28
To Learn More, visit MySCOBenefits.com
To Learn More, visit MySCOBenefits.com
To Learn More, visit MySCOBenefits.com 2
Introduction ...........................................................................3 Eligibility - Who is Eligible? .................................................4 Family Status Changes ........................................................5 MySCOBenefits.com .............................................................6 Medical Plan .........................................................................7-9 Dental Plan ............................................................................10 Flexible Spending Accounts ................................................11 Supplemental Plans ...........................................................12 Critical Illness Plan .............................................................13 Accident Plan ........................................................................14 Term Life, Voluntary Life, Dependent Life Plans ................15-16 Universal Life Plans ............................................................17 Disability Coverage Plans ....................................................18 Legal Notices .........................................................................19-25 Rates…………………………...…………………………………..26-27
Every reasonable effort has been made for the information provided in this booklet to be accurate. It is intended to provide the employees
with Southern College of Optometry an overview of the coverages offered. It is in no way a guarantee or offer of coverage. Each carrier
has the ability to underwrite based on its contract with Southern College of Optometry or its employees. Each carrier’s contract,
underwriting, and policies will supersede this document. Please be aware that each carrier may have exclusions or limitations and you
must consult your summary plan description and/or policies for details.
Look for the Different Colors at
the top of each page to Designate
the Section you are Viewing TA
BL
E O
F C
ON
TE
NT
S
UNITED HEALTHCARE Customer Service …………… 800-345-1520
UNITED HEALTHCARE DENTAL Customer Service .... 800-335-8266
MUTUAL OF OMAHA (to file a life claim) ........................ 800-775-8805
MUTUAL OF OMAHA (to file a disability claim) ............... 800-877-5176
CORPORATE PLANNING NETWORK ............................ 800-737-0125
ALLSTATE BENEFITS Customer Service ..................... 800-521-3535
ENROLLMENT ASSISTANCE (BenefitHelp).................. 888-663-1285, Option 2
WHO TO CONTACT
To Learn More, visit MySCOBenefits.com 3
Your Southern College of Optometry
Benefits Package
The Southern College of Optometry takes pride in providing our employees with one of the most competitive, affordable benefit packages in the industry. Employees enjoy favorable purchasing power due to negotiated discounts as well as a company contribution towards your healthcare coverage. In addition, our Cafeteria Plan allows our employees to pay for certain benefit plans with pre-tax dollars.
All of our benefit programs are designed to work cohesively to protect you and your family from catastrophic losses. Keeping our annual healthcare increases year-over-year to a minimum takes a joint effort. We depend on our employees to become educated healthcare consumers and to spend your health care dollars wisely. Visit your primary care physician annually and take advantage of the ‘no cost to you’ preventive screenings included in all of our medical plan options. When medical tests or surgical procedures are recommended, use United Healthcare’s on-line quality and cost compari-son tools. This will reduce your out-of-pocket expenses and helps manage the cost to the plan.
Faculty and Staff have an annual opportunity to review benefit option selections and make changes to plan selections. The annual open enrollment period takes place during the month of August for a September 1st effective date.
Your Benefit Options…
Medical Plan: Choose from 3 different PPO plans.
Dental Plan: Plan covers routine annual cleanings and x-rays at no cost to you.
Flexible Spending Accounts - Both Health Care and Dependent Care.
Critical Illness Plan - What can living with a Critical Illness mean to you?
Accident Plan - Protected from life accidents?
Term Life Insurance - For you and your dependents. Take care of those you love.
Universal Life Insurance - Life Insurance that builds cash value.
Short Term Disability Coverage - Protect your paycheck.
Long Term Disability Coverage - When savings aren’t always enough.
To Learn More, visit MySCOBenefits.com 4
ELIGIBILITY - Who is Eligible?
When am I Eligible for Benefits?
Faculty and Staff working .75 FTE are eligible for benefits based upon the below
schedule.
When does my coverage begin
as a new full-time employee?
Benefit Eligible Employee Waiting Periods: Medical and Dental – Effective the first day of the
month following with your date of hire.
Life and Long Term Disability – 1st of month following 1 year of employment.
Short Term Disability – 1st of the month following 60 days of employment.
Ancillary Plans — 1st of month following your date of hire.
Special Eligibility — if you become disabled as defined by the college’s LTD policy or employees
who retire on or after their 55th birthday are eligible to continue on the group plan one year for each
year of service until they reach age 65 or become eligible for Medicare. Coverage is at the
employee’s expense at the same rate as all other employees. Also, spouses up to age 65 or when
eligible for Medicare and dependent children who were enrolled in the plan on the day before the em-
ployee gave notice of retirement or disability are eligible to continue on the plan.
To Learn More, visit MySCOBenefits.com 5
FAMILY STATUS CHANGES
Life Event Supporting Documentation Marriage
Copy of Marriage Certificate Note: Coverage for new dependent(s) is effective the date of marriage.
Divorce
Copy of Section of Divorce Decree indicating names and date of Final Judgment
Note: A change in enrollment is effective at the end of the month in which the divorce occurred, or the date immediately following loss of other cover-age.
Birth/Adoption/Legal Guardianship of Child Birth Certificate or Hospital discharge paperwork, Note: Coverage for new dependent(s) is effective the date of birth or date of adoption.
For Adoption - court documents showing effective custody date
Loss of Legal Guardianship Court documents indicating name(s) and effective date of the status change
Gain Eligible Tax-Dependent Grandchild Tax-Qualified Dependent Grandchild Affidavit
Dependent Child Reached age 26
No employee action required for supporting documents
Note: Eligibility for change in enrollment varies by circumstance, but no break in coverage is permitted if other insurance coverage was previously in effect. If you have other dependents, you will not be able to cancel their coverage due to this status change.
Death of Dependent Copy of Death Certificate
Note: Coverage continues through the date of death.
Gain or Loss of Coverage Thru Spouse's Employer (Commencement or termination of employment or eligibility)
Letter from employer or carrier(s) listing name of individual(s) affected, type of coverage(s) gained or lost and the effective
date(s) of coverage or termination Note: Eligibility for change in enrollment varies by circumstance, but no break in coverage is permitted if other insurance coverage was previously in effect. If you have other dependents, you will not be able to cancel their coverage due to this status change.
Qualified Medical Child Support Order (QMSCO) Copy of signed QMSCO listing dependent's name and effective date
Gain or Loss of Medicaid Letter from program listing the name(s) of the person affected and the effective date
Conflicting Open Enrollment Period Letter from spouse's employer or a confirmation of benefits statement listing the dates of open enrollment period, type of coverage and the effective date and the individual(s) affected
Change in Employee’s Eligibility Status
No employee action required for supporting documents
Note: Eligibility for change in enrollment varies by circumstance, but no break in coverage is permitted if other insurance coverage was previously in effect. If you have other dependents, you will not be able to cancel their coverage due to this status change.
Employee's Commencement of, or Return from, Unpaid
Leave of Absence No employee action required for supporting documents
You are able to make changes to your plan elections during the year if you experience a qualified
family status change. If you experience such an event and want to make changes you must contact
the Human Resources Department within 31 days of the qualifying event. Please refer to the chart
below for the required supporting documentation.
To Learn More, visit MySCOBenefits.com 6
Have you ever had trouble locating information about your benefits? What about trying to remember how to find a participating doctor or dentist?
Problem Solved!
It’s All Online
MySCOBenefits.com
Watch Videos About Your Benefits Get Important Phone Numbers &
Search for a Doctor or Dentist Print Important Documents &
24 Hours a Day / 7 Days a Week Learn More About Your Benefits
To Learn More, visit MySCOBenefits.com 7
To fit your specific needs, your benefit package provides you with three options in medical plans. The plan with the lowest deductible has the highest payroll deduction. The plan with the highest deductible has the lowest payroll deduction. All three plans cover the same services, just with different copayments and deductibles that apply. It’s up to you to take advantage of everything your health plan offers. To choose the plan that is right for you ask yourself the questions that will help you assess your needs. Think about the ways you use healthcare, the medical needs you can foresee, and how you can balance cost and coverage.
Terms and Definitions
Deductible
This is the amount of money you pay for health services before your medical Insurance begins paying. For some services you have to pay the deductible before the plan pays. Your deductible starts over each January 1st.
Copay
This is the amount of money that you pay each time a particular service is utilized.
Coinsurance
This is the rate that you will essentially be splitting the cost of your healthcare with your insurance provider. For instance, if your health plan has an 80/20 coinsurance rate, your insurance plan pays for 80% of your eligible medical expenses and you’re responsible for the remaining 20%.
Out-of-pocket Coinsurance Maximum
This is the most you will have to pay under your medical plan each year. Includes copays, deductible & coinsurance. This protects you from the financial drain of high medical expenses. Copays do count towards your out-of-pocket maximum and still apply after you meet your maximum.
In-Network / Out-of-Network
If your medical plan has “in and out” coverage, this means you can see any provider you wish. However, if you choose to see a provider that is not on the approved in-network list, you will pay a greater share of the cost. Determining whether or not a provider is in-network is your responsibility. Please check with the provider to see if he or she is in the network. before services are rendered, preferably when making the appointment.
To locate a provider or to review the policy details,
please visit the medical tab on
www.MySCOBenefits.com
If you are a new employee and not registered on myUHC.com you will need to view the
general directory for participating providers.
UHC
MEDICAL OVERVIEW
MySCO
Benefits
To Learn More, visit MySCOBenefits.com 8
Pick the medical plan that best fits your needs...
MEDICAL PLANS
Rates
Page 26
Need HELP meeting your out of pocket expenses?
Find out how supplemental plans can help you on pages 14-16.
SOUTHERN COLLEGE OF OPTOMETRY MEDICAL PLANS (in network benefits)
PLATINUM GOLD BRONZE
Physician Office Visit $20 copay $ 20 copay $ 25 copay
Specialist Office Visit $40 copay $ 40 copay $ 50 copay
Wellness Benefit
(age appropriate screenings apply)
100% Coverage
(no copay, no annual
maximum if in-network)
100% Coverage
(no copay, no annual
maximum if in-network)
100% Coverage
(no copay, no annual
maximum if in-network)
Urgent Care Center $ 50 copay $ 75 copay $ 75 copay
Emergency Room Visit $ 250 copay $ 250 copay $ 250 copay
Inpatient Hospitalization $ 250 copay per
admission
80% coverage after
deductible
80% coverage after
deductible
Outpatient Hospitalization 100%
80% coverage after
deductible
80% coverage after
deductible
Annual Deductible $ 0 Single
$ 0 Family
$ 500 Single
$ 1,000 Family
$ 2,000 Single
$ 4,000 Family
Coinsurance 100% coverage after
copayments
80% coverage after
deductible
80% coverage after
deductible
Annual Out-of-Pocket Maximum
(includes copays, deductibles and
coinsurance)
$ 6,250 Single
$12,500 Family
$ 2,500 Single
$ 5,000 Family
$ 6,000 Single
$12,000 Family
To Learn More, visit MySCOBenefits.com 9
Drugs on the Drug List/Formulary are grouped by ‘tiers.’ A number of factors are considered when
classifying drugs into tiers, including, but not limited to: the absolute cost of the drug; the cost of the drug relative
to other drugs in the same therapeutic class; the availability of over-the-counter alternatives; and other clinical
and cost-effectiveness factors.
To View the Drug List, visit www.MySCOBenefits.com and select the three tier drug list located under the medical tab.
RETAIL PHARMACY
31 Day
Supply
PLATINUM &
GOLD Plans BRONZE Plan
Tier 1 $ 10 Copay $ 10 Copay
Tier 2 $ 30 Copay $ 35 Copay
Tier 3 $ 50 Copay $ 60 Copay
MAIL ORDER PHARMACY
90 Day
Supply
PLATINUM &
GOLD Plans BRONZE Plan
Tier 1 $ 20 Copay $ 20 Copay
Tier 2 $ 60 Copay $ 70 Copay
Tier 3 $ 100 Copay $ 120 Copay
PRESCRIPTION DRUG COVERAGE
To Learn More, visit MySCOBenefits.com 10
Southern College of Optometry offers dental protection through
United Healthcare.
On the base dental plan services are only covered when you see a dentist in United Healthcare dental network. On the buy-up plan you can receive care from the dentist of your choice. However, United has contracts with a large network of dentists who have agreed not to charge more than a specified amount for particular services. If you use one of these network dentists, you won’t have to worry about being charged for addi-tional amounts above the allowable amount covered by the plan.
DENTAL PLAN
Rates
Page 26
BASE PLAN
In-Network Benefits
Only
Preventive Services
Exams, cleanings 100%
Basic Services
Fillings, radiographs, simple extractions
50%
Major Services
Oral surgery, root canals, crowns
50%
Plan Deductibles and Maximums
Deductibles (3 per family)
$50
Benefit Maximum $1,500
BUY-UP PLAN
In-Network Benefits
Out-of-Network Benefits
Preventive Services
Exams, cleanings, radiogrpahs, sealants,
space maintainers, fluoride treatment
100% 100%
Basic Services
Fillings, simple extractions, oral surgery, periodontics,
endodontics
90% 80%
Major Services
Crowns, dentures, bridgework
60% 50%
Plan Deductibles and Maximums
Deductibles (3 per family)
$50
Benefit Maximum $1,000
To Learn More, visit MySCOBenefits.com 11
Flexible Spending Accounts (FSAs) enable you to put aside money for important expenses and help you reduce your income taxes at the same time. Southern College of Optometry offers two types of Flexible Spending Accounts, a Health Care FSA and a Dependent Care FSA. These accounts allow you to set aside pre-tax dollars to pay for certain out-of-pocket health care or dependent care expenses.
How Flexible Spending Accounts Work
1. Each year during Annual Enrollment, you decide on how much to set aside for health care and/or dependent care expenses. 2. Your contributions are deducted from your paycheck on a pre-tax basis in equal installments throughout the calendar year. 3. You will be issued a debit card which can be used at the time of service to pay for your unreimbursed medical expenses. Please note that you may be required to produce receipts for your transactions to substantiate Flexible Spending Account claims. Please note that these accounts are separate and you may choose to participate in one, both or neither. You cannot use money from the Health Care FSA to cover expenses eligible under the Dependent Care FSA or vice versa.
REMINDER
Remember to calculate your expenses conservatively
when making your FSA elections. IRS regulations require that you forfeit any
money left in your account at the end of the plan year.
Plan Annual Maximum
Contribution
Examples of
Covered Expenses
Health Care Flexible Spending Account
$2,550 Copays, deductibles,
prescriptions, orthodontia, eyeglasses, etc.
Dependent Care Flexible Spending Account
$5,000 ($2,500 if married and filing
separate tax returns)
Day care, nursery school, elder care expenses, etc.
FLEXIBLE SPENDING ACCOUNTS
You must re-enroll each
year
To Learn More, visit MySCOBenefits.com 12
What exactly are Supplemental Benefits and how can they benefit you?
Basically, Supplemental Benefits can help protect your health and savings.
What would happen to you if you had a medical catastrophe or unforeseen accident that you could not afford?
When this happens, enormous bills and expenses can add up fast.
If you were in the hospital for a few weeks or more, would you have enough money to cover your other expenses that your insurance would not? You may not be able to earn a living which could be devastating. How would you be able to support yourself or your family? The cost of financial misfortune can escalate fast. In fact, recent research shows that medical bills contributed to over 60% of all bankruptcies.
But what can you do now to help prevent a crisis?
One way is through supplemental benefit plans. Supplemental benefits provide cash directly to you to use as you need it. The amount of cash you would receive and how it is paid out depends on the specific supplemental plan or policy you select. Only you can decide if a supplemental plan is right for you. Some things to consider when deciding if you need supplemental coverage are your health risk factors, your savings, and how much coverage you can afford. Let’s take a look at some of the plans available to you.
SUPPLEMENTAL PLANS
HOW TO FILE CLAIMS GO TO PAGE 27
How much does it cost?
The per day cost is less than you think...
Critical Illness Plan Accident Plan
Less than a
Cup of Coffee
Less than a
Soda Drink
To Learn More, visit MySCOBenefits.com 13
How it Works...
What can living with a Critical Illness mean to you?
Plans Available from $0.14 / Day
What is the need?
Critical illness benefits help families pay off debts and other
expenses not covered by medical insurance such as loss of
income, childcare services, and travel to treatment centers.
What are the key features?
With critical illness coverage, employees receive a lump sum benefit after a serious
condition such as a heart attack, stroke, coronary artery disease, or cancer occurs.
You can take it with you if you change jobs.
Coverage is available for you and your family members.
What plans are available?
You select the amount of coverage that best meets
your needs either $10,000 or $20,000 in coverage.
Every 40 seconds,
on average, someone in the United States has a stroke.
-American Heart Association
CRITICAL ILLNESS PLANS
John chooses to
enroll in a $20,000
Critical Illness plan
during his annual
enrollment.
Some time later, John
suffers a heart attack.
His prognosis is good
and he is expected to
make a full recovery.
However, John is unable
to work during his recov-
ery period and bills con-
tinue to pile up.
BILLS
John can focus on his
recovery without worry,
because John has a
Critical Illness Policy
paying him a $20,000
benefit.
Rates
Page 26
To Learn More, visit MySCOBenefits.com 14
Protected from life’s accidents?
Plans Available from
$0.39 / Day
What is the need?
Accidents can happen anytime,
anywhere and can often lead to
medical care. In your lifetime, which
of these accidental injuries has
happened to you or someone you
know?
Sports-related accidental injury
Broken bone
Burn
Concussion
Laceration
Back or knee injuries
Accident coverage provides cash
benefits to help cover out-of-pocket
medical costs and other incidental
expenses. Even if you already have
life and disability, accident coverage
is a complementary plan because
the benefits don’t overlap.
What are the key
features?
A schedule of benefits based
upon your injury and treatments
are paid directly to you.
You can take it with you if you
change jobs.
Available to protect you, your
spouse, your children or your
family.
What plans are
available?
Covers you for off the job
accidents.
Two options from which to
select.
ACCIDENT PLAN
How it Works...
Melissa elected during her
open enrollment period an
Accident Plan. Some time
later, she took a nasty spill.
Melissa incurred expenses
for services provided to
treat her injuries. The plan
paid the following:
What a difference an
accident plan can make
when life takes a tumble!
Ambulance………………….…..$200
Emergency Room………….… $200
X-Ray……………………………….$200
Broken Arm…………………… $2200
Hospitalization……………… $1000
* This is an example. For specifics, see plan
details at MySCOBenefits.com .
With Accident Coverage: $3800
Additional dollars to pay for copay, deductible
and other expenses
Without Accident Coverage: $0
In a year,
more than 1 in 5
children go to the
Emergency
Room. National Center for Health Statistics
Health, United States 2007
Rates
Page 27
To Learn More, visit MySCOBenefits.com 15
Southern College of Optometry provides an employee benefits program that is intended to protect you and your family from catastrophic
financial losses.
As an employee, you will receive a company paid life insurance and AD&D benefit equal to 2.5 times your annual salary to a maximum of $300,000. Coverage is provided at no cost to you after
1 year of employment.
Who depends on you? Term life
insurance can help you take care
of those you love. How much life
insurance do you need?
TERM LIFE AND AD&D
To Learn More, visit MySCOBenefits.com 16
You have the opportunity to purchase additional life coverage for yourself and your dependents at your expense.
How Much Coverage Can You Buy?
Employee: You may purchase additional term life insurance in $10,000 increments to a
maximum of $250,000, not to exceed 5 times your annual salary
Spouse: You may purchase term life insurance for your spouse in the amount of $5,000 increments, not to
exceed $50,000. You must have coverage for yourself under the voluntary term life plan to have coverage on your spouse.
Child/Children: Life insurance in the amount of $10,000 is available for your children provided that you have
optional life insurance for yourself.
Guaranteed Issue:
Guaranteed issue means that you are guaranteed coverage without having to answer any health questions or provide
evidence of good health.
Employee: Guaranteed issue up to $100,000.
Guaranteed Issue for your Spouse is
$35,000 and $10,000 for your children.
If you elect coverage above the guarantee issue amount you will be required to answer health questions on an Evidence of Insurability form. Mutual of Omaha must approve all coverage amounts above the guarantee is-sue amount. You will be covered at the guarantee issue amount until a determination is made by Mutual of Omaha at which point your coverage will increase to the requested amount or will remain at the guarantee issue amount (if denied). You may receive a request for additional information, if you fail to provide the additional information you will only be covered for the guarantee issue amount.
Reductions in Insurance: By the time you or your spouse reach age 70, chances are that your children will be grown and your mortgage paid.
At age 70, providing you are still employed, your coverage will decrease to 65% of the benefit amount. It will decrease to 45% at age 75, 30% at age 80, 20% at age 85 and once you reach
age 90 coverage will be reduced to 15% of your original election amount.
Voluntary Life Insurance coverage is available on a Guaranteed Issue basis when you enroll during your new hire
enrollment period.
If you do not enroll when first eligible you will be required to complete an Evidence of Insurability
Form if you later decide to elect this coverage.
VOLUNTARY TERM LIFE
Rates
Page 27
To Learn More, visit MySCOBenefits.com 17
UNIVERSAL LIFE
What is Universal Life Insurance?
As a complement to Term Life coverage, you may want to consider
purchasing Universal Life insurance coverage. Universal Life is permanent life insurance you
can take with you when you leave or retire.
Permanent life insurance builds cash value that earns interest. The interest rate credited will never be less
that the guaranteed minimum rate built into the coverage. Under current law, taxes are deferred on these
interest earnings. You may also borrow or withdraw from your fund value once sufficient cash value has
accumulated.
Coverage: You may purchase coverage for yourself, spouse and/or children. Policy issue ages for em-
ployee and spouse are 18-65 and for dependent children to age 18. You may purchase this coverage on
your spouse or child with purchasing coverage on yourself.
How Much Do You Need?
You decide how much life insurance fits your family’s needs and your budget. Once you start paying
premiums, they’re added to your fund value. Cost of insurance charges and expense charges are
deducted each month.
Whether or not you have dependents yet, it’s smart to consider applying for permanent life insurance now.
The younger you are when you start, the lower your cost of insurance. And the sooner you start, the longer
You may purchase up to $150,000 in coverage or $25
per week in premium (whichever is less) with minimal
health questions.
To Learn More, visit MySCOBenefits.com 18
When savings aren’t always enough. You and your family rely on your income. But what would happen if you became ill or suffered a serious accident and were unable to work? Who would pay the bills? You may never even think that you could be laid up for an extended period of time. But what if you had a stroke or some other injury that kept you from working? How many months could you continue your standard of living from your savings? The chances of becoming disabled prior to age 65 are 1 in 3, yet the chances of your house burning down are 1 in 1,000.
In helping you prepare to meet financial obligations should you face a period of disability, Southern College of Optometry offers both Short Term Disability (STD) insurance and Long Term Disability (LTD) insurance.
Who’s at risk?
More than 26 million Americans suffer disabling injuries each year.
More than two-thirds of disabling injuries suffered by American workers occur off the job and are not covered by workers’ compensation.
Short Term Disability Insurance (STD)
Your Short Term Disability plan is administered through Mutual of Omaha and is provided at no cost to you 1st of the month after 6 months of employment. The plan requires that you be out of work, and certified disabled by your doctor, due to illness or injury for a minimum of 7 days before your weekly benefit is paid. Your weekly benefit is equal to 60% of your weekly salary to maximum weekly benefit of $1,675 and will continue for 25 weeks provided that you remain disabled.
Long Term Disability Insurance (LTD)
Your long term disability plan is also administered through Mutual of Omaha and is provided at no cost to you 1st of the month after 1 year of employment. The plan includes a 180 day elimination period, that is the amount of time you are disabled by your doctor and unable to work. Once you complete your elimination period the plan will begin paying a monthly benefit equal to 66 2/3% of your monthly salary, to a maximum of $10,000/month. The benefit will continue until you are able to return to work or you reach the age of 65, whichever occurs first.
Your disability benefits help you cover
what matters most.
SHORT & LONG TERM DISABILITY
Legal Notices 19
Legal Notices
Legal Notices 20
Legal Notices
Legal Notices 21
Legal Notices
Legal Notices 22
Legal Notices
Legal Notices 23
Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a pre-mium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance
coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your em-ployer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in
your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The follo-
wing list of states is current as of January 31, 2015. Contact your State for more information on eligibility –
ALABAMA – Medicaid GEORGIA – Medicaid
Website: www.myalhipp.com
Phone: 1-855-692-5447
Website: http://dch.georgia.gov/
- Click on Programs, then Medicaid, then Health Insur-ance Premium Payment (HIPP)
Phone: 1-800-869-1150
ALASKA – Medicaid INDIANA – Medicaid Website: http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
Website: http://www.in.gov/fssa
Phone: 1-800-889-9949
COLORADO – Medicaid IOWA – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-221-3943
Website: www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
FLORIDA – Medicaid KANSAS – Medicaid Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
Legal Notices
Legal Notices 24
Legal Notices
KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP
Website: http://www.lahipp.dhh.louisiana.gov
Phone: 1-888-695-2447
Medicaid Website: http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
MAINE – Medicaid NEW YORK – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html
Phone: 1-800-977-6740
TTY 1-800-977-6741
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831
MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
MINNESOTA – Medicaid NORTH DAKOTA – Medicaid
Website: http://www.dhs.state.mn.us/id_006254
Click on Health Care, then Medical Assistance
Phone: 1-800-657-3739
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-800-755-2604
MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
MONTANA – Medicaid OREGON – Medicaid
Website: http://medicaid.mt.gov/member
Phone: 1-800-694-3084
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075
NEBRASKA – Medicaid PENNSYLVANIA – Medicaid
Website: www.ACCESSNebraska.ne.gov
Phone: 1-855-632-7633
Website: http://www.dpw.state.pa.us/hipp
Phone: 1-800-692-7462
NEVADA – Medicaid RHODE ISLAND – Medicaid
Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900
Website: www.ohhs.ri.gov
Phone: 401-462-5300
Legal Notices 25
SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm
CHIP Phone: 1-855-242-8282
SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/ index.aspx
Phone: 1-800-562-3022 ext. 15473
TEXAS – Medicaid WEST VIRGINIA – Medicaid
Website: https://www.gethipptexas.com/
Phone: 1-800-440-0493
Website: www.dhhr.wv.gov/bms/
Phone: 1-877-598-5820, HMS Third Party Liability
UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP
Website:
Medicaid: http://health.utah.gov/medicaid
CHIP: http://health.utah.gov/chip
Phone: 1-866-435-7414
Website:
https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
Phone: 1-800-362-3002
VERMONT– Medicaid WYOMING – Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
Website: http://health.wyo.gov/healthcarefin/equalitycare
Phone: 307-777-7531
To see if any other states have added a premium assistance program since January 31, 2015, or for more information on special enroll-ment rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
Legal Notices
Rates 26
Me
dic
al
(pg
. 12)
Medical Plan - Semi-Monthly Payroll Deduction
Who to Cover? PLATINUM GOLD BRONZE
Employee $ 57.00 $ 39.00 $ 24.00
Employee + 1 Dependent $ 205.00 $ 177.00 $ 104.00
Family $ 317.00 $ 274.50 $ 159.00
Dental Plan - Semi-Monthly Payroll Deduction
Who to Cover? Base Plan Buy-up Plan
Employee $ 8.82 $ 18.84
Employee + Spouse $ 17.72 $ 37.69
Employee + Child(ren) $ 16.90 $ 36.71
Family $ 26.82 $ 57.81
Den
tal
(pg
. 14)
Review your worksheet prior to your enrollment session.
Pick the Plan that Best Meets Your Needs...
RATES
Critical Illness Plan SAMPLE Rates Semi-Monthly Payroll Deduction
Sample Rates are based on a $10,000 policy - non-tobacco user
Age Named Insured Family 17 - 24 $ 1.11 $ 1.66
25 - 29 $ 1.43 $ 2.17
30 - 34 $ 1.80 $ 2.77
35 - 39 $ 2.54 $ 3.88
40 - 44 $ 3.46 $ 5.31
45 - 49 $ 4.75 $ 7.29
50 - 54 $ 6.23 $ 9.60
55 - 59 $ 7.80 $ 11.95
60 - 64 $ 9.88 $ 15.14
65 - 70 $ 11.08 $ 16.98
Cri
tic
al
Illn
es
s (
pg
. 20)
What can Living with a Critical Illness Mean to You?
Cri
tic
al
Illn
es
s (
pg
. 20)
Cri
tic
al
Illn
es
s (
pg
. 20)
Rates 27
Accident Plan Rates—Semi-Monthly Payroll Deduction
Who to Cover? Basic Plan Basic Plan with Health
Screening Benefit
Named Insured
(Employee, Spouse, or Child) $ 6.66 $ 7.66
Team Member + Spouse $ 9.06 $ 10.58
One-Parent Family $ 10.64 $ 11.64
Two-Parent Family $ 13.04 $ 14.56
Ac
cid
en
t P
lan
(p
g.
21)
How to File Claims
To file a claim, visit
www.MySCOBenefits.com or
contact Allstate Benefits with questions
at 1-800-325-4368.
Protected from Life’s Accidents?
RATES
AGE 10K 20K 30K 40K 50K 60K 70K 80K 90K 100K
15 - 24 .28 .55 .83 1.11 1.38 1.66 1.94 2.22 2.49 2.77
25 - 29 .42 .83 1.25 1.66 2.08 2.49 2.91 3.32 3.74 4.15
30 - 34 .51 1.02 1.52 2.04 2.54 3.05 3.55 4.06 4.57 5.08
35 - 39 .55 1.11 1.66 2.22 2.77 3.32 3.88 4.43 4.98 5.54
40 - 44 .69 1.38 2.08 2.77 3.46 4.15 4.85 5.54 6.23 6.92
45 - 49 .97 1.94 2.91 3.88 4.85 5.82 6.78 7.75 8.72 9.69
50 - 54 1.20 2.40 3.60 4.80 6.00 7.20 8.40 9.60 10.80 12.00
55 - 59 1.66 3.32 4.98 6.65 8.31 9.97 11.63 13.29 14.95 16.62
60 - 64 2.58 5.17 7.75 10.34 12.92 15.51 18.09 20.68 23.26 25.85
65 - 69 4.94 9.88 14.82 19.75 24.69 29.63 34.57 39.51 44.45 49.38
70+ 7.80 15.60 23.40 31.20 39.00 46.80 54.60 62.40 70.20 78.00
Voluntary Employee and Spouse Life Semi-Monthly Payroll Deduction
Take Care of Those You Love…
Vo
lun
tary
Lif
e—
(pg
.23
)
Dependent Life
Child or Children $5,000 per child (6 months of age or
older) $1,000 (birth to 6 months of age) Per paycheck (24) D
ep
. L
ife
RATES
© BenefitHelp Southern College of Optometry, 2015 v5
