents Dependent children are eligible until age 26 for dental, vision, and life coverage.

Basic Life Age Reduction Schedule

• 65% at age 70• 50% at age 75

Carve-outs• Only Union/Non-union carve-outs will be allowed.• Allowed if non-carved-out employees are either not covered or covered by DeltaCare USA.• Carve-out groups will receive Level 2 rates.

1099 Employees Not eligible

Product Combinations Not allowed

Voluntary No.

Orthodontia No.• Available to groups 5+ enrolled• Yes, for CoPower ONE Better and CoPower ONE Best• Child only up to age 26

Open Enrollments Open enrollment is not allowed.

Case Submission Deadlines Varies by month

Administrative Fees None

Plan Benefits and Enrollment Guidelines


Plan Benefits, Enrollment Guidelines, and Rates

Plan Benefits, Enrollment Guidelines, and Rates

Buy-up Option: Unum Voluntary Life Plan Benefits and Enrollment Guidelines

Unum Group Lifestyle Protection Life Benefits, AD&D, and EAP

Employee SpouseChild

(Covers all children up to age 26)

Group Size 2–249 employees 2–249 employees 2–249 employees

Standalone Requires the employee to have Basic Life in place

Requires the employee to have Voluntary Life in place

Requires the employee to have Voluntary Life in place

Contribution 100% employee-paid 100% employee-paid 100% employee-paid

Participation None required None required None required

Guarantee Issue• 2–9 employees: $10,000• 10–49 employees: $30,000• 50–249 employees: $80,000

All group sizes: $10,000 All group sizes: $6,000

Amounts Available $10,000 increments $5,000 increments $6,000 is the only option

Maximum Amount Lesser of $100,000 or five times earnings

Lesser of $100,000 or 100% of employee’s voluntary life amount

$6,000 per child

Age Reduction Schedule• 65% at age 70• 50% at age 75

• 65% at age 70• 50% at age 75

Not applicable

Rates—CoPower ONE

Southern California RegionLos Angeles, Orange, San Diego,

San Bernardino, Riverside, Ventura, and Central Valley ZIP codes 932, 933, 935–938,

952,953,956–958

Northern California RegionAlameda, Contra Costa, Marin, Santa Clara,

San Francisco, San Mateo, and other areas of California not otherwise mentioned

Level 1 Level 2 Level 1 Level 2

CoPower ONE Good

Single $45.00 $50.00 $45.00 $50.00

Two-Party $77.00 $89.00 $80.00 $94.00

Three-Party+ $112.00 $131.00 $117.00 $138.00

CoPower ONE Better

Single $55.00 $63.00 $55.00 $63.00

Two-Party $98.00 $113.00 $102.00 $119.00

Three-Party+ $157.00 $183.00 $163.00 $193.00

CoPower ONE Best

Single $75.00 $85.00 $75.00 $85.00

Two-Party $129.00 $149.00 $135.00 $156.00

Three-Party+ $198.00 $231.00 $207.00 $243.00

Note: Rates are effective January 1, 2011, through December 31, 2011.


Rates and Delta Dental SIC Codes

Delta Dental SIC Codes—Level 1

Eligible Industries SIC Code(s) Eligible Industries SIC Code(s)

Advertising (except Misc., not classified #7319) 7311–7313 Hospitals 8062–8069

Agriculture, Forestry, and Fishing (except seasonal employees)

0100–0999 Independent Auto Repair and Services 7532–7599

Auto Rental Agencies 7513–7519Laundry/Garment Services and Shoe Repair Services

7211–7219/7251

Automobile Parking Services 7521 Manufacturing (except Jewelry Manufacturing) 2000–2699

Building Maintenance/Equipment Rental 7349–7359 Manufacturing (Chemicals, Allied, and Other) 2810–3999

Collection Agencies and Credit Reporting Services 7322–7323 Mining, Oil, and Gas Extraction 1000 –1499

Communication (Radio, Telephone, TV/Radio, and Broadcasting)

4800–4899 Miscellaneous Repair (Welding, etc.) 7692–7699

Community Services Organizations/Social Services 8300–8499 News Syndicates 7383

Computer Programming and other Computer Services 7371–7379 Photofinishing Labs 7384

Construction Contractors 1500–1799 Printing and Publishing 2700–2799

Rates and Delta Dental SIC Codes

Rates—Unum Voluntary Life

Employee and Spouse Per $1,000

Age Band Rate

Unum Group Lifestyle Protection Life with AD&D and EAP

<25 $0.12

25–29 $0.13

30–34 $0.15

35–39 $0.21

40–44 $0.29

45–49 $0.44

50–54 $0.69

55–59 $1.04

60–64 $1.84

65–69 $2.78

70–74 $4.94

75+ $9.66

Child Per $1,000

Age Band Rate

Unum Group Lifestyle Protection Life with AD&D and EAP

Up to age 26 $0.33

Delta Dental Standard Industrial Classification (SIC) Codes


Delta Dental SIC Codes



Direct Mailing, Reproduction, and Secretarial Services 7331–7338Public Administration (Cities, Counties, Police, etc.)

9000–9720,9722–9999

Disinfecting and Pest Control Services 7342 Retail

5200–5510,5610–5699,5712–5736,5912–5999

Public Education (except Private Schools) 8200–8299 Private Schools (Elementary and High School) 8221

Electrical Repair (Radio, TV, A/C, and Refrigerator) 7622–7629 Security Systems, Detectives, and Armored Cars 7381–7382

Engineering and Management Services 8711–8748 Transportation 4000–4799

Finance (Banks, Securities, and Credit Agencies) 6000–6299 Utilities 4900–4999

Funeral Services and Crematories 7261 Wholesale Trade 5000–5199

Furniture Repair/Re-upholstery 7641



Advertising (Miscellaneous, not classified) 7319 Medical Groups8000–8059

and8071–8099

Automobile Dealerships 5511–5599 Photographic Studios 7221

Amusement, Recreation, and Entertainment 7800–7999 Restaurants 5800–5899

Hotels 7000–7099Tax Return Preparation Services and Miscellaneous Personal Services

7291–7299

Insurance Carriers/Brokers 6300–6499 Real Estate 6500–6799

Jewelry Manufacturing 3911–3915Religious Organizations (Administration and Management Staff only)

8661

Legal 8100–8199 Watch, Clock, and Jewelry Repair 7631

Ineligible Industries SIC Code(s) Ineligible Industries SIC Code(s)

Associations and Trusts8600–8660;8662–8699

Professional Employer Organizations (PEO) 7361

Beauty and Barber Shops 7231–7241 Private Households 8811

International Affairs 9721 Partnerships No SIC

Dental Offices, Dental Labs, and Medical Labs8021, 8071, and 8072

Seasonal Employees (Christmas/Part-time Help) No SIC

Employment Agencies 7361–7363 Seasonal Employees (Agriculture) 0761–0783

Groups with high turnover Varies Miscellaneous Services not classified elsewhere 8999

Miscellaneous Business Services 7389

Delta Dental SIC Codes

Delta Dental of California888.335.8227www.deltadentalins.com

VSP800.877.7195www.vsp.com

Unum866.679.3054www.unum.com

Carrier Contact Information

CPE-005 6/11

For plan administration, contact CoPower at:1600 W. Hillsdale Blvd.San Mateo, CA 94402T: 888.920.2322F: 650.348.1149www.copower.com

For sales, contact LISI at:866.570.LISI (5474)www.lisibroker.com

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