Sample Employee Benefits Newsletter-JS Clark Agency-Employee Benefits Consultants

8/14/2019 Sample Employee Benefits Newsletter-JS Clark Agency-Employee Benefits Consultants

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EmployeeEmployeeEmployee BenefitBenefitBenefit

InformationInformationInformation

For the 2009 Plan Year For the 2009 Plan Year For the 2009 Plan Year

ABCABCABCCompanyCompanyCompany


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Employee Benefit News

If you wish to continue your dentalcoverage, you must complete a ABCElection Form.

If you wish to continue or enroll for the firsttime in the vision, you must complete anAlwaysCare Vision Enrollment Form and aABC Election Form 1..

The medical plan you select is the plan inwhich you will remain until the next openenrollment period with an effective date ofJanuary 1, 2010.

Please submit all forms to HumanResources no later than November 7, 2008 toavoid delays in the effective date of yourcoverage.

Plan Year January 1, 2009December 31, 2009

This description of the benefits and options that are available for this plan year provides a generaloverview of the benefits. Actual provisions contained in the insurance contracts and plandocuments will be relied upon solely, in administration and interpretations of the plans.

R ising healthcare costs affect almosteveryone. Factors impacting theseincreases include technology, cost shifting,prescription drug costs, lifestyle choices, and anaging population. As health plan premiumscontinue to rise, we maintain a commitment toyou and your family by offering an excellentbenefit package.

The ABC Company (ABC) is pleased to giveyou the opportunity to participate in one of thefollowing medical plans effective January 1,2009:

Your medical plan options are:Blue Cross Blue Shield (BCBS)Community Blue PPO 3 Plan;Blue Care Network (BCN) Healthy BlueLiving HMO.

During the open enrollment period you may:

Enroll in the medical plan of your choice (if you have previously waived coverage, you may only enroll in coverage during open enrollment ).

Enroll eligible dependents previously notenrolled.

Some things to remember

You and your eligible dependents must eachenroll in the same plan.

You must complete a ABC Election Formand a BCBSM / BCN Enrollment-Change ofStatus Form if you would like to participatein one of the medical plans.

You must complete the ABC Election Formif you wish to waive any coverage.

Page 3ABC Employee Benefits Plan 2009

IN THIS ISSUE:

BCN Healthy Blue Living HMO ............... 4BCBS Community Blue PPO ................... 7Member Services Contact Info ................. 7Prescription Drugs .................................... 8Medical Benefits Comparison .................. 11Delta Dental ............................................. 13AlwaysCare Vision ................................... 15Life and Disability ..................................... 16Premium Contribution Schedule .............. 18Eligibility and Waiving Coverage .............. 19Plan Status ............................................... 20

BCBS and BCN Discounts ....................... 20Womens and Childrens Rights ............... 21Emergencies ............................................ 22Definitions ................................................ 23

ABCABCABCCompanyCompanyCompany


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5/24Page 5ABC Employee Benefits Plan 2009

The chart above highlights those areas in which your PCP will evaluate you on the Qualification Form. Each area ofconcern is assigned a possible point value ranging from 15 to 25 points. From a beginning value of 100 points, yourPCP will subtract the correlating points if he/she determines a certain area needs attention. If your overall point valuefalls below 80 points, you must agree to a treatment plan prescribed by your PCP.

If you or your spouse smoke, you must enroll in the Quit the Nic ! through BCN in order to remain in the EnhancedBenefit Level.

A Description of Your Medical BenefitsThe BCN Healthy Blue Living HMO

High-Impact HealthMeasures Wellness Targets

What Can I Do to Qualify for EnhancedBenefits if I Do Not Meet the WellnessTargets?

Alcohol Use(15 Points)

Pass a physicianadministered screening exam

Agree to follow treatment plan. Physicianfollow-up visit required.

Blood pressure Control(15 Points) At or below 140/90


Diabetes Management(15 Points)

Blood sugar at or belowtarget


Cholesterol Management(15 Points)

LDL-C below target (basedupon risk factors)


Smoking Status

(25 Points)Non-smoker Agree to enroll in BCNs free Quit the Nic!

smoking cessation program.

Weight(15 Points)

Body Mass Index at or below30

Agree to participate in physician-supervisedapproved weight management program.Physician follow-up visit required.

How Points are Scored on the Qualification Form

Things to Remember about HBLThe Qualification Form and the HRA must becompleted within the first 90 days of the plan.

Failure to do so will result in your being movedfrom the Enhanced to the Standard Level ofbenefits. Both the subscriber and the spousemust complete individual Qualification Formsand HRAs.

The information contained in the QualificationForm and Health Risk Appraisal is confidential

and available only to healthcoaches.

While your doctor maycomplete the Qualification Form,

it is ultimately your responsibilityto ensure it is mailed or faxed toBCN before the 90 day deadline.Late entries are not considered.Keep copies of all documentation.

If you smoke, you must

join the BCN Quit the Nic! smoking cessationprogram within 30 days of your visit to yourPCP. You may call the BlueHealthConnection at 800.775.BLUE (2583) to enroll.

If your doctor requires a follow-up visit, you musthave him/her complete another QualificationForm at that follow-up visit. Failure to submit acompleted Qualification Form for each follow upvisit will result in being moved to the StandardBenefit Level. Keep copies of your form.

If a BCN Health Coach phones, you mustcooperate and return any calls. They are anintegral part of the HBL plan and are there tooffer you support and resources.

Do not complete your Health Risk Appraisal ormake your appointment for the QualificationForm until you have your BCN card. Once youhave your card, your enrollment information islogged with BCN and you may complete theHRA and Qualification Form requirements.



A Description of Your Medical BenefitsThe BCN Healthy Blue Living HMO

No you and/or your spouse donot complete the Qualification

Form within 90 days

Yes you and your spousecomplete the Qualification

Form within 90 days

You enroll in the HBL Plan

If a New Enrollment: You and your familyare automatically enrolled in the Enhanced Benefit Level

for the first 90 days of the plan.If a Renewal: You remain in your current plan for the first

90 days following November 1st.

Health RiskAssessment

Qualification Form

Youand/or

your spouseDo Not agreeto work with your

physician, BCN HealthCoaches or enroll in

Quit the Nic! , if necessary

Youand/or

your spouseagree to work

with your physician,BCN Health Coaches

and enroll in Quit the Nic! ,if necessary, to work towards

a healthier lifestyle

You and your family areenrolled in the Standard

Benefit Level after 90 days

You and your family areenrolled in the Enhanced

Benefit Level after 90 days

Yes you and your spousecompleted the HRA within 90

days

No you and your spouse did not complete the HRA within

90 days

Youand/or your

spouse scoredless than 80

points each on theQualification

Form

You and yourspouse scoremore than 80

points each onthe Qualification

Form

W a i t u n t i l y o u r e c e i v e y o u r B C N I D c a r d b e f o r e c o m p l e t i n g y o u r

Q u a l i f i c a t i o n F o r m a n d H e a l t h

R i s k Ap p r a i s a l , b u t b e s u r e t o c o m p l e t e b o t h i t e m s w i

t h i n

t h e f i r s t 9 0 d a y s o f t h e p l a n ( b y M a r c h 3 1 s t ) .



The BCBSM Community Blue PPO Plan

A Description of Your Medical Benefits

T he BCBS Community Blue PPO planprovides you with freedom of choice. BluePreferred plan members are not required to

select a Primary Care Physician and they donot need a referral to see another PPOnetwork provider.

Blue Preferred members do not haveto notify BCBSM when changingphysicians. When you choose toreceive services from a provider whois not a member of the PPO network,the copayment, deductible andcoinsurance amount for which you areresponsible increases.

In addition to increasedcopayment amounts, someservices are not payable whenrendered by non-PPO providers.However, if a PPO membergoes to a non-PPO provider witha referral from a PPO provider,out-of-network copayments arewaived.

Delta DentalMember Services

800.482.8915www.deltadentalmi.com

BCBSMMember Services

800.637.2227www.bcbsm.com

AlwaysCare VisionMember Services

888.729.5433 www.alwayscarebenefits.com

BCN MemberServices

800.662.6667www.mibcn.com

Carrier Contact Information

T he Member Service Departments of BCBSM, Delta Dental and AlwaysCare Vision are available tohelp you. If you have questions regarding your benefit coverage, need a claim issue resolved, or havean eligibility question, call your carrier at one of the numbers shown below for assistance.

Calling Member Services should be your first step in resolving any problems you may have. If you feelMember Services has not resolved your issue, contact Human Resources for further direction. Be sure tohave the name of the Member Services representative with whom you spoke, what they told you regardingthe issue, and any necessary documentation ( i.e., copies of EOBs and bills, patient and subscriber information ) before contacting Human Resources.

You are the one to determine the best providerfrom whom to receive care, regardless ofwhether that provider is in the Blue Preferred

PPO provider network or not; however, yourout-of-pocket costs for related services willbe less ( i.e. lower deductible and coinsurance ) if you utilize Blue PreferredPPO network providers. In other words,

the plan will pay a higher percentage ofthese services if you receive them fromBlue Preferred PPO providers.

Be aware you may still be responsible forcharges which exceed the BCBS approved

amount if you do not use participatingproviders.

Please see your plan coordinator for a provider listor go to www.bcbsm.com/directories .

It should be noted Preventive Services under theCommunity Blue PPO are subjected to a $500 perperson calendar year maximum. Any expensesoutside of this amount will be the subscribersresponsibility.



Prescription Drugs with BCBSM and BCN

A Description of Your Medical Benefits

I f you are enrolled in the BCN HBL HMO plan,you will receive up to a 30-day supply with acopayment of $10 for generic drugs and a $20copayment for brand name drugs if you areenrolled in the Enhanced Benefit Level .

If you are enrolled in the Standard Benefit Level you pay a copayment of $15 for generic drugs and$50 for brand name drugs.

When you use your BCBS Community Blue PPO prescription drug card at the pharmacy, youreceive up to a 30-day supply of medication for acopayment of $10 for generic drugs and $40 forbrand name drugs under the Community Blue PPOplan.

Mail Order Prescription Drugs

Save money by using the MedcoMail Order Prescription Drug ( MOPD )

service plan. You pay two PPOcopayments or two HMO

copayments for a 90-day supply ofmaintenance medication and your

prescription orders are mailed directlyto your home.

For instance, if you have the Blue Cross BlueShield PPO or the HBL Enhanced Benefit Leveland take a brand name maintenance medicationevery day, a three month supply at the pharmacycould cost you $120. Using Medco Mail Order

service, your cost for athree month supplywould be $80. That is a savings of $40 every three months, or $160 per year.

If you have the HBLStandard Benefit Level,a three month supply ofa b r a n d n a m emaintenance medicationcould cost you $150 atthe pharmacy versus$100 through Medco

Mail Order service. That is a savings of $50 every three months, or $200 per year.

Your Medco order will be sent to your home viaUPS or First Class Mail. Reorder information willbe included in your prescription shipment.

Go to www.medcohealth.com for more informationon the Blue Cross Blue Shield and Blue CareNetwork mail order prescription program withMedco.

To participate in the mail order plan, have yourdoctor write you a 90-day prescription and requestan enrollment form from Human Resources.Complete the form and mail it, with yourcopayment and original prescription, in theenvelope provided. Your prescription will bemailed directly to your home and you will savemoney on the copayments required.

Maintenance medication is taken ona regular or long-term basis.For example, the followingconditions may be treated withmaintenance medication: High blood pressure Ulcers, Arthritis Heart Conditions Thyroid conditions Emphysema, and Diabetes.



B CBSM and BCN monitor the use of certainmedications to ensure members receive themost appropriate and cost-effective drug therapy.Physicians are required to get Prior Authorization on some medications. This means certain clinicalcriteria must be met before coverage is provided.

Depending on the medication, previous treatmentwith formulary drugs may be required. Theformulary is a list of medications identified byBCBSM and BCN as being therapeutically effectiveand offering the best value.

Your physician can contact the BCBSM and BCNMedImpact help desk to request prior authorizationfor these drugs. You may be required to pay forthe full cost of the drug if your physician does notobtain prior authorization.

For more information regarding step therapy andprior authorization, and a list of medications on theformulary list, go to www.bcbsm.com if enrolled inthe BCBSM Community Blue PPO plan orwww.mibcn.com if enrolled in the BCNHealthy Blue Living HMO plan.

Click on the I am a Member tabs on eithersite. Each web site allows you to access

Heres a Tip!

K eep the MedImpact Customer Service number handy! Call 800.788.2949 if you are at thepharmacy and the pharmacy staff tells you a prescription is not covered or you are chargedmore than your prescription copayment. Call MedImpact immediately, without leaving thepharmacy, and MedImpact can tell you if your physician failed to receive prior authorization or ifyour medication is not covered under your plan. If you need prior authorization, you can contactyour physicians office right from the pharmacy and remind them to call in for prior authorizationor request an equivalent alternative prescription covered by your plan.

the BCBSM and BCN prescription drug formulariesrespectively and provide you with specificinformation regarding your plans drug program.

MedImpact is contracted with BCBSM and BCN toadminister your retail prescription program. If youever experience difficulty getting a prescriptionfilled at a retail pharmacy, call MedImpact at800.788.2949 and follow the prompts to speak witha Member Services representative. TheMedImpact representative can advise you on why

your prescription may not be authorized or whatneeds to be done to fix any issues.

A Description of Your Prescription Coverage

Prior Authorization and Step Therapy

Prescription Member Services Contact Information

MedCo Mail OrderMember Services

800.903.8346

MedImpact RetailMember Services

800.788.2949


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ITEMBCBSM Community Blue 3 PPO BCN Healthy Blue Living HMO

Network Non-Network EnhancedBenefit LevelStandard

Benefit LevelCalendar Year Deductible

For an Individual You Pay $250 $500 $0 $500For a Family You Pay $500 $1,000 $0 $1,000

Calendar Year Coinsurance See hospital and MH/SA See hospital and MH/SAFor an Individual You Pay 20% to $1,000 40% to $3,000 None 20% to $1,500For a Family You Pay 20% to $2,000 40% to $6,000 None 20% to $3,000

Your Total Maximum Cost(does not include flat dollar or 50% coinsurance amounts)

Does not include In-patient Mental Healthcoinsurance and deductible

Does not include In-patient Mental Healthcoinsurance and deductible

For an Individual You Pay $1,250 $3,500 None $2,000For a Family You Pay $2,500 $7,000 None $4,000

Lifetime Maximum Unlimited UnlimitedWhen You Go to the Hospital, You Pay

Hospital Pre-Certification Required of physician - no penalty to insured Required Required

Hospital Room & Board 20% after deductible 40% after deductible $0Covered 100% 20% after deductible

In-Patient Surgery 20% after deductible 40% after deductible $0Covered 100% 20% after deductible

In-Patient PsychiatricAnnual & Lifetime Maximums Apply

50% after deductibleCombined max of 60 days per

calendar year with lifetimemax of 120 days per member



25%$1,000 individual / $2,000

family maximum, 30 days peryear

25% after deductible$1,000 individual / $2,000

family maximum, 30 days peryear

In-Patient Substance AbuseAnnual & Lifetime Maximums Apply





50%up to state mandated dollar

limitation, 1 program per year

50% after deductibleup to state mandated dollar

limitation, 1 program peryear

Emergency RoomWaived if admitted

$100 copaymentSubject to balance billing if non-network provider used

$50 copayment $75 copayment afterdeductible

Diagnostic X-Ray & Lab 20% after deductible 40% after deductible $0Covered 100% 20% after deductible

When You Go to the Doctor's Office You PayDoctor Office Visits(medically necessary)

$20 copayment 40% after deductible $10 copayment $15 copayment afterdeductible

Outpatient and Home Visits $20 copayment 40% after deductible $10 copayment $15 copayment afterdeductible

Second Surgical Option $20 copayment 40% after deductible $10 copayment $15 copayment afterdeductible

Pre & Post Natal Care $0Covered 100% 40% after deductible $10 copayment$15 copayment after

deductible

Allergy Testing & Therapy $0Covered 100% 50% after deductible50% - testing & serum

$5 copayment -injections

50% after deductible -testing & serum$5 copayment -

injections

Chiropractic Care $20 copayment24 visits per calendar year40% after deductiblecombined with network benefit

maximum

PCP Referral Only $10 copayment

PCP Referral Only $15 copayment

Out-Patient Surgery 20% after deductible 40% after deductible$0

Covered 100%Office visit copayment may

apply

20% after deductibleOffice visit copayment may

apply

Out-Patient PsychiatricAnnual & Lifetime Maximums Apply

50% after deductibleLimited to 50 visits per

calendar year with lifetimemax of 120 visits per member

50% after deductibleLimited to 50 visits per

calendar year with lifetimemax of 120 visits per member

50%20 visits per year

50% after deductible20 visits per year

Out-Patient SubstanceAbuseAnnual & Lifetime Maximums Apply

50% after deductibleUp to state mandated dollar

amount

50% after deductibleUp to state mandated dollar

amount


limitation, 1 program per year


limitation, 1 program peryear

$5,000,000

Medical Benefits Comparison


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D ental benefits are providedthrough the Delta Dental PPOplan. The PPO plan provides avaluable dental benefits programwhile giving subscribers the freedomto choose the provider that is right forthem.

A national network with more than 61,000 PPOdentists is available with the PPO plan. While youwill save more out-of-pocket money with the DeltaPPO plan, this dental plan also allows access toDelta Dental Premier Network dentists.

Because this is a passive PPO plan, enrollees

may go to any licensed dentist anywhere, but theywill save money by choosing a Delta Dental PPOdentist. Delta Dental PPO dentists agree to acceptour fee determination as full payment for coveredservices. This guaranteed acceptance of paymentreduces group claims costs while protectingenrollees from balance-billing problems.

Employees who are eligible for dental benefits canbe covered on the first day of the month following90 days of employment (eligible employees include all full-time employees excluding those positions subsidized by the City of Detroit) .

Delta Dental provides members with resources tomake managing your dental benefits easy. Go towww.deltadentalmi.com and click on the Members tab. You will be directed to the Members pagewhere you may access provider directories,download claim forms, and researchdental related topics, such as OralHealth and Wellness.

From the Members page youmay also access the ConsumerToolkit. The Consumer Toolkit enables you toreview benefit and claims information online. Foryour convenience, it is also possible to print DeltaDental Identification Cards via the Consumer

Toolkit. The card will also serve as anidentification card for any eligible dependents.Simply click on the Consumer Toolkit link from theMember page or go to www.ConsumerToolkit.com .Follow the on-screen instructions.

The Summary of Dental Plan Benefits on thefollowing page should be read in conjunction withyour Delta Dental Certificate. In the event youseek treatment from a dentist that does notparticipate in the Delta Dental PPO program, youmay be responsible for more than the percentage

indicated above.To see if your dentist participates, or to find a DeltaDental PPO dentist, please call 800.482.8915 orgo to www.deltadentalmi.com and click on theMember tab.

A Description of Your Dental Coverage

Delta Dental PPO Plan

Go to www.deltadentalmi.com and click on the Members tab for helpful information .



ITEM Delta Dental PPO Plan

Your out-of-pocket cost will dependupon which provider you choose.

If you select a Delta PPODentist you pay:

If you select a premier orNon-Participating Dentistsyou pay:

Coinsurance

Type IPreventive 0% 0%

Type IIBasic/Routine 20% 20%

Type IIIMajor 50% 50%

Type IVOrthodontic 50% 50%

Annual Maximum (Types I-III) $1,000

Lifetime Maximum (Type IV)To age 19 $1,000

Examples of Dental Benefits/Services

Type IPreventive

Oral Examinations

Cleanings

Fluoride Treatments (to age 19)

Emergency Palliative Treatment

Type IIBasic/Routine

X-RaysOral Surgery

Endodontics

Periodontics

Bridge & Denture Repair and Relines

Minor Restorative Services

Crowns

Bridges

Dentures

Type IVOrthodontic Braces (dependent children under age 19)

Type IIIMajor

A Description of Your Dental Coverage

Dental PPO Plan Outline



A Description of Your Vision Coverage

AlwaysCare Vision Plan

A s of January 1, 2009, AlwaysCare, aStarmount life insurance company, willprovide the vision care benefits for ABC.

Annual eye exams not only ensure healthy vision,but can also help detect many medical problemsearly.

Members may access the nationwide PPO networkof 22,000+ locations, or choose an out-of-networkprovider. Options include independentoptometrists and ophthammologists, plus regionaland national retail chains, such as WalMart, Sams Club, Pearle Vision, Target, Sears, JC Penney and Eyemasters ).

Members may choose different providers for visionexams and vision supplies. Visit www.

DescriptionIn-Network

Member CostNon-Network

ReimbursementNetwork* 22,000 providers

Frequency (Exam/Frame/Lenses) 12/24/12

Exam $10 Copay Up to $35Frame $120 Allowance Up to $50

Standard Plastic Lenses

Single Vision Covered by Copay Up to $25

Bifocal Covered by Copay Up to $40

Trifocal Covered by Copay Up to $60

Lenticular $80 allowance Up to $40

Lenses Options (standard)

Tint (solid and gradient) $15** N/A**UV Coating $15** N/A**

Scratch Resistance $15** N/A**

Anti-reflective 20% discount** N/A**Progressive (add-on to bifocal) 20% discount** N/A**

Contact Lenses

Conventional $120 allowance Up to $100

Disposables $120 allowance Up to $100Medically Necessary $210 allowance Up to $210

Lasik Preferred Pricing - see Provider for details.

AlwaysCareElite Vision Plan B Option

Alwayscarebenefits.com or call 888.729.5433extension 2013 for a list of participating providers.

Members should log in to AlwaysAssist atwww.alwayscarebenefits.com to see the providersthat accept their plan. We encourage you tocontact AlwaysCare or your selected provider priorto visiting their location.

Wal-Mart locations will not extend discounts onframes above the plan allowance, lens options,contact lenses or contact lens fittings. Someproviders may not offer discounts on prestigeframes or amounts over the allowed benefit.

For information on how to use your benefits atCostco Optical locations please login as a currentmember at www.alwayscarebenefit.com .

AlwaysCare VisionMember Services

888.729.5433 Ext. 2013www.alwayscarebenefits.com

**AlwaysCare lens options varyby provider. Value Added

Providers provide UV coating,scratch resistance coating, anti-reflective, transition, tints andpolycarbonates for fixed copays.Other AlwaysCare providers,such as Service Plus Providers,offer a 20% discount for theseadd-on services.

*AlwaysCare providers includeWalMart, Pearle Vision, SearsOptical, Target Optical, JCPenney Optical and Eyemasters.



U pon your date of hire with ABC, all full-time,active employees working at least 40 hoursper week are enrolled in the ABCs groupemployee life and accidental death anddismemberment (AD&D) plan through Mutual ofOmaha. These plans are provided at no cost toyou.

Your Basic Life and AD&D insurance provides youwith one times your Basic Annual Earnings up to a

Group Basic Life/AD&D Insurance

If you are eligible for the ABCs Basic Life/AD&Dcoverage, you also have the option of

purchasing additional supplemental employee Lifeand AD&D insurance at your own expense. Thereare two options available:

Option I: From a minimum benefit of $20,000 to amaximum benefit of the lesser of $500,000 or 5times your Basic Annual Salary, in increments of$10,000. AD&D benefits are NOT available withthis option.

Option II: From a minimum benefit of $20,000 up

to a maximum benefit of the lesser of $500,000 or5 times your Basic Annual Salary, in increments of$10,000. AD&D amount is equal to your amount ofOptional Life Insurance in force.

maximum of $160,000.Your Basic Life and AD&Dreduces to 67% when youreach age 65 and to 50%when you reach age 70.Both these plans cancelupon your retirement.

Please see your Mutual of Omaha employeecertificate for more information on your Life/AD&Dbenefits.

Optional Supplemental Life/AD&D InsuranceA Group Life Insurance Enrollment card must becompleted in order for you to purchase thisadditional coverage. In addition, you will berequired to complete an Evidence of Insurability (proof of good health) form if you increase theamount of insurance which you have previouslypurchased, or elect any amount greater than$100,000.

Long Term Disability Insurance

T he ABC Company provides for all full-timeemployees, working at least 40 hours perweek, Long Term Disability (LTD) Insurance.

This benefit is designed to provide you with incomeshould you become disabled and are unable towork. You are eligible to collect LTD benefits afterfulfilling an elimination period of 90 daysthat is,you are continuously Totally or Partially disabledfor a period of 90 days. After this period, you areeligible to collect 60% of your Total MonthlyEarnings, up to a maximum of $6,000.

Should you wish to purchase, at your ownexpense, additional LTD coverage of 60% of your

income up to a maximum of$7,000, you will need tocomplete an Evidence of

Insurability Form .Your LTD payment is subject toreductions of your employmentearnings.

Please see your employeecertificate from Mutual of Omahafor more details regarding your Long TermDisability Benefit.

Life and Disability Benefits



support.

The maximum benefitamount for children undersix months of age is $4,000.

Your amount of DependentOptional Life may notexceed 50% of your Optional Life Insuranceamount.

You must purchase additional Supplemental Life Insurance for yourself in order to purchase it for your children.

You must complete a Group Life Enrollment Cardto enroll in optional dependent life benefitcoverage.

Please see your Mutual of Omaha employeecertificate for more information.

Insurance for yourself in order to purchase it for your spouse.

You must complete a Group Life Enrollment Cardto enroll in optional dependent life benefitcoverage.

Evidence of Insurability is required for your Optional Supplemental or Optional Dependent Life for anyof the following reasons:

You, on your initial Eligibility Date, elect no Dependent Life coverage and subsequently electDependent Optional Life Insurance at a later date;

You elect an amount of Life Insurance for your dependent in excess of the Guarantee Issue Amount;

You elect Employee Basic Life Insurance only and subsequently elect Employee Optional LifeInsurance and Dependent Optional Life Insurance; or

You elect an increase in your amount of Optional Life Insurance.

Optional Dependent Spouse Life

I f you are eligible for the DIAs Basic Life/AD&Dcoverage, you also have the option ofpurchasing, at your own expense, additional

Supplemental Life Insurance for your dependentspouse.

You may elect an amount of Dependent SpouseOptional Life Insurance in $5,000 increments up toa maximum benefit of $10,000, not to exceed 50%of your amount of Optional Life Insurance. If youwish to purchase coverage in excess of $10,000 toa maximum of $50,000, an Evidence of Insurability Form must be completed for your dependent.

You must purchase additional Supplemental Life

Optional Dependent Child Life

E mployees eligible for ABCs Basic Life/AD&Dcoverage, may also have the option ofpurchasing, at your own expense, additionalSupplemental Dependent Child Optional LifeInsurance for your dependent, unmarried children.

For children under the age of 19 you may purchaseDependent Child Optional Life in one of threeoptions:

Option I : $1,000Option II : $5,000

Option III : $10,000

C o v e r a g e m a y b eextended for children age19 to 25 if your child is afull-time enrolled studentand depends on you for50% or more of their

Life and Disability Benefits



Premium Contribution Schedule

BCBSM Community Blue 3 PPO Individual 2 Person Family Fam. Cont.

Twice Monthly Contribution $76.31 $171.70 $206.04 $38.16

Estimated Tax Bracket 1 x 27.05 x 27.05 x 27.05 x 27.05

Tax Savings $20.64 $46.44 $55.73 $10.32Effect to take home pay $55.67 $125.26 $150.31 $27.84Annual Tax Savings $495 $1,208 $1,449 $268

BCN Healthy Blue Living HMO Individual 2 Person Family Fam. Cont. 2

Twice Monthly Contribution $25.41 $58.45 $66.07 $12.71Estimated Tax Bracket 1 x 27.05 x 27.05 x 27.05 x 27.05

Tax Savings $6.87 $15.81 $17.87 $3.44Effect to take home pay $18.54 $42.64 $48.20 $9.27Annual Tax Savings $165 $379 $429 $83

Delta Dental Individual 2 Person Family Fam. Cont. 2



Tax Savings $0.40 $0.80 $1.98 $0.00Effect to take home pay $1.07 $2.14 $5.33 $0.00Annual Tax Savings $10 $19 $47 $0

AlwaysCare Vision Individual 2 Person Family Fam. Cont. 2



Tax Savings $0.07 $0.38 $0.53 $0.00Effect to take home pay $0.18 $1.02 $1.44 $0.00Annual Tax Savings $2 $9 $13 $01. Estimated tax bracket - Assumes the lowest federal income tax bracket which is currently 15%, 4.4% state income tax and7.65% FICA tax. If you are in a higher tax bracket your savings will be greater.2. Fam. Cont. - Family Continuation is an additional rate charged for dependents age 19 to age 25 if a full time student or meet theIRS definition of a dependent. See page 19 for more information on the Family Continuance rider.

P ayroll contributions are required for employees to participate in either of the BCBSM and BCN medicalplans, Delta Dental and the AlwaysCare vision coverage. If you have elected voluntary coveragethrough Mututal of Omaha for optional employee life and dependent life insurance, you will find those rateson the carriers age-banded rate table. You must complete an ABC Election Form to acknowledge yourunderstanding of the payroll deductions taken on a twice monthly basis for the premium.



Eligibility and Waiving Coverage

W hen you enroll in ABCs medical plan, yourcoverage is as follows:BCBS and BCN define eligible dependents as yourspouse and unmarried children until the end of thecalendar year in which they reach age 19.

Coverage may be extended, by way of a family continuance to the end of the year in which adependent turns age 25. See below for moreinformation on the family continuance.

Delta Dental defines eligible dependents as yourspouse and unmarried children until the end of thecalendar year in which they reach age 19.Coverage may be extended to the age of 25 if theylegally reside with and are a member of thehousehold and dependent upon the subscriberwithin the meaning of the IRS personal exemption

code.AlwaysCareAlwaysCareAlwaysCare Vision Care defines eligibledependents as spouse and unmarried children tothe age of 19. Coverage may be extended to theage of 25 if a dependent is unmarried, and a fulltime student.

Children over 19 who are physically or mentallyhandicapped may also be eligible for coverage.Contact Human Resources if you have a specialsituation. Note: You must notify BCBSM and BCNof this situation before the end of the year in which

the dependent turns 19 ( or age 25 if meeting the criteria of a family continuance. See page 23 for definition ).

Same gender domestic partners may be added tothe plans, provided certain criteria is met. Thedomestic partner must be 18 years or older andneither domestic partner may be legally marriednor related.

BCBS requires proof the subscriber and domesticpartner have lived together for the past 12consecutive months in the form of a driver's

license, voter registration, student ID, etc. Also, asigned and notarized affidavit of domesticpartnership must be submitted to BCBS.

BCN requires proof of financial interdependency ofthe subscriber and domestic partner by submission

of proof of joint bank accounts, joint homeownership or some other specified documentedproof. BCN requires proof the subscriber anddomestic partner have lived together for the past12 consecutive months in the form of a driver'slicense, voter registration, student ID, etc. Also asigned and notarized affidavit of domesticpartnership is required. Delta and AlwaysCarealso require documentation.

You and your eligible dependents will becomeeligible to participate in any or all of the selectedplan benefits upon completion of your waitingperiod. Human Resources will advise you of yourwaiting period and effective date of coverage.

Keep in mind you mustenroll your eligible

dependents (new baby ornew spouse) within 30days of the qualifyinge v e n t ( t h e i r b i r t h ,adoption, your marriage,etc. ). If you fail to do so,they will not be eligibleuntil the next open enrollment period for aneffective date of January 1, 2010.

In the case of legal separation or divorce, coveragefor your former spouse will terminate on that date.Do not assume coverage will automatically continuesimply because you are required to providecoverage under the terms of a divorce decree.

When enrolling in the medical plan, complete theenrollment/change of status form for the plan andthe ABC Election Form and turn it into HumanResources.

If you are covered under another group healthplan, you may waive medical coverage ( with proof of other coverage ). Keep in mind if you choose towaive coverage, you may not be able to return to

the plan until the next openenrollment of January 2010unless specific circumstancesapply ( e.g. a qualifying event such as involuntary loss of spouses employment, divorce,etc .).

If you should lose coverage inthis way, you may enroll in theplan within 30 days from thedate of loss.

You must enroll your eligible dependents(new baby or new spouse) within 30 daysof the qualifying event ( their birth,adoption, your marriage, etc. ).



Your Plan Status

W hen you enroll in a benefit plan, your planstatus is as follows:Individual Coverage:Provides coverage for the employee only.

Two-Person Coverage:Provides coverage for the employee plus onedependent (combination of employee plus spouseor employee plus one dependent child).

Family Coverage:Includes the employee plus two or moredependents (combination of employee plus spouseand one or more dependent children or employeeplus two or more dependent children).

Family Continuance Coverage:If you enroll in the BCBS or BCN medical plans,coverage may be extended, by way of a Family Continuance , to the end of the year in which a

dependent child turns age 25, if they are unmarriedand a full time student, or earning a gross incomeof less than four times the current IRS personalexemption.

The Family Continuance is an additional rideradded to the subscribers BCBS or BCN contract toallow coverage for 19-25 year old childdependents. If you have a dependent child age 19who meets this criteria, be sure to contact HumanResources before the end of the year to have yourdependent childsstatus changed tothat of FamilyC o n t i n u a n c e .Failure to do so willresult in BCBSM orBCN removing yourdependent fromyour plan effectiveJanuary 1st.

The Blues Discount Services and Programs

W hen you become a BCBSM or BCNcustomer, there are several wellnessprograms available to members and theirdependents. Designed to improve health and

complement traditional health care, some of theprograms also save employees money. Go towww.bcbsm.com/member/ or www.mibcn.com forinformation on money saving discount programsand services.

BlueSafeBlueSafeBlueSafe This is a discount program at variousMichigan retailers. Members save money on avariety of safety and health equipment like bikehelmets, life vests, and more.

Naturally Blue Members can obtaincomplementary health services at a discount. This

program includes services such as acupuncture,exercise/movement, diet and supplement advisors,wellness/fitness centers, reference library, andmore.

Quit the Nic! A free smoking cessation program,Quit the Nic! , has a proven track record of helpingmembers give up tobacco for good. Participantsreceive telephone support, educational materials,and opportunities to speak with a health coachabout how to kick the habit. Our health coacheshelp develop a plan of action and establish a quit

date. They also serve as a support system byoffering encouragement, answering questions andevaluating progress.

If you are enrolled in the BCN HBL HMO plan, youmust join Quit the Nic! if you smoke in order toremain in the Enhanced Benefit Level. Call800.775.BLUE (2583) to join.

BlueHealth Connection The BlueHealthConnection Health Coach Hot Line provides youwith access to registered nurses and other healtheducation materials. Supported by board-certifiedphysicians, their nurses assist individuals who maybe uncertain about whether to seek medical care.

If you are enrolled in the BCN Healthy Blue Living

HMO plan, a BlueHealth Connection Health Coachmay contact you on a case management basis.To ensure continued enrollment in the EnhancedBenefit Level, you must return any phone callsfrom the Health Coach.

Weight Watchers Membersreceive a discount on WeightWatchers memberships and feesby showing their identificationcard.



Womens and Childrens Rights

The Womens Health and Cancer Right Act (WHCRA) of 1998 was a part of the omnibusappropriations bill passed by Congress and signed

into law on October 21, 1998. This law applies togroup health plans, health insurance companiesand HMOs, if the plans or coverage providemedical and surgical benefits for a mastectomy.

Under WHCRA, mastectomy benefits must includecoverage for:

Reconstruction of the breast upon which themastectomy has been performed,

Surgery and reconstruction of the other breastto produce a symmetrical or balanced appearance,

Prostheses (or breast implant), and

Physical complications at all stages ofmastectomy, including lymphedema.

Coverage for reconstructive breast surgery maynot be denied or reduced on the grounds that it iscosmetic in nature or that it otherwise does notmeet the coverage definition of medicallynecessary. Benefits must be provided on the

The Newborns Act Group health plans and health insurance issuers

generally may not, under Federal law, restrictbenefits for any hospital length of stay inconnection with childbirth for the mother ornewborn child to less than 48 hours following avaginal delivery, or less than 96 hours following acesarean section. However, Federal law generallydoes not prohibit the mother's or newborn'sattending provider, after consulting with themother, from discharging the mother or hernewborn earlier than 48 hours (or 96 hours asapplicable).

same basis as for any otherillness or injury under themedical plan.

Mastectomy benefits mayhave yearly deductibles andcoinsurance like thoseestablished for other benefitsunder the plan or coverage.

The WHCRA will not allow:

Plans and insurance issuers to deny patientseligibility or continued eligibility to enroll or renewcoverage under the plan to avoid the requirementsof WHCRA.

Plans and insurance issuers to provideincentives to, or penalize doctors to cause them toprovide care in a manner not supportive withWHCRA.

WHCRA is administered by the U.S. Departmentsof Labor and Health and Human Services. Moreinformation is available from the Department ofLabors website, at www.dol.gov/ebsa.

Coverage for reconstructive breast surgery may not be denied or reduced on the grounds that it is cosmetic in nature or that it otherwise does not meet the coverage definition of medically necessary. Benefits must be provided on the same basis as for any other illness or injury under the medical plan.

In any case, plans and issuers may not, underFederal law, require that a provider obtainauthorization from the plan or the insurance issuerfor prescribing a length of stay not in excess of 48hours (or 96 hours).

Newborns & Mothers Health Protection Act

Womens Health and Cancer Rights Act



authorizing payment fortreatment only in emergencysituations.

When an emergency roomclaim has been denied, andyou feel it was an emergencysituation, you should requesta copy of the emergency room report or ask thehospital to resubmit the claim with the emergencyroom notes. The claim will be reviewed by amedical professional to see if the signs andsymptoms met the criteria of an emergency at thetime of treatment.

Y our health plan will pay for the treatment ofserious symptoms only when the condition ( or its symptoms ) occurs suddenly and unexpectedlyand the physician agrees when the patient arrivedin the emergency room, a threat to life and bodilyfunctions appeared to exist. Treatment must begiven within 72 hours of the onset of the condition

to be deemed an emergency.Services not covered in the Emergency Roominclude the following:

Routine medical care given in a hospitalemergency room. Routine means carenormally provided in a physicians office forconditions such as a common cold, headache,back pain, or slight fever.

Treatment of chronic (long lasting)conditions requiring repeated visits to thehospital, unless there is a sudden life

threatening change in the condition, orsymptoms the attending physician agreesappeared life threatening.

Follow up visits after treatment for the originalemergency.

Physicians and hospitals use insurance guidelinesto determine what services qualify as medicalemergencies.

The guidelines ensure you are covered in anemergency, but minimize health care costs by

O ne of the most frequently asked questions is,When are emergencies covered under theplan? To avoid unnecessary expenses, you needto know what qualifies as an emergency, and thebenefits available for emergency services.

Covered services for emergencies include twocategories:

Accidental Injury

Medical Emergency

An accidental injury is any injury caused by anexternal action, object or chemical agent.

Examples of accidental injuries include, but are notlimited to: sprains or cuts requiring prompttreatment by a physician; inhalation of smoke and

burns; swallowing ofpoison; overdoses ofmedication; frostbite;

allergic reactions causedby bee stings or insectbites; and attemptedsuicide.

A medical emergency is an internal condition thatthreatens life or bodily functions, or one that couldresult in serious bodily harm unless treatedpromptly.

Examples of a medical emergency include, but arenot limited to: severe chest pain; severe bleeding(not a result of an injury); convulsions; and loss of

consciousness.

EmergenciesWhen Are Emergencies Covered?

What Will My Health Plan Cover in the ER?

An alternative to the Emergency Room is anUrgent Care Facility . An urgent care facilityis a medical facility separate from a hospital,where ambulatory patients can be treated on awalk-in basis without an appointment, andreceive immediate, non-routine, urgent care.This does not include primary care physiciansor specialists.

Urgent Care is for those times when yourcondition is not serious enough to be anemergency but you need urgent medicalattention. Your copayment is lower in anurgent care facility than in the emergencyroom.


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This brief description of the benefits and options that are available for this plan year provides a general overview of the benefits. Actual provisions contained in the insurance contracts and plan documents will be relied upon solely, in administration and interpretations of the plans.

25900 W. 11 Mile Road, Suite 210Southfield, MI 48034

Phone: 248.355.9600 Fax: 248.355.3145www.jsclarkagency.com

Documents

Sample Employee Benefits Newsletter-JS Clark Agency-Employee Benefits Consultants