2017-2018 employee benefit plan overview for€¦ · this plan allows you to pay for unreimbursed...
TRANSCRIPT
HR Contact:Whitney Marinoff(312) [email protected]
Produced on: 06/13/2017 www.benefitpartnersgroup.com
2017-2018 Employee Benefit Plan Overview
for
Employee Benefits Overview
Employee Benefits – Enrollment Guide
Open Enrollment: June 1ST – 15th, 2017 Effective Date: July 1st, 2017
New Hire Waiting Period: 1st of the month following date of hire
Enrollment will be completed through your Employee Portal on the Paylocity site, under the Web Benefits section.
IMPORTANT - If you are not returning to Distinctive Schools next year, but wish to continue your benefits through the summer, you must participate in Open Enrollment. Failure to do so will result in a lapse in your benefits. Health Insurance – BlueCross BlueShield You and your dependents may enroll in one of the two plan options illustrated in the summary provided. Detailed plan and rate details are included in the BlueCross BlueShield enrollment booklet. Here are the instructions to search for providers in the BlueCross BlueShield PPO Network:
Go to www.bcbsil.com Click on the link “Find a Doctor” on the right-hand side Choose State and click “Start Search” Under Select a Health Plan, choose Participating Provider Organization (PPO) Search by Doctor Name, Facility or Location Participating Physicians/Hospitals will appear on the list
Dental Insurance – Guardian You and your dependents may enroll in one of the two plan options illustrated in the summary provided. Detailed plan and rate details are included in the Guardian enrollment booklet. Here are the instructions to search for dentists in the Guardian Group Dental PPO or DMO Network:
Go to www.guardianlife.com Click on the link “Find a Provider” at the top Click on “Find a Dentist” link Once you provide your City, State or Zip Code, click PPO or Managed Dental Care (DMO) Participating Dentists will appear on the list
Basic Term Life Insurance – Guardian Basic Term Life Insurance is provided to all full-time eligible employees. Plan details are included in the Guardian enrollment booklet. Distinctive Schools pays the full premium for this benefit. Short Term Disability Insurance – Guardian Short Term Disability Insurance is provided to all full-time eligible employees. Plan details are included in the Guardian enrollment booklet. Distinctive Schools pays the full premium for this benefit.
Long Term Disability Insurance – Guardian Long Term Disability Insurance is provided to all full-time eligible employees. Plan details are included in the Guardian enrollment booklet. Distinctive Schools pays the full premium for this benefit. Voluntary Term Life Insurance – Guardian You are eligible for Voluntary Term Life insurance. This is a voluntary benefit and paid by the employee. Plan and rate details are included in the Guardian enrollment booklet. Voluntary Vision Insurance – Vision Service Plan (VSP) You and your dependents may enroll in the vision plan. Plan and rate details are included in the Vision Service Plan enrollment booklet.
Here are the instructions to search for vision providers in the Vision Network: Go to www.vsp.com You can search providers by location or name Select the “Choice” Network under Doctor Network and click Search Participating Optometrists/Facilities’ will appear on the list
Flexible Spending Account (FSA) Full-time employees are eligible to participate in a Flexible Spending Account through Employee Benefit Corporation. This plan allows you to pay for unreimbursed medical and dependent care with pre-tax dollars. 403(B) Plan – Principal Financial Group You are eligible to participate in the 403(B) Plan with Distinctive Schools. This plan is administered through Principal Financial Group. Details are provided both online and in your 403(B) enrollment booklet.
Each employee is responsible to review their plan benefits and make an informed decision regarding coverage elections. If you have any questions regarding your benefits, you should speak with Whitney Marinoff in HR. If you have personal questions, you are welcome to call one of the advisors at Benefit Partners Group. They are available Monday through Friday between 8am and 5pm, toll-free at 877.247.8817.
Michaelanne Berktold Kristin Nelson Agency Manager - ext. 103 Account Manager - ext. 114
[email protected] [email protected]
Jolie Duval 403(B) Support - ext. 105
This document contains general information regarding Distinctive School’s benefits. It is not an official plan document. The provisions of the plan document prevail in any conflict between this summary and the plan documents. Distinctive School reserves the right to change, amend or terminate any of the plans at any time.
BlueCross BlueShield
Medical
-Medical Plan Options and Rates
-Summary of Benefits and Coverage (SBC’s)
-Wellness Benefits
-Online Resources and Additional Information
5/26/2017
INSURER
MEDICAL BENEFITS Out-of-Network In-Network Out-of-Network
Annual Deductible $500 (3x's family) $1,000 (3x's family) $2,600 (3x's family) $5,200 (3x's family)
Benefits Paid at Following PPO Discount Usual & Customary PPO Discount Usual & Customary
Hospital Stay 80% after deductible $300 co-pay then 100% after deductible 80% after deductible60% after deductible
Out-patient Surgical Care 80% after deductible 60% after deductible 100% after deductible 80% after deductible
Out-patient Non-Surgical Care 80% after deductible 60% after deductible 100% after deductible 80% after deductible
Emergency Room
Maternity 80% after deductible $300 co-pay then 100% after deductible 80% after deductible60% after deductible
Doctor Office Visits $30 co-pay 60% after deductible 100% after deductible 80% after deductible
Specialist Office Visits $50 co-pay 60% after deductible 100% after deductible 80% after deductible
Preventive Care Coverage at 100% Included Coverage at 100% IncludedDeductible does not apply Deductible does not apply
Prescription Drugs - Retail
Prescription Drugs - Mail Order
Annual Out of Pocket Maximum (Includes Deductible) -Individual $3,500 $7,000 $2,600 $10,400 -Family $10,500 $21,000 $7,800 $31,200
Lifetime Medical Maximum
NETWORK ACCESS
MONTHLY COST TO EMPLOYEEEmployeeEmployee + SpouseEmployee + Child(ren)Family
In-Network
This spreadsheet represents a brief summary of benefits. Please refer to policy certificate for actual benefits.
$1,000 (2x's family) RX Out-of-Pocket Limit
Unlimited
$50 - Level 3
2x's co-pay - 90 day supply
PPO - www.bcbsil.com
$159.10$499.60
PPO - www.bcbsil.com
Medical Plan Options
$15 - Level 1$30 - Level 2
$552.22$802.58
BlueCross BlueShield PPO$500 Deductible Plan
(Option #1)
$150 co-pay then 80%
BlueCross BlueShield HSA$2,600 Deductible Plan
(Option #2)
**Embedded Deductible
100% after deductible
$136.60$428.95$474.12$689.07
Plans and rates effective July 1, 2017.
100% after deductible
100% after deductible
Unlimited
Sum
mar
y of B
enef
its an
d Co
vera
ge: W
hat th
is Pl
an C
over
s & W
hat Y
ou P
ay F
or C
over
ed S
ervic
es
Cove
rage
Per
iod:
07/01
/2017
06
/30/20
18
Dist
inct
ive S
choo
ls: P
PO P
lan
Cove
rage
for:
Indivi
dual
+ Fa
mily
| Plan
Typ
e: P
PO
Blue
Cro
ss a
nd B
lue
Shie
ld o
f Illi
nois,
a D
ivisi
on o
f Hea
lth C
are
Serv
ice C
orpo
ratio
n, a
Mut
ual L
egal
Rese
rve
Com
pany
, an
Inde
pend
ent L
icen
see
of th
e Blu
e Cr
oss a
nd B
lue S
hield
Ass
ociat
ion
SBC
IL PP
O LG
20
17-2
1 of
6
The S
umm
ary o
f Ben
efits
and
Cove
rage
(SBC
) doc
umen
t will
help
you
choo
se a
healt
h pl
an. T
he S
BC sh
ows y
ou h
ow yo
u an
d th
e plan
wou
ld
shar
e the
cost
for c
over
ed h
ealth
care
serv
ices.
NOT
E: In
form
atio
n ab
out t
he co
st o
f thi
s plan
(call
ed th
e pre
miu
m) w
ill be
pro
vided
sepa
rate
ly.
This
is on
ly a s
umm
ary.
For m
ore i
nfor
matio
n abo
ut yo
ur co
vera
ge, o
r to
get a
copy
of th
e com
plete
term
s of c
over
age,
call 1
-800
-892
-280
3 or
at
For g
ener
al de
finitio
ns of
comm
on te
rms,
such
as a
llowe
d am
ount,
balan
ce b
illing
, coin
sura
nce,
copa
ymen
t, ded
uctib
le, p
rovid
er, o
r othe
r und
erlin
ed te
rms s
ee th
e Gl
ossa
ry. Y
ou ca
n vie
w the
Glos
sary
at ww
w.do
l.gov
/ebsa
/pdf/S
BCUn
iform
Glos
sary
.pdf o
r call
1-80
0-89
2-28
03 to
requ
est a
copy
. Im
porta
nt Q
uest
ions
An
swer
s W
hy T
his M
atte
rs:
Wha
t is t
he o
vera
ll de
duct
ible?
For I
n-Ne
twor
k:
$500
Indiv
idual/
$1,50
0 Fa
mily
For O
ut-of-
Netw
ork:
$1
,000 I
ndivi
dual/
$3,00
0 Fa
mily
Gene
rally
, you
mus
t pay
all o
f the
costs
from
pro
vider
s up t
o the
dedu
ctible
amou
nt be
fore t
his pl
an be
gins t
o pay
. If y
ou h
ave o
ther f
amily
mem
bers
on th
e pla
n, ea
ch fa
mily
memb
er m
ust m
eet th
eir
own i
ndivi
dual
dedu
ctible
until
the t
otal a
moun
t of d
educ
tible
expe
nses
paid
by al
l fam
ily m
embe
rs me
ets th
e ove
rall f
amily
ded
uctib
le.
Are t
here
serv
ices
cove
red
befo
re yo
u m
eet
your
ded
uctib
le?
Yes.
Certa
in pr
even
tive c
are,
is co
vere
d be
fore y
ou m
eet y
our d
educ
tible.
This
plan
dedu
ctible
am
ount.
But
a cop
ayme
nt or
coins
uran
ce m
ay ap
ply.
For e
xamp
le, th
is pla
n co
vers
certa
in pr
even
tive s
ervic
es w
ithou
t cos
t sha
ring a
nd
befor
e you
mee
t you
r ded
uctib
le. S
ee a
list o
f cov
ered
prev
entiv
e se
rvice
s at
https
://www
.healt
hcar
e.gov
/cove
rage
/prev
entiv
e-ca
re-b
enef
its/.
Are t
here
oth
er
dedu
ctib
les fo
r spe
cific
serv
ices?
Yes.
$300
dedu
ctible
for O
ut-of
-Netw
ork
hosp
ital a
dmiss
ion. T
here
are n
o othe
r sp
ecific
dedu
ctible
s. Yo
u mu
st pa
y all o
f the c
osts
for t
hese
servi
ces u
p to t
he sp
ecific
ded
uctib
le am
ount
befor
e this
plan
begin
s to p
ay fo
r the
se se
rvice
s.
Wha
t is t
he o
ut-o
f-poc
ket
limit
for t
his p
lan?
For I
n-Ne
twor
k:
$3
,500 I
ndivi
dual/
$10,5
00 F
amily
Fo
r Out-
of-Ne
twor
k:
$7
,000 I
ndivi
dual/
$21,0
00 F
amily
The
out-o
f-poc
ket li
mit is
the m
ost y
ou co
uld pa
y in a
year
for c
over
ed se
rvice
s.
If you
hav
e othe
r fam
ily m
embe
rs in
this p
lan, th
ey ha
ve to
mee
t their
own o
ut-of-
pock
et lim
its un
til the
over
all fa
mily
out-o
f-poc
ket li
mit h
as be
en m
et.
Wha
t is n
ot in
clude
d in
th
e out
-of-p
ocke
t lim
it?
Prem
iums,
balan
ced-
billed
char
ges,
and
healt
hcar
e this
plan
out-o
f-poc
ket li
mit
Will
you
pay l
ess i
f you
us
e a n
etwo
rk p
rovid
er?
Yes.
See w
ww.bc
bsil.c
om or
call
1-80
0-89
2-28
03 fo
r a lis
t of n
etwor
k pr
ovide
rs.
This
plan u
ses a
pro
vider
netw
ork.
You w
ill pa
y les
s if y
ou us
e a p
rovid
er
netw
ork.
You w
ill pa
y the
mos
t if yo
u use
an o
ut-o
f-netw
ork p
rovid
er, a
nd yo
u migh
t re
ceive
a bi
ll fro
m a
prov
ider f
or th
e diffe
renc
e betw
your
plan
pays
(bala
nce b
illing
). Be
awa
re, y
our n
etwor
k pro
vider
migh
t use
an o
ut-of
-ne
twor
k pro
vider
for s
ome
servi
ces (
such
as la
b wor
k). C
heck
with
your
pro
vider
befor
e yo
u ge
t ser
vices
. Do
you
need
a re
ferra
l to
see a
spec
ialist
? No
. Yo
u ca
n see
the
spec
ialist
you c
hoos
e wi
thou
t a re
ferra
l.
https
://poli
cy-sr
v.box
.com
/s/hn
z8ch
o0wo
geaie
bsvc
3lenb
jftsljd
h.
2
of 6
* For
mor
e info
rmati
on ab
out li
mitat
ions a
nd ex
cepti
ons,
see
the p
lan or
polic
y doc
umen
t at
All c
opay
men
t and
coin
sura
nce c
osts
show
n in
this c
hart
are a
fter y
our d
educ
tible
has b
een m
et, if
a de
duct
ible
appli
es.
Com
mon
Me
dica
l Eve
nt
Serv
ices Y
ou M
ay N
eed
Wha
t You
Will
Pay
Lim
itatio
ns, E
xcep
tions
, & O
ther
Im
porta
nt In
form
atio
n In
-Net
work
Pro
vider
(Y
ou w
ill pa
y the
leas
t) Ou
t-of-N
etwor
k Pro
vider
(Y
ou w
ill pa
y the
mos
t)
If yo
u vis
it a h
ealth
ca
re
offi
ce
or cl
inic
Prim
ary c
are
visit t
o tre
at an
injur
y or
illne
ss
$30 c
opay
/visit
; de
ducti
ble do
es no
t app
ly 40
% co
insur
ance
No
ne
Spec
ialist
visit
$5
0 cop
ay/vi
sit;
dedu
ctible
does
not a
pply
40%
coins
uran
ce
None
Prev
entiv
e car
e/scre
ening
/ im
muniz
ation
No
Cha
rge;
dedu
ctible
do
es no
t app
ly 40
% co
insur
ance
pr
even
tive.
Ask y
our p
rovid
er if
the se
rvice
s ne
eded
are p
reve
ntive
. The
n che
ck w
hat
your
plan
will
pay f
or.
If yo
u ha
ve a
test
Di
agno
stic t
est (
x-ray
, bloo
d wor
k)
20%
coins
uran
ce
40%
coins
uran
ce
None
Im
aging
(CT/
PET
scan
s, MR
Is)
20%
coins
uran
ce
40%
coins
uran
ce
None
If yo
u ne
ed d
rugs
to
treat
your
illne
ss o
r co
nditi
on
More
infor
matio
n abo
ut pr
escr
iptio
n dr
ug
cove
rage
is av
ailab
le at
www.
bcbs
il.com
.
Gene
ric dr
ugs
$15 c
opay
/pres
cript
ion
(retai
l) $3
0 cop
ay/p
resc
riptio
n (m
ail o
rder
) de
ducti
ble do
es no
t app
ly
$15 c
opay
/pre
scrip
tion
(retai
l) de
ducti
ble do
es no
t app
ly 34
-day
supp
ly at
Ret
ail
90-d
ay su
pply
at M
ail O
rder
Rx
Out
-of-P
ocke
t Exp
ense
Limi
t: $1
,000 I
ndivi
dual/
$2,00
0 Fa
mily
For O
ut-of-
Netw
ork d
rug
prov
ider,
you a
re
resp
onsib
le fo
r 25%
of th
e elig
ible
amou
nt aft
er th
e cop
ay.
cove
red
with
no co
st to
the m
embe
r. Fo
r a
full li
st of
thes
e pre
scrip
tions
and/o
r ser
vices
, ple
ase c
ontac
t Cus
tome
r Ser
vice.
Prefe
rred b
rand
dru
gs
$30 c
opay
/pres
cript
ion
(retai
l) $6
0 cop
ay/p
resc
riptio
n (m
ail o
rder
) de
ducti
ble do
es no
t app
ly
$30 c
opay
/pre
scrip
tion
(retai
l) de
ducti
ble do
es no
t app
ly
Non-
prefe
rred
bran
d dru
gs
$50 c
opay
/pres
cript
ion
(retai
l) $1
00 co
pay/p
resc
riptio
n (m
ail o
rder
) de
ducti
ble do
es no
t app
ly
$50 c
opay
/pre
scrip
tion
(retai
l) de
ducti
ble do
es no
t app
ly
Spec
ialty
drug
s $5
0 cop
ay/pr
escr
iption
(re
tail)
dedu
ctible
does
not a
pply
Not C
over
ed
https
://poli
cy-sr
v.box
.com
/s/hn
z8ch
o0wo
geaie
bsvc
3lenb
jftsljd
h.
3
of 6
* For
mor
e info
rmati
on ab
out li
mitat
ions a
nd ex
cepti
ons,
see
the p
lan or
polic
y doc
umen
t at
Com
mon
Me
dica
l Eve
nt
Serv
ices Y
ou M
ay N
eed
Wha
t You
Will
Pay
Lim
itatio
ns,E
xcep
tions
, & O
ther
Im
porta
nt In
form
atio
n In
-Net
work
Pro
vider
(You
will
pay t
he le
ast)
Out-o
f-Netw
ork P
rovid
er(Y
ou w
ill pa
y the
mos
t)
If yo
u ha
ve o
utpa
tient
su
rger
y
Facil
ity fe
e (e
.g., a
mbula
tory
surg
ery c
ente
r) 20
% co
insur
ance
40
% co
insur
ance
No
ne
Phys
ician
/surg
eon
fees
20%
coins
uran
ce
40%
coins
uran
ce
None
If yo
u ne
ed
imm
ediat
e med
ical
atte
ntio
n
Emer
genc
y roo
m ca
re
$150
copa
y/visi
t; de
ducti
ble do
es no
t app
ly plu
s 20%
coins
uran
ce
$150
copa
y/visi
t; de
ducti
ble do
es no
t app
ly plu
s 20%
coins
uran
ce
Copa
y waiv
ed if
admi
tted.
Emer
genc
y med
ical tr
ansp
ortat
ion
20%
coins
uran
ce
40%
coins
uran
ce
None
Ur
gent
care
20
% co
insur
ance
40
% co
insur
ance
No
ne
If yo
u ha
ve a
hosp
ital
stay
Fa
cility
fee
(e.g.
, hos
pital
room
) 20
% co
insur
ance
40
% co
insur
ance
$3
00 de
ducti
ble pe
r adm
ission
Out-
of-
Netw
ork p
rovid
ers.
Phys
ician
/surg
eon
fees
20%
coins
uran
ce
40%
coins
uran
ce
None
If yo
u ne
ed m
enta
l he
alth,
beh
avio
ral
healt
h, o
r sub
stan
ce
abus
e ser
vices
Outpa
tient
servi
ces
20%
coins
uran
ce
40
% co
insur
ance
$3
0 PCP
copa
y app
lies t
o psy
choth
erap
y off
ice vi
sit on
ly.
Inpati
ent s
ervic
es
20%
coins
uran
ce
40%
coins
uran
ce
$300
dedu
ctible
per a
dmiss
ion O
ut-of
-Ne
twor
k pro
vider
s.
If yo
u ar
e pre
gnan
t
Offic
e vis
its
$30 c
opay
/visit
40
% co
insur
ance
Co
pay a
pplie
s to f
irst p
rena
tal vi
sit (p
er
preg
nanc
y).
Cost
shar
ing do
es no
t app
ly for
prev
entiv
e se
rvice
s. De
pend
ing on
the t
ype o
f ser
vices
, a c
opay
ment
, coin
sura
nce,
or de
ducti
ble
may a
pply.
Mate
rnity
care
may
inclu
de te
sts
and s
ervic
es de
scrib
ed el
sewh
ere i
n the
SB
C (i.e
. ultra
soun
d.)
Child
birth/
deliv
ery p
rofes
siona
l se
rvice
s 20
% co
insur
ance
40
% co
insur
ance
Child
birth/
deliv
ery f
acilit
y ser
vices
20
% co
insur
ance
40
% co
insur
ance
$3
00 de
ducti
ble pe
r adm
ission
Out-
of-
Netw
ork p
rovid
ers.
https
://poli
cy-sr
v.box
.com
/s/hn
z8ch
o0wo
geaie
bsvc
3lenb
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Guardian Ancillary
-Dental Plan Options and Rates
-Life, STD and LTD Benefits
-Voluntary Life Benefits and Rates
-Wellness Benefits
-Online Resources and Additional Information
5/26/2017
INSURER
DENTAL BENEFITS
Annual Deductible*Only applies to Basic and Major Services
Benefits are paid at the following
Diagnostic & Preventive- Oral examination- X-rays- Cleaning
Basic Procedures- Emergency Exams- Simple Oral Surgery- Fillings- Periodontics- Endodontics
Major Procedures- Crowns- Inlays- Dentures
Annual Benefit Maximum
Orthodontia Procedures Lifetime Maximum - Child
MONTHLY COST TO EMPLOYEEEmployeeFamily
Not Covered
Co-pay Schedule
HMO
In-Network
Plans and rates effective July 1, 2017.
80th percentile
This spreadsheet represents a brief summary of benefits. Please refer to policy certificate for actual benefits.
50% 50%
Co-pay Schedule
Not Covered
$5 Office Visit Co-pay
Dental Plan Options
(Option #1)
Out-of-Network
No Deductible Not Covered
HMO Discount Not Covered
Co-pay Schedule
80%
Co-pay Schedule Not Covered
Unlimited Not Covered
Not Covered
$1,000
$1,000
100%
In-Network Out-of-Network
$50 (3x's family) $50 (3x's family)
80%
(Option #2)PPO
50% 50%
$4.60$19.56
$8.90$43.70
PPO Discount Usual & Customary
100%
5/26/2017
INSURER
LIFE INSURANCE BENEFITS
STD INSURANCE BENEFITS
LTD INSURANCE BENEFITS
Weekly Maximum - $600
Benefit Duration - To SSNRA
Benefit Percentage - 60% of Salary
1x's salary to $300,000 maximum
Elimination Period - 15 days Injury / 15 days Sickness
Age Reduction Schedule:
35% at age 65; 50% at age 70
Employer Paid Benefits
Plans and rates effective July 1, 2017.This spreadsheet represents a brief summary of benefits. Please refer to policy certificate for actual benefits.
Benefit Duration - 11 weeks
Benefit Percentage - 60% of salary
Monthly Maximum - $6,000
Elimination Period - 90 days
5/26/2017
Plans and rates effective July 1, 2017.
60-64
INSURER
Child(ren) Benefits
$0.090Employee Benefits
15-34
AM BEST: A+ (Superior)
$10,000 minimum to $250,000 maximumGuarantee Issue: $150,000
$5,000 minimum to 100% of employee coverage,up to $100,000 maximumGuarantee Issue: $50,000
$0.420Spouse Benefits
$3.130
$10.040
35-39
RATE TABLE
Age Table
BENEFIT DESCRIPTION
$0.640
Monthly Rates (per $1,000)
65-69
80-99
40-4445-4950-54
70-74
55-59
Voluntary Life / AD&D Insurance
$0.990
$0.110$0.160$0.260
This spreadsheet represents a brief summary of benefits. Please refer to policy certificate for actual benefits.
75-79 $5.140
$1.760
10% of employee amount to $10,000 maximumChild Rate - $.205 per $1,000
Guardian®Disability and Absence Management
TeleGuardTM Claims SubmissionOne call, no forms, equals faster return to work outcomes1
Guardian works smarter to keep claims submission simple for your clients. We offer claims services that allow employers to focus on their business, and employees to focus on recovery and getting back to work.
TeleGuard Advantages• Innovative TeleGuard pre-authorization cards conveniently provide employees with everything they need to know in
order to phone in a claim, while also allowing us to obtain medical certification quickly from physicians.
• Employees make just one call to our toll-free, in-house telephonic intake unit.
• Specially-trained TeleGuard experts collect all information from employees over the phone, and get answers we need the first time, helping to expedite claims review and determination. Employees always speak with a knowledgeable Guardian claims representative — not a representative from an outsourced customer service center.
• No claim forms to complete. No mail delays. Just fast, easy claim filing and accurate claims decisions.
The ABC Company G#999999
Instructions
To expedite your Short Term disability claim filing process, please call to initiate your claim as soon as your disability begins. We can be reached at 1-888-262-5670, Monday through Friday between the hours of 9:00 am – 9:00pm (EST). Please be prepared to provide the following information:
1. Your full name, address, phone number and social security number 2. Your employer contact name and phone number 3. Your physician’s name, address, phone number and fax number 4. If you have not already done so, please sign the authorization portion of this
card (on the reverse side) and provide a copy to your physician to be retained in your patient file.
Important: Prior to initiating your claim, please inform your physician that a Guardian representative will be contacting their office by phone, to obtain medical information concerning your claim.
The ABC Company G#999999
Authorization
In order to determine if Short Term Disability benefits are payable, Guardian requires your authorization for the release of medical information pertaining to your claim. Please authorize the release of this information by signing below and ask your physician(s) to retain a photo-copy of this card. You should also advise your physician that a Guardian Representative will be calling shortly to obtain the needed information. Please retain your original card, in the event that it is needed in the future. I authorize my physician and/or medical provider to disclose to Guardian any information regarding my diagnosis, treatment, disability status and medical history.
________________________________ ___________________Employee / Patient Signature Date
STD DISABILITY CLAIMS
TELEGUARD
Contact your Guardian Group Sales Representative for more information.
Claims are processed within 7 days or less2
Nurse outreach is made within 2 business days
1. Short term disability durations are 7% shorter when TeleGuard is used compared to industry average duration on all STD claims. Gen Re Group Disability Rate & Risk Management Study 2012. 2. Based on average turnaround time with Guardian Short Term Disability Claims Department. Guardian's Group Short Term Disability Insurance is underwritten and issued by The Guardian Life Insurance Company of America, New York, NY. Products are not available in all states. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents are the final arbiter of coverage. Policy Form # GP-1-STD07-1.0
2014-14683 Exp. 11/16
• Claim intake is done by Disability Intake Unit
• Claim is reviewed by dedicated Case Manager
• Outreach to Employer to verify eligibility
• Outreach to Nurse for medical information and treatment plan
• Satisfy elimination period
• Claim is reviewed by Guardian and decision made
The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004. GUARDIAN® and the GUARDIAN G® logo are registered service marks of The Guardian Life Insurance Company of America and are used with express permission.
GuardianAnytime.com
LIFE DENTAL VISION DISABILITY ABSENCE STOP LOSS ASOSUPPLEMENTAL HEALTH
Day 1 Days 2-3 Days 4-5 Days 6-7
Guardian®
Value-AddedServices
• 86% of identity theft victims experienced the misuse of an existing credit card or bank account1
• 2/3 of identity thief victims reported a direct financial loss1
• People in households with an annual income of $75,000 or more had the highest prevalence of identity theft, compared to those in all other income brackets1
Contact your Guardian Broker or Group Sales Representative for more information.
ID theft can be stressful, costly and confusing to anyone who experiences it. Unfortunately it is not uncommon. In fact in 2014, an estimated 17.6 million Americans (about 7% of U.S. residents) age 16 or older — were victims of identity theft.1
We can help. Our WorkLife Matters2 employee assistance program offers dedicated support — both online and by phone — that can help members avoid, identify and resolve incidences of ID theft and fraud. These include:
Fraud CounselingCertified Fraud Resolution Specialists (FRS) are available to help members who suspect or know they are victims of ID theft/fraud. In addition to an up to 60-minute, free personalized consultation, the FRS will provide:
• An action plan for notifying creditors and third parties of the ID theft, including assistance with ID theft affidavits
• A comprehensive Emergency Response Kit™ to help members dispute fraudulent debt, and restore their identity, good credit and financial reputation
• Steps necessary to avoid future ID theft losses and damages to their credit score
Financial CounselingID theft or fraud may have unwanted financial consequences. Members will have access, by phone, to a specially trained financial counselor who can provide guidance for up to 30 days — all at no cost.
Legal Counseling If legal support is needed, members are entitled to a free 30 minute consultation with an attorney and discounts on legal services through network attorneys. Referrals to mediation specialists can also be provided to assist members with resolving disputes.
ID Theft LibraryHelpful articles, FAQs and tips can be accessed online anytime on the WorkLifeMatters website. These cover a broad range of topics, such as fraud prevention, individual state ID theft laws, credit and check fraud — as well as links to government agencies that can also assist members.
Enhance your Benefits ProgramEmployers are automatically eligible for WorkLifeMatters when they offer three or more qualifying lines of Guardian coverage3 — making it the ideal complement to your overall employee protection program.
File# 2016-31718 Exp. 1/18
The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004. GUARDIAN® and the GUARDIAN G® logo are registered service marks of The Guardian Life Insurance Company of America and are used with express permission.
GuardianAnytime.com
LIFE DENTAL VISION DISABILITY ABSENCE STOP LOSS ASOSUPPLEMENTAL HEALTH
1 Victims of Identity Theft Report 2014, the Bureau of Justice Statistics, www.bjs.gov. 2 WorkLifeMatters Program services are provided by Integrated Behavioral Health, Inc., andits contractors. Guardian does not provide any part of WorkLifeMatters program services. Guardian is not responsible or liable for care or advice given by any provider orresource under the program. This information is for illustrative purposes only. It is not a contract. Only the Administration Agreement can provide the actual terms, services,limitations and exclusions. Guardian and IBH reserve the right to discontinue the WorkLifeMatters program at any time without notice. Legal services provided throughWorkLifeMatters will not be provided in connection with or preparation for any action against Guardian, IBH, or your employer. WorkLifeMatters Program is not an insurance benefit and may not be available in all states. 3 Qualifying groups with up to 500 lives. Groups with more than 500 lives will be determined on a case by case basis
WORKLIFEMATTERSEMPLOYEE ASSISTANCE PROGRAM
Identity Theft and Fraud Resolution Services
Contact your Guardian Group Sales Representative for more information.
Legal and Financial ServicesWorkLifeMatters, an Employee Assistance Program, through Integrated Behavioral Health, provides a range of legal and financial services to eligible members to help with issues related to:
File# 2016-21788 Exp. 4/18
The Guardian Life Insurance Company of America®(Guardian), 7 Hanover Square, New York, NY 10004. GUARDIAN® and the GUARDIAN G® logo are registered service marks of The Guardian Life Insurance Company of America and are used with express permission.
GuardianAnytime.com
LIFE DENTAL VISION DISABILITY ABSENCE STOP LOSS ASOSUPPLEMENTAL HEALTH
Guardian®
Value-AddedServices
WORKLIFEMATTERSEMPLOYEE ASSISTANCE PROGRAM
Employee Program Highlights
• Assistance with a wide range of legal and financial services
• Complimentary consultations with financial and legal professionals – plus discounts on legal services
• Simple and inexpensive legal document preparation available online
• Unlimited access to a dedicated website
www.ibhworklife.com
1-800-386-7055
Work Life Matters Program services are provided by Integrated Behavioral Health, Inc., and its contractors. Guardian does not provide any part of WorkLifeMattersprogram services. Guardian is not responsible or liable for care or advice given by any provider or resource under the program. This information is for illustrative purposes only. It is not a contract. Only the Administration Agreement can provide the actual terms, services, limitations and exclusions. Guardian and IBH reserve the right to discontinue the WorkLifeMattersprogram at any time without notice. Legal services provided through WorkLifeMatterswill not be provided in connection with or preparation for any action against Guardian, IBH, or your employer. WorkLifeMatters Program is not an insurance benefit and may not be available in all states.
• Budgeting
• Civil/Consumer Issues
• Criminal Matters
• Debt/Credit Counseling
• Estate Planning Law
• Financial Services
• Immigration
• IRS Matters
• Motor Vehicle
• Personal/Family Legal
• Real Estate
• Tax Consultation/ Preparation
• And more!
Financial ServicesEmployees can receive telephonic consultations with seasoned financial professionals and certified public accountants (CPA). Unlimited telephonic counseling, and 30 days of financial coaching is available. Local referrals are available for more complex financial planning issues, such as: credit counseling, debt and budget assistance, basic tax planning, and retirement and college planning questions.
Legal ServicesEmployees can receive an initial 30 minute office or telephone consultation with an attorney. Plus, if the attorney is retained to provide legal services, the member can apply a 25% discount off the attorney’s normal hourly rate on legal fees. Virtually all types of legal matters are eligible for these services.
Assistance with Document PreparationA simple and inexpensive online process enable members to complete their own legal document preparation from home. This eliminates the cost of an attorney or dealing with lengthy completion and delivery periods!
Dedicated Legal/Financial WebsiteEach member is provided with unlimited access to a dedicated legal/financial website, which includes legal and financial tools. Examples include legal and financial forms, financial calculators, helpful articles and answers to frequently asked questions.
The Guardian Life Insurance Company of America®(Guardian), 7 Hanover Square, New York, NY 10004. GUARDIAN® and the GUARDIAN G® logo are registered service marks of The Guardian Life Insurance Company of America and are used with express permission.
The College Selection and Application Process Just Got Easier
Sending a child off to college is an exciting time for both parents and students, but the process of researching, applying, and selecting a college can be time-consuming and frustrating. There are many factors to consider – quality, cost, location, social life, etc. –and it’s hard to go it alone through the maze of applications and deadlines.
That’s why Guardian gives you access to College Planning USA, one of the nation’s leading providers of college planning services. Offered through your WorkLifeMatters Employee Assistance Program (EAP), in conjunction with Integrated Behavioral Health (IBH), College Planning USA gives you the knowledge and expertise to find the right college that fits your child academically, socially and financially.
College Planning USA will work with you and your child through a series of steps to figure out the right college experience for your son or daughter:
• Calculate the Expected Family Contribution (EFC): Understanding the minimum expected cost your family can pay for a year in college helps determine which colleges could be a good match financially.
• Look for the best fit: We’ll take into account the wants and needs of a student based on size of school and class, geographic location, type of campus, Greek system, and athletics. We’ll look at colleges where the student is in the top 10-25% of incoming freshman and should receive the highest amount of merit-based scholarships.
• Complete Financial Aid Forms: We’ll encourage you and your child to submit the Free Application for Federal Student Aid, the CSS/Profile Form, and the institutional forms (required directly by certain colleges). Filling out these forms saves time, eliminates stress, ensures accuracy, and guarantees meeting college and state deadlines.
• Review Financial Aid Awards for accuracy and comparative advantages: We’ll conduct an annual review of more than 1,900 colleges’ award history for the past year, assist in the “appeals” process when appropriate, and provide a rationale for an appeal.
• Communicate regularly via monthly teleconferences and webinars: These events will be appropriately timed throughout the year, will address what your student should be working on, and what his/her grades should be. We offer additional services covering test preparation, essay writing and critique, assistance with applications, academic coaching, and private tutoring (additional fees may apply).
WorkLifeMatters
Manage Your College Planning Online!
The Engus System is an online hub you can use to plan for college.
• Access to timelines, tasks for each year of high school, virtual tours of colleges, and fact sheets.
• “What if” scenarios for possible college acceptance.
• Financial aid packages based on your child’s “vital signs” (GPA, SAT, ACT scores, Class Rank).
• Color coding system helps your child see how he/she compares to other applicants based on vitals.
2017-37504 Exp. 3/19
Work Life Matters Program services are provided by Integrated Behavioral Health, Inc., and its contractors. Guardian does not provide any part of WorkLifeMatters program services. Guardian is not responsible or liable for care or advice given by any provider or resource under the program. This information is for illustrative purposes only. It is not a contract. Only the AdministrationAgreement can provide the actual terms, services, limitations and exclusions. Guardian and IBH reserve the right to discontinue the WorkLifeMatters program at any time without notice. Legal services provided through WorkLifeMatters will not be provided in connection with or preparation for any action against Guardian, IBH, or your employer. WorkLifeBenefits program is not an insurance benefit and may not be available in all states.
Need Help Choosing a College for Your Child?
To learn more about College Planning USA, call EAP at1-800-386-7055, 9:00 a.m. - 8:00 p.m. EST Monday - Friday, or visit www.collegeplanningusa.net
College Tuition Benefit Self-Registration Welcome to the College Tuition Benefits Rewards program! You can now create your Rewards account and start accumulating your Tuition Rewards that can be used to pay up to one year’s tuition at SAGE Scholar Consortium colleges. How does it work? You can use your College Tuition Benefits Rewards at over 330 private colleges and universities across the nation. 80% of SAGE colleges have received an “America’s Best” ranking by US News and World Reports.
Each Tuition Reward point equals a $1 tuition reduction
You will receive rewards each year you have Guardian Dental Plan benefits
Tuition Rewards can be given to your relatives including children, nephews, nieces, and grandchildren.
See how quickly your account can grow!
Policy Year Subscriber Reward* Subscriber’s Reward Balance (Balance does not accrue interest)
Initial Registration Subscriber and Student Rewards 2,500 (2,000 + 500) 2 2,000 4,500 3 2,000 6,500 4 4,500 (Bonus Year) 11,000 5 2,000 13,000 6 2,000 15,000 7 2,000 17,000
*After initial registration, future points credited 30 days after plan anniversary.
To learn more about the program and how to get started, go to: www.Guardian.CollegeTuitionBenefit.com to set up your account. If you have any questions,
please feel free to visit the website or contact College Tuition Benefit directly at 215-839-0119. Guardian's Group Dental Insurance is underwritten by The Guardian Life Insurance Company of America (Guardian) or its subsidiaries. The Tuition Rewards program is provided by College Tuition Benefit. The Guardian Life Insurance Company of America (Guardian) does not provide any services related to this program. College Tuition Benefit is not a subsidiary or an affiliate of Guardian. #2014-15077 Exp. 12/16.
Register Today! (Print and cut out ID Card)
Register @ www.Guardian.CollegeTuitionBenefit.com
User ID: 468966
Password: Guardian
College Tuition Benefits Rewards – ID Card
The College Tuition Benefit 150 E. Swedesford Road, Suite 100
Wayne, PA 19087 Phone: (215) 839-0119
Fax: (215) 392-3255
fold
The Guardian Life Insurance Company of America®(Guardian), 7 Hanover Square, New York, NY 10004. GUARDIAN® and the GUARDIAN G® logo are registered service marks of The Guardian Life Insurance Company of America and are used with express permission.
New Maternity Education Site!
Get Maternity and Parenting Resources in One LocationWhen you’re starting or expanding your family, there’s a lot of things you need to know about, and it’s not always easy to find the right information. WorkLifeMatters Employee Assistance Program (EAP) provides maternity and parenting resources all in one location on guardianmaternity.ibhworklife.com so you can easily find what you need. From articles to FAQs to videos, you can get information on topics including fertility, labor and delivery, first-time parenting, working with your partner, and much more.
WorkLifeMatters
Connect with a Counselor for Free Support Services:
Email: [email protected]
Phone: 1-800-386-7055Available 24 hours a day, 7 days a week*
Web: www.ibhworklife.comUser name: Matters Password: wlm70101
File#2017-33584 Exp. 1/19
*Office hours: Monday-Friday 6am-5pm PST. Live answer exchange available after hours. WorkLifeMatters Program services are provided by Integrated Behavioral Health, Inc., and its contractors. Guardian does not provide any part of WorkLifeMatters Program services. Guardian is not responsible or liable for care or advice given by any provider or resource under the program. This information is for illustrative purposes only. It is not a contract. Only the Administration Agreement can provide the actual terms, services, limitations and exclusions. Guardian and IBH reserve the right to discontinue the WorkLifeMatters Program at any time without notice. Integrated Behavioral Health Laguna Niguel, CA. WorkLifeMattersProgram is not an insurance benefit and may not be available in all states.
TopicsCovered
Available Resources
Special Features
• Fertility• Pregnancy• Labor & Delivery• New parenting • Working with your
partner
• Articles• FAQs• Videos• Contacts
• Easy online access• One stop shop• Information
updated regularly• Help with related
issues such as stress management
Visit our new maternity site at guardianmaternity.ibhworklife.com and get answers to all your parenting questions!
Your Employee Assistance ProgramWorkLifeMatters offers services to help promote well-being and enhance the quality of life for you and your family:
• Support & guidance with family and personal issues
• Unlimited access to resources online or over-the-phone
• Up to 3 free face-to-face counseling sessions with an IBH network provider
• Free 30 minute consultation with an attorney, CPA, or other financial professional
Vision Service Plan Voluntary Vision
-Voluntary Vision Plan and Rates
5/24/17
Your VSP Vision Benefits Summary DISTINCTIVE SCHOOLS and VSP provide you with an affordable eye care plan.
VSP Coverage Effective Date: 07/01/2017 VSP Provider Network: VSP Choice Benefit Description Copay Frequency
Your Coverage with a VSP Provider
WellVision Exam Focuses on your eyes and overall wellness $10 Every 12 months
Prescription Glasses $25 See frame and lenses
Frame
$130 allowance for a wide selection of frames $150 allowance for featured frame brands 20% savings on the amount over your allowance $70 Costco® frame allowance
Included in Prescription
Glasses
Every 24 months
Lenses Single vision, lined bifocal, and lined trifocal lenses
Polycarbonate lenses for dependent children
Included in Prescription
Glasses
Every 12 months
Lens Enhancements
Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 20-25% on other lens enhancements
$55 $95 - $105 $150 - $175
Every 12 months
Contacts (instead of glasses)
$130 allowance for contacts; copay does not apply Contact lens exam (fitting and evaluation) Up to $60 Every 12 months
Extra Savings
Glasses and Sunglasses Extra $20 to spend on featured frame brands. Go to vsp.com/special offers for details. 20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam.
Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam
Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
Your Monthly Contribution $5.51 Member only $8.81 Member + spouse $9.00 Member + child(ren) $14.50 Member + family
Your Coverage with Out-of-Network Providers
Visit vsp.com for details, if you plan to see a provider other than a VSP network provider.
Exam .............................................................................. up to $45 Lined Bifocal Lenses ........................................... up to $50 Progressive Lenses ............................................. up to $50 Frame ............................................................................ up to $70 Lined Trifocal Lenses ......................................... up to $65 Contacts .................................................................... up to $105 Single Vision Lenses ........................................... up to $30
Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.
Contact us. 800.877.7195 | vsp.com
1Brands/Promotion subject to change.
©2014 Vision Service Plan. All rights reserved. VSP, VSP Vision care for life, WellVision Exam, and eyeconic.com are registered trademarks of Vision Service Plan. Flexon is a registered trademark of Marchon Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.
Employee Benefit Corporation Flexible Spending Account
-Flexible Spending Account Plan Information
My Company PlanThis document defines the BESTflex Plan options by yourcompany and helps you complete your BESTflex PlanEnrollment Form.
Appendix to the BESTflex Plan Summary PlanDescription and Program Summary
My PlanDistinctive Schools Flexible Compensation Plan - D1074Plan Name:
The BESTflexSM PlanType of Plan:
My Plan DatesJuly 1Plan Effective Date:July 1 - June 30Plan Year:
EligibilityCoverage Type Eligibility
Dependent Care FSA Employees are eligible the first of the month following date of hire. Only employees who are regularlyscheduled to work at least 30 hours weekly can participate.
Health Care FSA Employees are eligible the first of the month following date of hire. Only employees who are regularlyscheduled to work at least 30 hours weekly can participate.
My BESTflex Plan BenefitsGroup Insurance PremiumsGroup Insurance Premiums are automatically withheld from your paycheck for each pay period before taxes for:
Benefit Renewal Date
Dental Insurance July 1
Medical Insurance July 1
My BESTflex Plan AccountsDependent Care FSA
You use the Dependent Care FSA for daycare expenses that are incurred for the care of your child(ren) or other eligible dependents.
Minimum Plan Year Contribution: None for this plan year
Maximum Plan Year Contribution: $5,000.00
The Dependent Care FSA limits spending to a $5,000 maximum for married and head-of-household filers or $2500 for those who are married and filingseparately. If you are married and your spouse is either a full-time student or is physically or mentally incapable of caring for him or herself, the reimbursement limitis: $250 in any one month if you have only one dependent or $500 in any one month if you have more than one dependent.
Health Care FSA
You use the Health Care FSA for out-of-pocket, unreimbursed medical, vision, and dental expenses incurred by you, your spouse, or your eligible dependent(s).
Minimum Plan Year Contribution: None for this plan yearMaximum Plan Year Contribution: $2,600.00
The Health Care FSA limits employee salary reduction contributions to the amount listed in the Maximum Plan Year Contribution section above. The limit applies ona per participant basis. Employer contributions to the Health Care FSA are not included in the limit. See the Employer Contributions section below.
My BESTflex Plan Options
Administration FeesAdministrative fees are paid by your employer.
Cash in Lieu of Health Coverage
Employer pays no cash to employees who decline coverage.
Web Address:www.ebcflex.com
U.S. Mail:Employee Benefits CorporationPO Box 44347Madison, WI 53744-4347
Phone:Monday-Friday, 7:00- 5:00 CST608 831 8445800 346 2126
Fax:608 831 4790
My Company PlanThis document defines the BESTflex Plan options by yourcompany and helps you complete your BESTflex PlanEnrollment Form.
Appendix to the BESTflex Plan Summary PlanDescription and Program Summary
Employer ContributionsEmployer makes no contribution for this plan year.
Additional Important Information About Your BESTflex PlanClaim Reimbursement Process
To receive reimbursement for eligible expenses, you need to submit a claim to Employee Benefits Corporation. You can get account information bycalling Participant Services at 800 346 2126.
You may submit claims for eligible expenses incurred during the plan year until September 30, 2018.
Grace Period
Grace Period is not available for this plan year.
Health Care FSA RolloverThe BESTflex Plan Health Care FSA allows up to $500 to be rolled over from the unused balances from the previous plan year. The $500 rolloveramount is not included towards your annual election for the future plan year. Reimbursements will be paid out using new dollars first and then rolloverdollars.
My Company InformationContact Person: Human Resources Representative
Employer Name: Distinctive Schools
Address: 910 W. Van Buren Street, Suite 315Chicago, IL 60607
Telephone: (312)332-4998
Federal ID Number: 27-4967763
ERISA Status: The Plan is governed by ERISA.
Legal Plan Name: Distinctive Schools Flexible Compensation Plan
Plan Number: 501
Agent of Process: Whitney Marinoff
Collectively Bargained: No
Legal Information
Your company, Distinctive Schools, has adopted the BESTflex Plan (the Plan) and has engaged Employee Benefits Corporation, P.O. Box44347, Madison, WI, 53744 (telephone: 608 831 8445; toll free: 800 346 2126), to provide services related to the Plan. For purposes offederal law, the Employer is the Plan Sponsor and the Plan Administrator.
Printed on: 5/30/2017
Web Address:www.ebcflex.com
U.S. Mail:Employee Benefits CorporationPO Box 44347Madison, WI 53744-4347
Phone:Monday-Friday, 7:00- 5:00 CST608 831 8445800 346 2126
Fax:608 831 4790
Enrollment Guide
SM Plan and you’ll pay less
Tax-Free Dollars
8037-7 06/16 Standard
SM |
Eligible Expenses List
Claim Form
800 346 2126
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Our online videos explain where extra FSA dollars come from, the
Watch them now!
Eligible Expenses
© 2016 Employee Benefits Corporation 198-16 08/16 Standard
Eligible Health Care FSA Expense Examples:
Dental ServicesCrowns/BridgesDental X-RaysDenturesExams/Teeth CleaningsExtractionsFillingsGum TreatmentsOral SurgeryOrthodontia/Braces
Insurance-Related ItemsCopaysCoinsuranceDeductibles
Lab Exams/TestsBlood TestsCardiographsDiagnostic FeesLaboratory FeesSpinal Fluid TestsUrine/Stool AnalysesX-Rays
MedicationInsulinPrescribed Birth ControlPrescribed Vitamins* Prescription Drugs*
Other Medical Treatments/ProceduresAcupunctureAlcoholism (inpatient treatment)Chiropractor ServicesDrug Addiction (inpatient treatment)Hearing ExamsHospital ServicesInfertility In-vitro FertilizationNorplant Insertion or RemovalPatterning ExercisesPhysical Examination (not employment related)Physical TherapySpeech TherapySterilizationVaccinations and ImmunizationsVasectomy and Vasectomy ReversalsWell Baby Care
Other Medical Supplies and ServicesAbdominal/Back SupportsAmbulance Services
Arch Supports/Orthopedic InsolesBlood Pressure MonitorsBreast Pumps and Lactation SuppliesCompression Hosiery Above 30 mmHgContact Lens Solution and CleanersContraceptivesCounseling (except for Marriage and Family)CrutchesGuide Dog (for visually/hearing impaired person)Hearing Aids & BatteriesHospital BedIce PackInsulin SuppliesLearning Disability (special school/teacher)Mastectomy BrasMedic Alert Bracelet or NecklaceMedical Miles, Tolls, and ParkingOrthopedic Shoes**Oxygen EquipmentPregnancy TestsPre-natal VitaminsProsthesisRubbing AlcoholSplints/CastsSuntan Lotion/Sunscreen greater than SPF 14Syringes
The BESTflexSM Plan | Eligible Expenses 2
We make it easy.
P: 800 346 2126 | 608 831 8445F: 608 831 4790P.O. Box 44347 Madison, WI 53744-4347An employee-owned companywww.ebcflex.com
Ineligible Health Care FSA Expense Examples:Baby-SittingCanceled Appointment FeesChapstick/Lip BalmContact Lens InsuranceCosmeticsCosmetic Surgery/ProceduresDance/Exercise/Fitness ProgramsDental BleachingDiaper ServiceElectrolysisExercise EquipmentEyeglass Insurance
Face CreamFeminine Hygiene ProductsHair Loss MedicationsHair TransplantHealth Club DuesIllegal Operation or TreatmentsInsurance PremiumsLong Term Care PremiumsMarriage or Family CounselingMassage Therapy***Maternity ClothesMattressesMeals that are not part of inpatient careMoisturizersNutritional Supplements***Personal Trainer
Prescription Drug Discount ProgramsPrescription Drugs for Hair LossProvider DiscountsRogaineShampoos/SoapsSpecial Foods***Suntan Lotion/Sunscreen less than SPF 15Supplements*** (for general health)Teeth Whitening/BleachingToiletriesToothbrushes (including battery operated)ToothpasteVision Discount Program PremiumsVitamins*** (for general health)Weight Loss Programs*** (for general health)
Transportation Expenses (essential to medical care)WheelchairWigs (hair loss due to disease)
Vision ExpensesContact LensesContact Lens Solution
Eye ExaminationsEyeglassesLaser Eye SurgeriesPrescription SunglassesRadial Keratotomy/LASIKReading Glasses
This list is not meant to be all inclusive. Other expenses not listed may also qualify. Please refer to Section 213 of the Internal Revenue Code or call our toll-free Participant Services line at 800 346 2126.
Eligible with Doctor’s Prescription:Important note about over-the-counter (OTC) drug reimbursement: Due to health care reform regulations, the Health Care FSA only reimburses OTC drug expenses if you have and provide a doctor’s prescription for them. Doctor’s prescriptions must include the patient name, medication name, dosage, time frame for treatment and any other state law requirements. Make sure you plan your annual election accordingly.
Allergy MedicinesAntihistaminesAnalgesicsAntacidsAnti-Diarrhea Medications
Anti-Itch MedicationsAnti-Nausea MedicationsAspirinAthletes Foot Creams and PowdersCold Sore RemediesCough DropsCough SyrupsDecongestantsEye DropsFever ReducersFirst Aid Cream (Bactine, diaper rash ointments, calamine lotion, bug bite medication, wart remover treatments)Digestive Tract Relief MedicationsFlu and Cold MedicationsHemorrhoidal MedicationsLaxativesLice and Scabies Treatments
Menstrual Cycle Products (medication for pain and cramp relief)Motion Sickness PillsMuscle/Joint Pain RelieversNasal Sinus SpraysNicotine Gum/PatchesPain RelieversPedialyteRetin A (non-cosmetic)Sinus MedicationsSleeping AidsSmoking Cessation ProductsSore Throat SpraysSpecial Ointments/Burn OintmentsThroat LozengesVapor RubsWeight Loss Drugs (to treat specific disease)***Yeast Infection Treatments
* Excludes drugs imported from Canada and other countries. Some medically necessary items may be covered by the Health Care FSA if prescribed by a physician for a specific medical condition. The prescription should contain the specific medical condition and timeframe for treatment.
** Custom made shoes to treat or alleviate a specific medical condition. Included with the receipt should be a Letter of Medical Necessity from a physician. The excess cost above the normal cost of shoes is the eligible medical expense.
*** Requires documentation from the doctor or care provider indicating use to treat a medical condition. A Letter of Medical Necessity template is available.
Principal Financial Group 403(B) Plan
-403(B) Plan Information
DISTINCTIVE SCHOOLS 403(B) PLAN PLAN HIGHLIGHTS
Eligibility: All employees are generally eligible to participate in the Plan. Please see the
Summary Plan Description about any excluded classes of Employees.
You may enter the Plan at any time specified in the "Enrollment Periods" section specified below.
Enrollment
Periods: On the date you are hired for purposes of Elective Deferrals.
Contributions: You may elect to defer from 0% to 100% of your Compensation on a pre-tax basis. You may also elect to make special 'Roth' contributions to the Plan on an after-tax basis. You may elect to change your elections to contribute to the Plan on the dates established pursuant to Plan Administrator procedures. Federal law also limits the amount you may elect to defer under the Plan ($18,000 in 2017). However, if you are age 50 or over, you may defer an additional amount up to $6,000 (in 2017) and if you have at least 15 years of service with a qualifying organization, you may be able to defer an additional catch-up amount.
Rollovers: The Plan may accept a rollover contribution made on behalf of any employee
who is eligible to participate in the plan; as determined in accordance with procedures established by the Plan Administrator.
Vesting: When you terminate employment you will generally be entitled to the vested
portion of each of your accounts. You will be 100% vested in the amounts you contribute to the plan, including any rollover contributions.
Investing Plan Contributions:
You may direct the investment of all of your Accounts in one or more of the available Investment Funds. Your elections will be subject to such rules and limitations as the Plan Administrator may prescribe. The Plan Administrator may restrict investment transfers to the extent required to comply with applicable law. You may change the investment direction of your Account(s) as of each business day, subject to applicable laws regarding market timing and/or requirements of the funding source. The Plan is intended to constitute a plan described in section 404(c) of ERISA. This means that Plan fiduciaries may be relieved of liability for any of your losses that are the result of your investment elections.
DISTINCTIVE SCHOOLS 403(B) PLAN PLAN HIGHLIGHTS
Distributions: You may receive a distribution from your account under the following
circumstances: Termination of employment After age 59-1/2 From the Rollover Contribution Account at any time Death Disability
Contact
Information: Plan Administrator: As appointed 910 W. Van Buren Street Suite 315 Chicago, Illinois 60607 3123324998
Financial Advisor: Russell Warye, CIC PPC
877-247-8817 Note: These plan highlights are intended to be a very concise overview of plan features. For a detailed description of plan features, please review the Summary Plan Description or contact the Plan Administrator for more information. The plan features described in these plan highlights are subject to change and in the event of a discrepancy between the legal plan document and these highlights (or any other summary of plan features), the plan document shall control.
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