Benefit Enrollment 2015 Printer Friendly Version
Avera Benefits Center
Open Enrollment
Open Enrollment is November 3, 2014 through November 21, 2014.
Benefit Details
Here is the list of specific benefit, which is followed by details, associated forms and more.
Health Insurance
Dental Insurance
Life Insurance
Leave of Absence (FMLA)
Long-Term Disability
Long Term Care Insurance
Voluntary Benefits
Avera Employee Assistance Program (EAP)
College Access 529 Plan
________________________________________
Helpful Benefits Information
Vendor-Contact-List
Dependents Benefits Eligibility January 2015
Health Insurance
Eligibility
You are eligible for health insurance the first of the month following 30 days of employment.
Enrollment
If you decide not to enroll in the Avera Employee Health Insurance Plan during the first 30 days of your benefits eligibility, you will not be able to enroll until open enrollment or within 30 days following a qualifying event. Every fall during open enrollment, benefits-eligible employees are allowed to make changes to their benefit plans. You can add members, remove members, enroll or terminate your coverage. Changes go into effect Jan. 1 of the following year. Contact the Human Resources Department for details.
To Enroll:
1. Complete and sign an enrollment application, requesting coverage for you and any eligible dependents.
2. Provide all information needed to determine your eligibility and the eligibility of any dependents, such as a Certificate of Creditable Coverage, in the case of a loss of other coverage.
Avera Health Plan Enrollment form
Shortly after you submit an enrollment application, you will receive an identification (ID) card from Avera Health Plans for yourself and each covered dependent. Each ID card lists your plan, your name (or name of the dependent) and co-payments for office visits, other services and prescription drugs. View the Member Handbook
Health Insurance Marketplace
As your employer, we offer affordable group health insurance to our employees. Health Care Reform has created Heath Insurance Marketplace for individuals to shop and compare coverage options and prices. Visit http://www.healthcare.gov to find more information about the Marketplace.
When you use the Health Insurance Marketplace, you will fill out an application and see all the health plans available in your area. You’ll provide some information about your household size and income to find out if you can get lower costs on your monthly premiums for private insurance plans. You can learn if you qualify for lower out-of-pocket costs. The Marketplace also will tell you if you qualify for free or low-cost coverage available through Medicaid or the Children’s Health Insurance Program.
Avera-Health-Employee-Health-Plan-SBC-2015
Dependents-Benefits-Eligibility-January-2015
Qualifying Events
Although you must enroll during the first 30 days of benefits eligibility, you can change your coverage during the year if you have a qualifying event. The changes you may make depend on the type of qualifying event that occurs. A qualifying event can be:
• Marriage, divorce, legal separation
• Birth of a child, adoption, placement for adoption
• Loss of other coverage
• New eligibility for other coverage
If you experience a qualifying event, you must notify the Human Resources Department within 30 days following the event.
Health Insurance change form:
Complete this form when you have a name change, address change, adding a newborn or newly adopted dependent(s), terminating your coverage or terminating coverage on a covered dependent. Please remember, if you are dropping coverage on your spouse, both you and your spouse must sign and date the Health Insurance Change Form.
Health Insurance Enrollment form:
Complete this form when enrolling in coverage for yourself and/or family members (except when adding a newborn or newly adopted dependent(s).
Premiums
Monthly premiums are deducted pre-tax from your payroll check unless you specifically notify the Human Resources Department to do otherwise.
Avera Employee Health Insurance Plan monthly premiums are shared by Avera and the employee. This amount is divided between the first and second pay periods of each month. In months with three payroll checks, the amount is not deducted from the third payroll check.
This group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of the preventative health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at 605-322-4500 605-322-4500.
Continuation of Coverage (COBRA)
If you are covered by the Avera Employee Health Insurance Plan, you have the right to continue coverage if the loss in coverage is because of a reduction in hours or termination of employment. Continuation also is available to your covered spouse and dependents for a variety of reasons. Under the law, you or your affected family member has the responsibility to inform Avera of a divorce, legal separation or a child’s loss of dependent status.
Dependent Coverage
Dependents (children) are eligible for coverage up to the end of the calendar month upon reaching age 26.
Eligible Dependent Out-of-Area Resident
If you have a dependent who lives outside our service area or is attending an out-of-area college or school, your dependent has access to in-network benefits through a broader local and regional network of participating providers. All covered services must be obtained from a participating provider in order to receive in-network benefits. To qualify:
• Your dependent must be eligible and enrolled in the Avera Employee Health Insurance Plan.
• Your dependent must reside outside the Avera Health Plans service area for more than 90 consecutive days.
• You will need to complete and return an eligible dependent out-of-area resident form. Out-of-Area Residence Dependents Registration Form. In-network benefits will be effective on the date the notice is received.
Avera Health Plans Service Area
Avera Health Plans has more than 90 hospitals and more than 3,600 physicians and licensed practitioners in our regional network, which includes more than 700 physicians providing primary care services.
Need to find a provider or a hospital?
We make it easy for you to locate a participating doctor, hospital or provider in the Avera Health Plans network.
1. Go to www.AveraHealthPlans.com
2. Click on “Member Login” in the upper right hand corner of the page
3. Enter your username and password
4. Click on “My Provider Directory”
5. At the Provider Directory Search screen, begin your search by entering all or part of the name or selecting from a list of provider specialties, cities or states.
Case Management
Avera Health Plans case management nurses can be your personal contact when you need help the most.
Out-of-Pocket Medical Expense Assistance
If you are a non-union benefits-eligible employee and have an unforeseen, unique or catastrophic financial situation, you can apply for assistance to help cover your deductible and out-of-pocket expenses under the Out-of-Pocket Medical Expense Assistance Policy.
If you experience an unforeseen, unique or catastrophic financial situation, you are eligible to apply for an award of up to $1,200 to help cover out-of-pocket medical expenses. The dollars that are awarded are to be used to help cover your or your covered dependent’s deductible and out-of-pocket expenses. To be eligible to receive this award, you or your dependents must be covered under the Avera Employee Health Insurance Plan. To apply, please submit in writing an explanation stating why you feel you would qualify for this award and provide documentation of medical bills. If your request is approved, payment will be made directly to the provider. Submit your request to the Human Resources Department.
Medical Plan Premium-Assistance Program
You are eligible to apply for a discount on the cost of your Avera Employee Health Insurance Plan premium if:
• You are a regular full-time or regular part-time employee
• You meet requirements based on your total household income and the size of your family
• If you are a non-union benefits-eligible employee and meet certain income guidelines, you can apply for a discount on your portion of the monthly health care premium.
Avera uses 200 percent of the United States Department of Health and Human Services (HHS) income guidelines for the previous year. Your adjusted gross income must be at or below the guidelines listed below.
Family Size Maximum Annual Income
1 $23,340
2 $31,460
3 $39,580
4 $47,700
5 $55,820
6 $63,940
7 $72,060
8 $80,180
If you or your family is eligible for a state-sponsored health care program, you are not eligible for the Medical Plan Premium-Assistance Program.
You may apply for the discount within 30 days of your date of hire for the current calendar year. You also may apply within 30 days following a qualifying event. If you do not apply within the 30-day time period, you can apply between Jan. 1 and April 30 of the following year for a discount effective May 1 of that year. Applications received outside of the time frames described here will not be accepted.
Once approved, the assistance will continue through April 30 of the next year. You must reapply each year. Applications and the complete policy details for the discount program are available in the Human Resources Department.
To Your Health, an Employee Wellness Program
Avera’s desire is to improve the health of our employees by offering a wellness program that:
• Empowers employess and family members to proactively take charge of their health
• Improves productivity and morale
• Establishes Avera as a company with a culture of health
• Reduces health care costs
Visit www.avera.org/employeewellness to learn more about Avera’s Employee Wellness Program.
Deductible Carryover
Any portion of the deductibles you pay during the fourth quarter (October through December) will apply to your deductible for the following year. This transfer of deductibles applies to the in-network deductible only, not to the out-of-network deductibles. For example, if you incur $100 in expenses in November from an in-network provider, this $100 will apply toward your deductible for the next year.
Hospitalization Discount
When you or your dependent is treated at an Avera-sponsored* acute care facility, the facility will credit 20 percent of any unpaid charges up to a maximum of $550 per insurance claim. It is your responsibility to apply for the benefit; it is not automatic. To apply, contact the business office of the facility providing services. You have up to 90 days from the date of the Explanation of Benefits (the statement you receive from the insurance company after services are provided). After the 90-day period has lapsed, no discount will be provided. This benefit applies to all Avera employees and their dependents, whether they are covered under the Avera Employee Health Insurance Plan or another health insurance carrier.
Avera St. Luke’s, Avera Holy Family Health, Avera Marshall, Avera Queen of Peace, Avera St. Anthony’s, Avera St. Benedict, Avera McKennan and Avera Sacred Heart. This also may include other facilities that choose to participate. Ask at the time of service.
Prescription Drug Coverage
Pharmacy Benefit Manager
The Avera Employee Health Insurance Plan provides Prescription Drug Coverage through a pharmacy benefit manager. A pharmacy benefit manager contracts with pharmacies throughout the country to provide prescription services to the members. Avera Health Plans and the pharmacy benefit manager work together to improve the health of members and reduce the cost of pharmacy benefit programs. All prescription drugs must be purchased from a pharmacy that accepts Innoviant. There is no coverage outside the Innoviant network. Generic drugs are paid with a co-payment. A $100 deductible first applies to formulary and non-formulary prescription drugs. A co-payment will apply once the deductible has been met.
Drug Formulary
• You pay the least for generic drugs.
• You pay more for a brand-name drug that is on the drug formulary list.
• You pay the most for a brand-name drug that is not on the drug formulary list.
Prescription Drugs In-Network Out-of-Network
Choice In-Network Out-of-Network__
30 Day Supply $12 co-payment generic drugs No Coverage
___________________________________________________________________________
A $100 deductible per member applies to formulary and non-formulary prescription drugs.
___________________________________________________________________________
30 Day Supply $35 co-payment formulary drugs No Coverage
$60 co-payment non-formulary drug
(after deductable)
___________________________________________________________________________
Vision Coverage
The Avera Employee Health Insurance Plan offers Vision Coverage through Vision Services Plan (VSP). To find a participating provider Contact VSP (800) 877-7195 (800) 877-7195 or visit www.VSP.com.
Vision Services
All vision services must be received by providers who accept VSP coverage or are in the provider directory. All Avera Employee Health Insurance Plan members are eligible for one free eye exam every 12 months for eyeglasses, or for a contact lens fitting and exam, up to the value of an eyeglasses exam. Participants receive up to a 20-percent discount on lenses and frames when a complete pair of glasses is purchased and up to a 15-percent discount on a contact lens fitting and evaluation exam. Contact your provider for exact discount amounts, as they vary by provider.
Have a question about your health benefits?
Health Insurance FAQs
Email the Avera benefits team: benefits@avera.org
Contact Avera Health Plans
3816 S Elmwood Ave, Suite 100 Sioux Falls, SD 57105-6538
605-322-4545 605-322-4545 or 888-322-2115 888-322-2115
www.AveraHealthPlans.com
Dental Insurance
Eligibility
You are eligible for dental insurance the first of the month following 30 days of employment.
If a subscriber or eligible dependent is covered for dental benefits or services by another dental contract (other than Delta Dental) or insurance policy, Delta’s liability for payment will be determined by established criteria available by contacting Delta Dental. Coordination of benefits provides maximum coverage, but is not to exceed 100 percent of the total fee for a given treatment plan.
Enrollment
Complete an enrollment application and submit it to the Human Resources Department.
2015Delta Dental Summary of coverage form
Delta Dental Enrollmentapplication/change form
Delta Dental cancellation form
Change of Coverage
The plan you choose is effective for the plan year, which is Jan. 1 to Dec. 31. You can make changes to your coverage during the year only if you experience a qualifying event. If you experience a qualifying event that causes you to lose coverage, you can enroll in the plan the first of the month following your loss of coverage. You can change from a family plan to a single plan. However, you cannot cancel a single dental plan until open enrollment, with an effective date of Jan. 1.
Delta Dental Enrollmentapplication/change form
Deductible
$25 individual/$75 family per calendar year (waived for diagnostic, preventative and orthodontic services)
Preventative and Diagnostic Services
100-percent coverage:
• Examination: two per calendar year
• Diagnostic X-rays: bitewings, two per calendar year for children up to age 19 and one per calendar year for adults age 19 and over
• Prophylaxis (cleaning): two per calendar year
• Topical fluoride: two per calendar year to age 19
• Space maintainers, fixed (band type)
• Dental sealants: for un-restored first and second permanent molars of children up to their 16th birthday
Ancillary Services
80-Percent coverage after deductible:
• Emergency treatment
• Oral surgery
• Regular restorative services
• Endodontic services (root canal treatment)
• Periodontal services
50-Percent Coverage After Deductible:
• Crowns
• Gold restorations
• Implants
• Prosthetic services
• Orthodontics: 50 percent up to $1,500 lifetime maximum
Calendar Year Maximum Benefit
$1,500 per individual (all services combined except orthodontics).
Exclusions
• Services for injuries or conditions that are compensable under Workers’ Compensation
• Services performed for purely cosmetic purposes or to correct congenital conditions other than by orthodontic care
• Charges for specific procedures undertaken prior to the date the person became covered under this program
• Loss or theft of prosthetic appliance
• Services with respect to any disturbances of the temporomandibular joints (jaw joints)
• Claims submitted more than six months after the date of service
• Procedures, appliances or restorations that are necessary to alter, restore or maintain occlusion, including but not limited to: increasing vertical dimension, replacing or stabilizing tooth structure lost by attrition, realignment of teeth, periodontal splinting and gnathalogic recordings
Limitations
• Dental sealants are covered only for unrestored first and second permanent molars of children up to age 16.
• Crowns, jackets and gold or cast restorations will be replaced only after five years have elapsed following any prior provisions of the dental procedure.
• Prosthodontic appliances will be replaced only after five years have elapsed following any prior installation of such appliances, except when Delta Dental determines there is such extensive loss of remaining teeth or change in supporting tissues that the existing appliance cannot be made satisfactory.
• If you select a more expensive plan of treatment than is customarily provided, Delta Dental will pay the applicable percentage of the lesser fee, and you are responsible for the remainder.
Dependent Coverage:
Dependents are eligible for coverage if they are unmarried and under age 19, or age up to 25 if they are unmarried and a full-time students at an accredited institution. Please notify Human Resources if your dependent loses eligibility and needs to be removed from your plan.
Continuation of Coverage (COBRA)
If you are covered by Dental Insurance through Avera, you have the right to continue coverage if the loss in coverage is because of a reduction in hours or termination of employment. Continuation also is available to your covered spouse and dependents for a variety of reasons. Under the law, you or your affected family member has the responsibility to inform Avera of a divorce, legal separation or a child’s loss of dependent status.
2015 Monthly Dental Premiums
Monthly Dental Premium
| Monthly Dental Premium |
Full Time | Part- Time |
| Total | Avera | Employee | Avera | Employee | |
| Single | $39.78 | $26.12 | $13.66 | $23.38 | $16.40 |
| Family | $104.00 | $64.56 | $39.44 | $56.66 | $47.34 |
Avera Marshall Contract Staff: Please contact your local Human Resources office for your 2015 Health and Dental premiums.
Maximum Bonus Account
If you pay attention to your oral health, with an emphasis on diagnostic, preventive and restorative procedures, you may leave unused benefits behind. With Delta Dental of South Dakota’s Maximum Bonus Account (MBA), $250 of your unused benefits may be placed in a special MBA account and can be carried over and added to the benefits available in future years. This option offers you new flexibility and helps if you need more extensive and costly dental treatment later.
You are eligible if:
• You have been covered under the plan for at least one full benefit year
• You have submitted at least one claim for a covered service during the benefit year
• The total cost of the claims applied to your annual maximum are less than half your annual maximum
The total amount available in your account can grow to an amount equal to your annual maximum, and each covered family member has his or her own account. MBA does not apply to orthodontic benefits. Call 800-627-3961 800-627-3961 to request a balance statement.
Smile Smart
Delta Dental of South Dakota’s Smile Smart program includes coverage for dental implants and enhanced care for members who are diabetic; who have a high-risk cardiac condition; with kidney failure or who are undergoing dialysis; who are undergoing cancer-related chemotherapy and/or radiation; with suppressed immune systems due to organ transplant, stem-cell transplants or with HIV-positive status; who have a high risk for oral cancer; who are pregnant women; and who have received periodontal surgery or have bone loss. The only documentation required is a notation on the claim form from your dentist about your health condition.
Lost Card?
If you are in need of a new insurance card, please contact Delta Dental for a replacement.
Contact Information:
Delta Dental of South Dakota
PO Box 1157
Pierre, SD 57501
1-800-627-3961 1-800-627-3961
http://www.deltadentalsd.com
Life Insurance
Avera offers Life Insurance through Voya Financial and issued by ReliaStar Life Insurance Company.
Contact Human Resources to:
• Purchase supplemental term life on yourself, spouse or eligible dependent children or to increase or decrease the amount of supplemental term life insurance on yourself, spouse or eligible dependent children.
• Cancel elected coverage on yourself, spouse or dependent children.
View Life Insurance Plan Summary document
Eligibility
You are eligible for life insurance the first of the month following 30 days of employment.
Enrollment
Enrollment is automatic. Complete a beneficiary enrollment form and submit it to the Human Resources Department.
Beneficiary
You may designate whomever you choose as your Life Insurance beneficiary. You also may list secondary beneficiaries. You may change your beneficiary information at any time. Contact the Human Resources Department to make this change.
Access the form Voya Life Insurance Beneficiary designation form.
Basic Group Term Life Insurance
Employees receive Basic Group Term Life Insurance coverage equivalent to two times (2x) your annual base salary rounded to the next highest $1,000 multiple, not to exceed $1,400,000.
Group Accidental Death and Dismemberment (AD&D)
Employees who, while insured, suffer bodily injury in an accident that results in loss of life, loss of foot, loss of hand or loss of eye will receive a benefit. The benefit for loss of life is two times (2x) your annual base salary rounded to the next highest $1,000 multiple, not to exceed $1,400,000.
Supplemental Term Life Insurance
New employees can enroll in this benefit on a guaranteed-issue basis (no medical questions required) during the first 30 days of hire or benefits eligibility. Premiums are based on your plan selection and are deducted from your payroll check. You can purchase Supplemental Term Life and AD&D Insurance coverage for yourself, your spouse and your dependents.
• Employee coverage: may elect coverage in $10,000 increments, not to exceed five times (5x) annual base salary or $1,000,000, whichever is less, rounded to the next highest $1,000. Employees are a guaranteed issue from $10,000 to a maximum of $250,000 or not to exceed five times (5x) annual base salary, whichever is less.
• Spouse Coverage: may elect spouse coverage in increments of $5,000 to $250,000. Spouse is guarantee issue for $25,000.
• Dependent Child(ren): may elect $1,000 for children from live birth to six months and $10,000 for children from six months to age 26.
Living Benefit Option
The Living Benefit feature lets you or your spouse receive a portion of the life insurance benefit if you or your spouse is terminally ill. You or your spouse may receive up to 50 percent of the Basic Group Term Life and Supplemental Term Life Insurance, not to exceed $750,000. The remaining 50 percent will be paid out upon death.
Premiums
The cost of the Basic Group Term Life Insurance and AD&D is fully funded by Avera and sponsored by the Benedictine and Presentation Sisters.
If the imputed value of your Basic Group Term Life Insurance is greater than $50,000, the IRS requires that you be taxed on the residual amount above $50,000 of this benefit. Taxation normally occurs every pay period.
Waiver of Premium
If you become totally disabled while you are insured and you continue to be disabled through the waiting period, the carrier will waive the premiums for the policy from the start of the total disability. In order to be considered for a waiver of premium, the onset of total disability must have occurred before your 60th birthday. Please refer to the Life Insurance Summary Plan document for more details. This benefit is not available on spouse coverage.
You may be eligible to continue your Basic and Supplemental Life Insurance after you leave employment. Please contact your Human Resources Department for information on portability and/or conversion options.
Long Term Disability
Insurance
Avera offers Long-Term-Disability Insurance through UNUM Life Insurance Company of America.
Eligibility
You are eligible for long-term-disability insurance the first of the month following 30 days of employment.
Enrollment
Complete an enrollment application and submit it to the Human Resources Department. You have 30 days from your hire date or benefits-eligible date to enroll in Long-Term-Disability Insurance under guaranteed issue. You also can sign up for coverage at any point in time. However, you will have to go through medical underwriting, and UNUM reserves the right to deny coverage.
• View Long Term Disability Plan Summary Document
• Access a printable Long Term Disability claim form
Pre-Existing Conditions
If you suffer a disability caused by, contributed to by or resulting from a pre-existing condition and the disability begins in the first 12 months after the effective date, that disability is not covered by this policy.
Pre-existing-condition exclusions apply only to conditions for which medical advice, diagnosis, care or treatment (including medications) was recommended or received during the six months immediately preceding your effective date of coverage.
In most circumstances employees who lose coverage due to termination of employment have the option to convert from a group plan to an individual plan. Election must occur within 30 days of the date group coverage ends.
You may terminate coverage at any time if paid post-tax. Plans will be terminated at the end of the month in which notice is given. If paid pre-tax, coverage can be cancelled only during open enrollment.
Benefit Collection
Employees who become disabled are eligible to receive a monthly benefit based on 60 percent of their monthly earnings up to a maximum of $10,000 per month. Benefits begin after the 90th day of total disability. Payment continues for as long as you continue to meet the policy’s definition of disabled or until age 67.
You are considered disabled and eligible for benefits if because of sickness or injury:
• You are limited from performing the material and substantial duties of your regular occupation
• You have 20-percent-or-more loss in monthly earnings due to the same sickness or injury
You will continue to receive benefits if:
• After benefits have been paid for 36 months, you are working in an occupation and continue to have 20-percent-or-more loss in monthly earnings due to the same sickness or injury; or
• You are not working and, due to the same sickness or injury, are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience
Benefits will not be paid if disability is caused by, contributed to by or resulting from:
• Intentionally self-inflicted injuries
• Active participation in a riot
• War, declared or undeclared, or any act of war
• Conviction of a crime under state or federal law
• Loss of professional license, occupational license or certification
• Pre-existing conditions
Emergency Travel Assistance Program
UNUM’s Long-Term-Disability Insurance also offers a worldwide Emergency Travel Assistance Program that is provided by Assist America, Inc. This benefit assists you, your spouse and dependent children if traveling in a foreign country or 100 miles or more away from home.
Should you become ill or have an accident, you can access proper medical care anywhere in the world. Coverage includes medical consultation, evaluation, referrals and monitoring of the care you are receiving. If you need to be hospitalized and if it is determined that the care you are receiving is not adequate for the medical incident, you will be evacuated to the nearest facility that can provide appropriate care.
To learn more about the program, please visit www.Unum.com/TravelAssistance
Premiums
You will not pay premiums while you are receiving Long-Term-Disability Insurance benefits. Monthly premiums are based on your age and annual salary and are deducted from your payroll check. Premiums are locked in for the calendar year but are subject to change each January due to your increase in age and change in annual salary. Premium changes reflect the age you will be in that new year.
You have the option to pay premiums with post-tax or pre-tax dollars. If premiums are paid with post-tax dollars, any benefit received will not be taxed. If premiums are paid with pre-tax dollars, any benefits received will be taxed. To elect to pay Long-Term-Disability Insurance premiums with pre-tax dollars, you must complete a Flexible Spending Program form.
Contact the Human Resources Department to:
• Apply for coverage
• Get answers to coverage and eligibility questions
• Cancel your coverage
UNUMLife Insurance Company of America
(800) 633-7479 (800) 633-7479
www.Unum.com
Long-Term Care Insurance
Avera offers Long-Term-Care Insurance through UNUM Life Insurance Company of America.
Eligibility
You are eligible for long-term-care insurance the first of the month following 30 days of employment.
Enrollment
Complete an enrollment application and submit it to the Human Resources Department. You have 30 days from your hire date or benefits-eligible date to enroll in Long-Term-Care Insurance under guaranteed issue. You also can sign up for coverage at anytime. However, you will have to go through medical underwriting, and UNUM reserves the right to deny coverage.
Long-Term-Care Insurance also can be purchased for your spouse, parents, parents-in-law, grandparents and grandparents-in-law. Medical underwriting is always necessary for your spouse, parents, parents-in-law, grandparents and grandparents-in-law.
Pre-Existing Conditions
Pre-existing condition means any condition that exists for which you received medical treatment, consultation, care or services, including diagnostic measures for the condition, or took drugs or medicines that were prescribed for the condition, during the six-month period right before your coverage began. UNUM will not make any payments to you for a disability caused by, contributed to by or resulting from a pre-existing condition, and that begins during the first six months after your coverage begins.
Plan Options
Participants need to choose from the following options:
| 1. Length of receipt of benefit (choose 1): • 3 years • 6 years |
• Unlimited duration* 2. Monthly amount received (choose 1): • $1,000 • $2,000 • $3,000 • $4,000 • $5,000* • $6,000* |
*requires medical underwriting
3. Plan level of care (choose 1):
| Plan 1 • Long Term Care Facility • Professional Home Care |
Plan 2 • Long Term Care Facility • Professional Home Care • Total Home Care |
| Plan 3 • Long Term Care Facility • Professional Home Care • Simple Inflation |
Plan 4 • Long Term Care Facility • Professional Home Care • Total Home Care • Simple Inflation |
Benefits are paid when you or your covered member loses the ability to perform at least two activities of daily living. Activities of daily living include bathing, toileting, dressing, eating and transferring. Losses due to severe cognitive impairment also are covered by the plan. A physician must certify that you or the covered member is unable to perform two or more activities of daily living for a period of 90 days.
Benefits will not be paid if disability is caused by, contributed to by or resulting from:
• War, attempted suicide (while sane or insane) or self-destruction
• A committed or attempted crime
• Alcoholism or voluntary use of a controlled substance
• Psychological or psychiatric conditions
• Pre-existing conditions
This list is not all-inclusive. Please refer to the plan document for additional information.
Premiums
Monthly premiums are determined by your age at the time of enrollment and the plan design options you choose. Rates will not increase as you grow older or because you use the benefits. Premiums are deducted from your payroll check.
Contact the Human Resources Department to:
• Apply for coverage
• Get answers to coverage and eligibility questions
• Check the status of your application
• Cancel your coverage
UNUM Life Insurance Company of America
(800) 227-4165 (800) 227-4165
www.Unum.com
Voluntary Benefits
Enrollment
Enrollment for these Voya products is online through the EZ navigator site https://www.employeenavigator.com/benefits/Login.aspx
For questions on the Voya voluntary products, please contact your local Human Resources Department.
Note: Voluntary benefits can be cancelled only during open enrollment.
These plans are offered separately and are designed to supplement your major medical plan.
Group Critical-Illness with Cancer Insurance
Voya offers these voluntary benefits. You will be able to purchase group critical illness up to $30,000 for yourself, up to $20,000 for your spouse and up to $10,000 for dependent children.
Wellness Benefit
Voya will pay a $100 wellness benefit for you and your covered spouse if the qualified test is performed while coverage is in force. Covered dependent children are eligible for a $50 wellness benefit. If you have the employer paid Wellness Reward $2,000 CI/C policy, only one wellness benefit will be paid out per participant per calendar year.
How to Apply for the $100 Wellness Payment Critical Illness with Cancer Plan
Employees who have coverage can submit a claim form after completion of the wellness activity. These forms are available on the Employee Navigator website or you to retrieve. Voya will review submitted documentation. If approved, they will process the documentation and send the wellness benefit.
Accident Insurance
This plan helps pay unexpected medical expenses from lacerations, fractures and other covered accidental injuries. You may use the benefits to help pay for expenses such as deductibles and co-payments.
How to Apply for the $50 Wellness Payment (Accident Plan)
The covered employee will receive a single standard annual benefit of $50 for each covered employee and spouse who completes a health screening test. The standard annual per-child benefits is 50% of the employee benefit amount with a maximum of $100 in child benefits payable per calendar year.
Premiums
Monthly premiums are based on plan selection, coverage level, coverage type and age, and are deducted from your payroll check. Premiums for these voluntary products are after tax.
College Access 529 Plan
The College Access 529 Plan is a college investment plan sponsored by the State of South Dakota and managed by Allianz Global Investors LLC. The plan allows your money to grow free from federal income tax through a variety of portfolios that invest in mutual funds from several highly regarded fund families. This program is designed to help you save for college-related expenses. Qualified expenses include tuition and fees, room and board, books and other supplies. It can be used for your children, grandchildren, nieces, nephews, yourself, spouse and others as defined by the plan. You can choose to enroll at any time. There is a minimum monthly contribution of $50 per designated beneficiary. For example, if you have two children you would like to start contributing for, your minimum monthly contribution would be $100 (split into the first two checks of every month).
Contact your local Human Resources Department for:
• An enrollment packet
• To change your payroll deferral amount or to stop your contribution
For specific questions, contact a College Access 529 Plan Investor Services Representative, Monday through Friday, 7:00am to 7:00pm Central Time, at 1-866-529-7462 1-866-529-7462
TAKE ACTION on the
To Your Health website
Set up your account on the new To Your Health website if you have not already. Go to Avera.org/EmployeeWellness to get started!
Make sure to:
• Schedule a health screening
• Complete a health assessment
• Learn about the 2015 reward
