EMPLOYEE BENEFITS PLAN
ARTSPACE CHARTER SCHOOL PLAN YEAR: July 1, 2019 through June 30, 2020
ARRANGED BY:
www.piercegroupbenefits.com
What’s Inside
ArtSpace Charter School Plan Year July 1, 2019 through June 30, 2020
ArtSpace Charter School is offering all eligible employees a comprehensive Benefits Program. This booklet highlights the benefits offered through your employer for the current plan year. Benefits described in this booklet are voluntary, employee-paid benefits unless otherwise noted. You have the opportunity to select the benefits in which you wish to participate. Please see the Benefits Plan Overview section of the booklet for more details. This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail. All information in this booklet including premiums quoted is subject to change. All policy descriptions are for information purposes only. Your actual policies may be different than those in this booklet.
Benefits Plan Overview………………………………………………..
2
Cancer Benefits…………………………………………...
4
Disability Benefits…………………………………………
7
Accident Benefits…………………………….……………
21
State of North Carolina Teachers’ and State Employees’ Health Plan – Plan Comparison**…………...……………
25
Medical Bridge Benefits………………………….………..
27
Critical Care Benefits……………...………………………
34
Life Insurance……………………………………………..
38
Dental Benefits……………………………………………
44
Vision Benefits……………………………….……………
47
Telemedicine – Call A Doctor Plus………..……………….
51
Identity Theft Shield & Life Events Legal Plan ……………..
54
Authorization Form……………………………………………………
55
Notice of Insurance Information Practices…………………………….
56
Continuation of Coverage for Benefits …………...…….……………..
57
Arranged & Enrolled by
Rev. 05/31/2019
**The State of North Carolina Teachers’ and State Employees’ Health Plan pages are included in this booklet for informational purposes only.
ArtSpace Charter School | 1
ARTSPACE CHARTER SCHOOL EMPLOYEE BENEFITS PROGRAM Provided by Pierce Group Benefits
Pre-Tax Benefits Cancer Benefits
Colonial Life
Accident Benefits
Colonial Life
Medical Bridge Benefits
Colonial Life
Dental Insurance
Principal
Vision Insurance
Envolve
Post-Tax Benefits Disability Benefits o Educator Income Plan o Long-Term Disability (High Option) o Long-Term Disability (Low Option)
Colonial Life Principal Principal
Critical Care Benefits
Colonial Life
Life Insurance o Term Life Insurance o Whole Life Insurance o Group Term Life Insurance (Employer-Paid)
Colonial Life Colonial Life Principal
Telemedicine
Call A Doctor Plus
Identity Theft Shield & Life Events Legal Plan
Legal Shield
Insurance Products will remain in effect unless you see a representative to change them.
ENROLLMENT PERIOD June 13, 2019 through June 14, 2019 EFFECTIVE DATES July 1, 2019 through June 30, 2020
2 | ArtSpace Charter School
Qualifications • You must work 20 hours or more per week. Important Facts: •
The plan year for Colonial Insurance products, Principal Dental, Principal Long-Term Disability, Envolve Vision, Call A Doctor Plus Telemedicine and Legal Shield Identity Theft Shield & Life Events Legal Plan lasts from July 1, 2019 through June 30, 2020. Please Note: Dental benefits are based on the Calendar Year, running from January 1st through December 31st. Dental benefits and deductibles will reset every January 1st.
•
Deductions for Principal Dental, Principal Long-Term Disability, Envolve Vision, Call A Doctor Plus Telemedicine and Legal Shield Identity Theft Shield & Life Events Legal Plan will begin July 2019. Deductions for Colonial Insurance products will begin June 2019.
•
If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when meeting with the Benefits Representative.
•
Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as defined by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time or vice-versa.
•
Once a family status change has occurred, an employee has 30 days to notify the North Carolina Service Center at 1-888-662-7500 to request a change in elections.
•
The Colonial Cancer plan and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until July 31, 2019.
•
Additionally, some policies may include a pre-existing condition clause. Please read your policy carefully for full details.
•
Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution.
To enroll or make changes to your Flexible Benefits Plan, please see the representative while he/she is at your location.
ArtSpace Charter School | 3
CANCER BENEFIT Provided by Colonial Life The following information highlights the benefits of the current Cancer policy available through your benefits package. If you enrolled in a Cancer Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions.
4 | ArtSpace Charter School
Cancer Benefit
ArtSpace Charter School | 5
Cancer Benefit
6 | ArtSpace Charter School
DISABILITY BENEFIT Short-Term Disability Benefit Provided by Colonial Life The following information highlights the benefits of the current Disability policy available through your benefits package. If you enrolled in a Disability Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions.
ArtSpace Charter School | 7
Disability Benefit Short-Term Disability
8 | ArtSpace Charter School
Disability Benefit Short-Term Disability
ArtSpace Charter School | 9
Disability Benefit Short-Term Disability
10 | ArtSpace Charter School
DISABILITY BENEFIT Long-Term Disability – High Option Provided by Principal
Principal Long Term Disability Rates Age
High Option
<24
$0.13 / $100
25-29
$0.22 / $100 $0.30 / $100 $0.42 / $100 $0.67 / $100 $0.82 / $100 $1.00 / $100 $1.32 / $100 $1.23 / $100 $0.51 / $100 $0.25 / $100
30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74
ArtSpace Charter School | 11
Disability Benefit Long-Term Disability High Option
12 | ArtSpace Charter School
Disability Benefit Long-Term Disability High Option
ArtSpace Charter School | 13
Disability Benefit Long-Term Disability High Option
14 | ArtSpace Charter School
Disability Benefit Long-Term Disability High Option
ArtSpace Charter School | 15
DISABILITY BENEFIT Long-Term Disability – Low Option Provided by Principal
Principal Long Term Disability Rates Age
Low Option
<24
$0.08 / $100
25-29
$0.14 / $100 $0.18 / $100 $0.23 / $100 $0.30 / $100 $0.38 / $100 $0.50 / $100 $0.81 / $100 $0.76 / $100 $0.31 / $100 $0.15 / $100
30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74
16 | ArtSpace Charter School
Disability Benefit Long-Term Disability Low Option
ArtSpace Charter School | 17
Disability Benefit Long-Term Disability Low Option
18 | ArtSpace Charter School
Disability Benefit Long-Term Disability Low Option
ArtSpace Charter School | 19
Disability Benefit Long-Term Disability Low Option
20 | ArtSpace Charter School
ACCIDENT BENEFIT Provided by Colonial Life The following information highlights the benefits of the current Accident policy available through your benefits package. If you enrolled in an Accident Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions.
ArtSpace Charter School | 21
Accident Benefit
22 | ArtSpace Charter School
Accident Benefit
ArtSpace Charter School | 23
Accident Benefit
24 | ArtSpace Charter School
STATE OF NORTH CAROLINA TEACHERS’ AND STATE EMPLOYEES’ HEALTH PLAN The following summary is included in this benefit booklet for informational purposes only. Open enrollment for the State of North Carolina Teachers’ and State Employees’ Health Plan is not part of this Flexible Benefits Plan Open Enrollment Period.
ArtSpace Charter School | 25
State of North Carolina Teachers’ and State Employees’ Health Plan
26 | ArtSpace Charter School
MEDICAL BRIDGE BENEFIT Provided by Colonial Life The following information highlights the benefits of the current Medical Bridge policy available through your benefits package. If you enrolled in a Medical Bridge Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions.
ArtSpace Charter School | 27
Medical Bridge Benefit Plan 2
28 | ArtSpace Charter School
Medical Bridge Benefit Plan 3
ArtSpace Charter School | 29
Medical Bridge Benefit Plan 3
30 | ArtSpace Charter School
Medical Bridge Benefit Health Screening
ArtSpace Charter School | 31
Medical Bridge Benefit Medical Treatment Package
32 | ArtSpace Charter School
Medical Bridge Benefit Optional Riders
ArtSpace Charter School | 33
CRITICAL CARE BENEFIT Provided by Colonial Life The following information highlights the benefits of the current Critical Care policy available through your benefits package. If you enrolled in a Critical Care Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions.
34 | ArtSpace Charter School
Critical Care Benefit Plan 3 – Specified Disease
ArtSpace Charter School | 35
Critical Care Benefit First Diagnosis Building Benefit Rider – Specified Disease (Plan 3)
36 | ArtSpace Charter School
Critical Care Benefit Health Screening Benefit
ArtSpace Charter School | 37
TERM LIFE INSURANCE Provided by Colonial Life The following information highlights the benefits of the current Term Life policy available through your benefits package. If you enrolled in a Term Life Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions.
38 | ArtSpace Charter School
WHOLE LIFE INSURANCE Provided by Colonial Life The following information highlights the benefits of the current Whole Life policy available through your benefits package. If you enrolled in a Whole Life Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions.
ArtSpace Charter School | 39
Whole Life Insurance Long-Term Care Benefit Rider
40 | ArtSpace Charter School
Whole Life Insurance Long-Term Care Benefit Rider
ArtSpace Charter School | 41
GROUP TERM LIFE INSURANCE Provided by Principal
42 | ArtSpace Charter School
Group Term Life Insurance
ArtSpace Charter School | 43
DENTAL INSURANCE Provided by Principal
Employee Only Employee & Spouse Employee & Child(ren) Employee & Family
44 | ArtSpace Charter School
$42.20 $85.32 $96.02 $144.50
Dental Insurance
ArtSpace Charter School | 45
Dental Insurance
46 | ArtSpace Charter School
VISION INSURANCE Provided by Envolve
ArtSpace Charter School | 47
Vision Insurance Materials Only Plan
48 | ArtSpace Charter School
Vision Insurance Comprehensive Plan
ArtSpace Charter School | 49
Vision Insurance Comprehensive Plan
50 | ArtSpace Charter School
CALL A DOCTOR PLUS
ArtSpace Charter School | 51
Telemedicine - Call A Doctor Plus
52 | ArtSpace Charter School
Telemedicine - Call A Doctor Plus
ArtSpace Charter School | 53
IDENTITY THEFT SHIELD & LIFE EVENTS LEGAL PLAN Legal Plan Benefits Provided by Legal Shield
Special Group Rates: 12 Month
54 | ArtSpace Charter School
Legal Plan Only
23.95
IDShield Individual
8.95
Legal + IDShield Individual
32.90
IDShield Family
18.95
Legal + IDShield Family
38.90
Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives. Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments. Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by those laws. This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202. You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, or Conservator.
________________________ (Printed name of individual subject to this disclosure)
_____________ (Social Security Number)
___________________ (Signature)
________________ (Date Signed)
If applicable, I signed on behalf of the proposed insured as __________________________ (indicate relationship). If legal Guardian, Power or Attorney Designee, or Conservator.
________________________________ (Printed name of legal representative)
_____________________________ (Signature of legal representative)
___________ (Date Signed)
ArtSpace Charter School | 55
56 | ArtSpace Charter School
ArtSpace Charter School | 57
CONTACT INFORMATION: LEGAL SHIELD - PRE-PAID LEGAL
PRINCIPAL- DENTAL INSURANCE
• Mark Spessard: 919-730-0720 • Email Address: mcs.legalshield@gmail.com
• Customer Service: 1-800-247-4695
ENVOLVE - VISION INSURANCE
CALL A DOCTOR PLUS - TELEMEDICINE
• Customer Service: 1-800-368-4790 • Website: www.myvisionplan.com
See pages 51-53 of your Benefit Booklet for information on how to set up your account and contact Call A Doctor Plus!
PRINCIPAL - LONG-TERM DISABILITY TO VIEW YOUR BENEFITS ONLINE
• Customer Service: 1-800-245-1522
Visit www.piercegroupbenefits.com/
NORTH CAROLINA STATE HEALTH PLAN • Customer Service: 1-888-234-2416 • Website: http://shpnc.org
artspacecharterschool
For additional information concerning plans offered to employees of ArtSpace Charter School, please contact our North Carolina Service Center at 1-888-662-7500, ext. 100
COLONIAL LIFE VISIT COLONIALLIFE.COM TO SET UP YOUR PERSONAL ACCOUNT • Website: www.coloniallife.com • Claims Fax: 1-800-880-9325
• Customer Service & Wellness Screenings: 1-800-325-4368 • TDD for hearing impaired customers call: 1-800-798-4040
If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 18 months, you need the name and date of the test performed as well as your doctor’s name and phone number. Colonial also needs to know if this is for you or another covered individual and their name and social security number. You may: • FILE BY PHONE! Call 1-800-325-4368 and provide the information requested by Colonial’s Automated Voice Response System, 24 hours per day, 7 days a week, or • SUBMIT ON THE INTERNET using the Wellness Claim Form at www.coloniallife.com, or • Write your name, address, social security number and/or policy/certificate number on your bill and indicate “Wellness Test.” Fax this to Colonial at 1-800-880-9325 or MAIL to PO Box 100195, Columbia, SC 29202 If your Wellness/Cancer Screening test was more than 18 months ago, you must fax or mail Colonial a copy of the bill or statement from your doctor indicating the type of procedure performed, the charge incurred and the date of service. Please write your full name, social security number, and current address on the bill. Please Note: If your cancer policy includes a second part to the screening benefit, bills for tests covered and a copy of the diagnostic report (reflecting the abnormal reading of your first test) must be mailed or faxed to us for benefits to be provided.
When you terminate employment, you have the opportunity to continue your Colonial coverage either through direct billing or automatic payment through your bank account. Please contact Colonial at 1-800-325-4368 to request the continuation of benefits form.