EMPLOYEE BENEFITS PLAN HALIFAX COUNTY PUBLIC SCHOOLS PLAN YEAR: July 1, 2019 through June 30, 2020
ARRANGED BY:
www.piercegroupbenefits.com
What’s Inside
Benefits Plan Overview…………………………..……………………
2
Health Insurance The Local Choice Benefits-At-A-Glance……….……...………...………
4
Employee Assistance Program……………….…………...
6
Dental Benefits
The Local Choice Benefits-At-A-Glance……….….…………….………
Halifax County Public Schools Plan Year July 1, 2019 through June 30, 2020
Halifax County Public Schools 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, employeepaid 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. Arranged & Enrolled by
Vision Benefits
The Local Choice Benefits-At-A-Glance……….……….……….………
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9
Contribution Schedule for The Local Choice Coverage ……..
11
Health Savings Account……………………….………….
12
Medical Bridge Benefits…………………….……………..
14
Disability Benefits…………………………………………
22
Cancer Benefits…………………………………………...
26
Accident Benefits…………………………………………
33
Critical Care Benefits…………………...…………………
37
Life Insurance………………………………………..……
40
Dental Benefits
Delta Dental Benefits-At-A-Glance……….….……….………….………
Vision Benefits
44
EyeMed Vision Benefits-At-A-Glance……….………….……….………
48
COBRA Continuation of Coverage Rights ……..…….…………………
50
Authorization Form……………………………………………………
52
Notice of Insurance Information Practices…………………………….
53
Supplemental Continuation of Coverage Form………………………..
54
Rev. 04/15/2019
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HALIFAX COUNTY PUBLIC SCHOOLS EMPLOYEE BENEFITS PROGRAM Provided by Pierce Group Benefits
Pre-Tax Benefits Health Insurance*
Anthem –The Local Choice
Dental Insurance*
Delta Dental – The Local Choice Delta Dental
Vision Insurance*
Anthem – The Local Choice EyeMed Vision
Health Savings Accounts* o Employee Maximum $3,500/year o Family Maximum $7,000/year HSA plans can only be established in conjunction with a qualified high-deductible health plan (HDHP)
Cancer Benefits
Colonial Life
Accident Benefits
Colonial Life
Medical Bridge Benefits
Colonial Life
Post-Tax Benefits Disability Benefits
Colonial Life
Critical Care Benefits
Colonial Life
Life Insurance o Term Life Insurance o Whole Life Insurance
Colonial Life Colonial Life
*EMPLOYEES WILL NEED TO RE-ENROLL IN HEALTH, DENTAL, VISION AND HEALTH SAVINGS ACCOUNTS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING JULY 1, 2019. Other Insurance Products will remain in effect unless you see a representative to change them.
ENROLLMENT PERIOD April 22, 2019 through May 10, 2019 EFFECTIVE DATES July 1, 2019 through June 30, 2020 2 | Halifax County Public Schools
Qualifications •Employees must work 25 hours per week or must be a contract employee.
Important Facts: • The plan year for The Local Choice benefits (Anthem Health, Delta Dental & Anthem Vision), Health Savings Accounts, Delta Dental, EyeMed Vision and Colonial Insurance products lasts from July 1, 2019 through June 30, 2019. • Deductions for The Local Choice benefits (Anthem Health, Delta Dental & Anthem Vision), Delta Dental (standalone policy), and EyeMed Vision (stand-alone policy) will begin June 2019. Deductions for Health Savings Accounts and Colonial Insurance products will begin July 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 Pierce Group Benefits Service Center at 1-800-387-5955 to request a change in elections. • The Colonial Cancer plan and the Health Screening Rider on the 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. • An employee taking a leave of absence, other than under the Family & Medical Leave Act, may not be eligible to re-enter the Benefits Program until the next plan year. Please contact your Benefit Administrator for more information.
To enroll or make changes to your Benefits Plan, please see the representative while he/she is at your location.
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HEALTH INSURANCE Provided by Anthem – The Local Choice Please visit www.piercegroupbenefits.com/halifaxcountypublicschools to review plan summaries and other required notices
Halifax County Public Schools 2019/20 Plan Year High Deductible Health Plan
Plan Year Deductible (applies as indicated)
In-Network
Plan Year Out-of-Pocket Expense Limit
In-Network
$5,000 $10,000
One Person Family (two or more people)
Individual Out-of-Pocket Maximum Family Out-of-Pocket Maximum
Out-of-Network
Key Advantage 1000 In-Network
Out-of-Network
$1,000 $2,000
$2,000 $4,000
Out-of-Network
In-Network
Out-of-Network
$10,000 $20,000
$5,000 $10,000
$9,000 $18,000
$2,800 $5,600
Unlimited For All Plans
Lifetime Maximum Covered Services
In-Network Benefits Only
Doctor's Visits (Outpatient or In-Office) 20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible
20% Coinsurance, after deductible
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Covered at 100%
Covered at 100%
20% Coinsurance, after deductible
20% Coinsurance, after deductible
20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible
20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible
Outpatient Therapy Services - Occupational, Speech, Physical, Cardiac,
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Diabetic Equipment
20% Coinsurance, after deductible
20% Coinsurance, after deductible
Primary Care Physician Visits -
Chiropractic, Spinal Manipulations (30 visit limit)
Specialist Visits -
Chiropractic, Spinal Manipulations (30 visit limit)
Shots - Allergy or Therapeutic Injections Doctor's Office, ER, or Outpatient Settin g
Diagnostic Tests, Labs, and X-Rays
Specific conditions/diseases at doctor's office, ER, or Outpatient Setting
Preventive Care Visits Emergency Room Visits
Hospital & Other Services
$25 Copayment $40 Copayment
Pre-certification may be required
Ambulance Services Inpatient Hospital Services Outpatient Hospital Services Outpatient Diagnostic Test, Labs, and X-Rays Chemotherapy, Radiation, Infusion, & Respiratory
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Health Insurance Benefit Highlights
Halifax County Public Schools 2019/20 Plan Year High Deductible Health Plan
Key Advantage 1000
Maternity Prenatal & Provider Services- PCP Prenatal & Provider Services - Specialist Hospital Services for Delivery Diagnostic Tests, Labs, and X-Rays
20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible
$25 Copayment $40 Copayment 20% Coinsurance, after deductible 20% Coinsurance, after deductible
Behavioral Health Inpatient Treatment/Residential Treatment Partial Hospitalization (Day) Program Outpatient Professional Provider Services
20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible
20% Coinsurance, after deductible 20% Coinsurance, after deductible $25 Copayment
Prescription Drug Benefit* Retail Pharmacy (up to a 34-day supply) Tier 1 Tier 2 Tier 3 Tier 4
Home Delivery Services-Mail Order (90-day supply) Diabetic Supplies
20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible 20% Coinsurance, after deductible
$10 Copayment $30 Copayment $45 Copayment $55 Copayment 2x Retail Copay 20% Coinsurance, no deductible
*You have a mandatory generic drug program. However, if there is no generic equivalent for the drug, you may get the brand and pay only the applicable benefit level. If there is a generic equivalent available, you may opt to use the brand but you'll pay the applicable brand level plus the difference between the brand and generic allowable charge. ** This plan will waive the hospital Copayment if the member enrolls in the maternity management pre-natal program within the first trimester of pregnancy, has a dental cleaning during pregnancy and satisfactorily completes the program.
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EMPLOYEE ASSISTANCE PROGRAM Provided by Anthem
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DENTAL INSURANCE Provided by Delta Dental – The Local Choice
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Dental Insurance Delta Dental – The Local Choice
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VISION INSURANCE Provided by Anthem – The Local Choice
Your routine vision benefit uses the Blue View Vision network – one of the largest vision care networks in the industry with a wide selection of ophthalmologists, optometrists and opticians. The network also includes convenient retail locations, many with evening and weekend hours, including 1-800 CONTACTS, LensCrafters®, Sears OpticalSM, Target Optical®, and JCPenney® Optical.
Welcome to Blue View Vision! Good news - your vision plan is flexible and easy to use. This Benefit Summary outlines the basic components of your plan, including quick answers about what's covered, discounts, and much more.
Go to www.anthem.com/tlc to find a Blue View Vision provider near you You can choose to receive care outside of the Blue View Vision network. You simply get an allowance toward services and you pay the rest. Just pay in full at the time of service and then file a claim for reimbursement. In-network benefits and discounts will not apply. IN-NETWORK
OUT-OF-NETWORK
High Deductible Health Plan
$15 copayment
$50 allowance
Key Advantage 1000
$40 copayment
$50 allowance
$100 allowance then 20% off remaining balance
$80 allowance
BLUE VIEW VISION PLAN AT-A-GLANCE Routine Eye Exam (once per year)
Eyeglass frames Once per plan year you may select any eyeglass frame* and receive the following allowance toward the purchase price:
Standard Eyeglass Lenses Polycarb onate lenses included for children under 19 years old. Once per plan year you may receive any one of the following lens options: · Standard plastic single vision lenses (1 pair)
$20 copay; then covered in full
$50 allowance
· Standard plastic bifocal lenses (1 pair)
$20 copay; then covered in full
$75 allowance
· Standard plastic trifocal lenses (1 pair) Upgrade Eyeglass Lenses (available for additional cost)
$20 copay; then covered in full $100 allowance When receiving services from a Blue View Vision provider, you may choose to upgrade your new eyeglass lenses at a discounted cost. Eyeglass lenses copayment applies, plus the cost of the upgrade. Lens Options Member cost for upgrades
UV Coating
$15
Tint (Solid and Gradient)
$15
Standard Scratch-Resistance
$15
Standard Polycarbonate Standard Progressive (add-on to b ifocal)
$40
Standard Anti-Reflective Coating Other Add-ons and Services
$65 $45
Discounts on lens upgrades are not available out-of-network
20% off retail price
Contact lenses Prefer contact lenses over glasses? You may choose to receive contact lenses instead of eyeglasses and receive an allowance toward the cost of a supply of contact lenses once per plan year. $100 allowance then 15% off the · Elective Conventional Lenses** $80 allowance remaining balance $100 allowance (no additional · Elective Disposable Lenses** $80 allowance discount) · Non-Elective Contact Lenses** $250 allowance $80 allowance *Discount is not available on certain frame brands in which the manufacturer imposes a no discount policy. **Elective contact lenses are in lieu of eyeglass lenses. Non-elective lenses are medically necessary when glasses are not an option for visio correction such as after cataract surgery.
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Vision Insurance Anthem Blue View Vision – The Local Choice
ROUTINE VISION CARE SERVICES (continued) BLUE VIEW VISION PLAN AT-A-GLANCE
IN-NETWORK
OUT-OF-NETWORK
Contact lens fitting and follow up A contact lens fitting and up to two follow-up visits are available to you once a comprehensive eye exam has been completed. Standard contact fitting
You pay up to $55
Discount not available
A standard contact lens fitting includes spherical clear contact lenses for conventional wear and planned replacement. Examples include but are not limited to disposable and frequent replacement.
Premium contact lens fitting
10% off retail price
Discount not available
A premium contact lens fitting includes all lens designs, materials and speciality fittings other than standard contact lenses. Examples include but are not limited to toric and multifocal.
Additional Savings on Eyewear & Assessories After you use your initial frame or contact lens benefit allowance, you can take advantage of discounts on additional prescription eyeglasses, contact lenses, and eyewear accessories courtesy of Blue View Vision network providers. Member Discounts
Additional Pairs of Complete Eyeglasses (as many pairs as you like)
Conventional Contact Lenses (Materials Only)
LASIK VISION CORRECTION
40% discount off retail
Glasses or contacts may not be the answer for everyone. That’s why we offer further savings with discounts on refractive surgery. Pay a discounted amount per eye for LASIK Vision correction. For more information, go to www.anthem.com/tlc and select Discounts under the Health and Wellness tab.
15% off retail price
NON-ROUTINE VISION SERVICES
Additional Eyewear & Accessories Includes eyeglass frames and eyeglass lenses purchased separately, some non-prescription sunglasses, eye glasses cases, lens cleaning supplies, contact lens solutions, etc.
20% off retail price
The additional savings program is subject to change without notice
The Blue View Vision Network is for routine eye care only. Non-routine vision care is covered under your medical benefits. Refer to your COVA Care member handbook for more information.
If you choose an out-of-network provider, you must complete the Blue View out-of-network claim form and submit it with your receipt. You will be reimbursed according to the out-of-network reimbursement schedule. Go to www.anthem.com/tlc and select Forms under the Resources & Tools tab. Your out-of-pocket expenses related to the vision benefits do not count toward your annual out of pocket limit and are never waived, even if your annual out-of-pocket limit is reached.
Questions? Contact Anthem member services at 1-800-552-2682
This benefit overview insert is only one piec of your entire enrollment package. Exclusions and limitations are listed in the enrollment brochure. The in-network providers referred to in this communication are independently contracted providers who exercise independent professional judgement. They are not agents or employees of Anthem. Anthem Blue Cross and Blue Shield is the trade name of Antehm Health Plans of Virginia, Inc. An independent licensee of the Blue Cross and Blue Shield Association. *Registered marks Blue Cross and Blue Shield Association. Blue View Vision is a service mark of the Blue Cross Blue Shield Association.
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HALIFAX COUNTY PUBLIC SCHOOLS THE LOCAL CHOICE BENEFITS CONTRIBUTION SCHEDULE Halifax County Public Schools July 1, 2019 - June 30, 2020 Employee Monthly Rates The Local Choice Package includes health, dental, and vision coverage High Deductible Health Plan (HDHP) Employee Only
Employee + Child
Employee + Children
Employee + Spouse
Employee + Family
Employee + Family x 2
$0.00
$320.00
$466.00
$345.00
$691.00
$288.00
Key Advantage 1000 Employee Only
Employee + Child
Employee + Children
Employee + Spouse
Employee + Family
Employee + Family x 2
$62.00
$411.00
$583.00
$513.00
$966.00
$411.00
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HEALTH SAVINGS ACCOUNT
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Health Savings Account
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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.
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Medical Bridge Benefit Plan 2
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Medical Bridge Benefit Plan 2
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Medical Bridge Indemnity Benefit Plan 3
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Medical Bridge Indemnity Benefit Plan 3
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Medical Bridge Indemnity Benefit Health Screening
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Medical Bridge Indemnity Benefit Medical Treatment Package
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Medical Bridge Indemnity Benefit Optional Riders
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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.
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Disability Benefit
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Disability Benefit
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Disability Benefit
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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.
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Cancer Benefit
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Cancer Benefit
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Cancer Benefit
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Cancer Benefit Level 4 Benefits
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Cancer Benefit Level 4 Benefits
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Cancer Benefit Wellness Benefit
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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.
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Accident Benefit
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Accident Benefit
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Accident Benefit
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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.
GROUP CRITICAL CARE – PLAN 3 – SPECIFIED DISEASE
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Group Critical Care Benefit Plan 3 – Specified Disease
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Group Critical Care Benefit Health Screening Benefit
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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.
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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.
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Whole Life Insurance Long-Term Care Benefit Rider
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Whole Life Insurance Long-Term Care Benefit Rider
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DENTAL INSURANCE Provided by Delta
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Dental Insurance Low Plan
Delta Dental – Low Plan Employee Only Employee + Spouse Employee + Child(ren) Employee + Family
12 month $21.57 $46.56 $44.76 $76.81
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Dental Insurance High Plan
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Dental Insurance High Plan
Delta Dental – High Plan Employee Only Employee + Spouse Employee + Child(ren) Employee + Family
12 month $38.36 $82.78 $79.71 $138.84
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VISION INSURANCE Provided by EyeMed
EyeMed Vision
Employee Only Employee + One Employee + Family 48 | Halifax County Public Schools
12 month $7.05 $13.38 $19.65
Vision Insurance
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General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction You are receiving this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.” Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Mecklenburg County Public Schools, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice. Applicable documentation will be required i.e. court order, certificate of coverage etc.
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General Notice of COBRA Continuation Coverage Rights (continued)
How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov. Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan Contact Information (Health, Dental and Vision) Halifax County Public Schools Attn: Pat Wilmouth 1030 Mary Bethune Street, Suite 100 Halifax, VA 24558 Phone: 434-476-3143
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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)
52 | Halifax County Public Schools
_____________________________ (Signature of legal representative)
___________ (Date Signed)
Halifax County Public Schools | 53
54 | Halifax County Public Schools
CONTACT INFORMATION: HEALTH SAVINGS ACCOUNT – AMERIFLEX
THE LOCAL CHOICE (TLC) HEALTH, DENTAL & VISION
• Customer Service: 1-888-868-3539 • Website: www.myameriflex.com • Claims Mailing Address: P.O. Box 269009, Plano, TX 75026
Medical, Pharmacy, Vision/Hearing 1-800-552-2682 Behavioral Health and Employee Assistance Program (EAP) 1-855-223-9277 ID Card Order Line 1-866-587-6713
MANAGE YOUR ACCOUNT ONLINE OR DOWNLOAD THE MYAMERIFLEX MOBILE APP
• • • •
Check your Balance Submit a Claim Check Claim Status Mark Your Card Lost or Stolen
Coverage While Traveling (BlueCard Program) 1-800-810-2583 24/7 NurseLine 1-800-337-4770
EYEMED - VISION INSURANCE • Customer Service: 1-866-804-0982 • Website: www.eyemed.com
Delta Dental 1-888-335-8296
DELTA - DENTAL INSURANCE
Website: www.thelocalchoice.virginia.gov www.anthem.com/TLC
• Customer Service: 1-800-237-6060 • Website: www.deltadentalVA.com
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.
TO VIEW YOUR BENEFITS ONLINE Visit www.piercegroupbenefits.com/
halifaxcountypublicschools
For additional information concerning plans offered to employees of Halifax County Public Schools, please contact our Pierce Group Benefits Service Center at 1-800-387-5955