polk school district benefits enrollment guide january 1, 2015 – … resources/benefits... ·...

Polk School District

Benefits Enrollment Guide

January 1, 2015 – December 31, 2015

Welcome to your new Employee Benefits Handbook. This guide is your summary of the non-medical benefit options that are available to eligible employees of Polk School District. Each benefit is designed to protect your health and well-being as well as provide valuable financial protection. Each section of the Employee Benefits Handbook is designed to provide you with plan highlights. The handbook contains information about your Benefit Plans administered by ShawHankins. While the Employee Benefits Handbook is an important component in the benefit communication process, your dedicated ShawHankins service team continues to provide annual enrollment meetings in addition to being available for questions and concerns regarding benefits throughout the plan year. Please review the plans contained in the Employee Benefits Handbook and see how these plans can work for you and your eligible dependents. Your participation is strictly voluntary. The plan year runs from January 1, 2015 to December 31, 2015. This Employee Benefits Handbook is intended for orientation purposes only. It is an abbreviated overview of the plan documents. Please refer to the Certificate Booklet (the contract) available from the plan carriers for complete details. Your Certificate Booklet will provide detailed information regarding copayments, coinsurance, deductibles, exclusions and other benefits. The certificate booklet will govern should a conflict arise relating to the information contained in this summary. This summary does not establish eligibility to participate in or receive benefits from any benefit plan.

Table of Contents

Changes and Eligibility 2

Enrolling in Benefits 3

Dental Benefits 5

Vision Benefits 7

Vision Providers 8

Voluntary Life Insurance 9

Voluntary Life Insurance Rates 10

Disability 11

Disability Rates 12

Flexible Spending Accounts 13

Whole Life with LTC 14

Critical Illness with Cancer 16

Group Accident 18

Disclosure Notices 19

Contact Information Back Cover

This guide is designed to provide you with an overview of the benefits options we offer. The actual benefits available to you and the descriptions of these benefits are governed by the relevant Summary Plan Document (SPD) and our contracts. For more detailed plan information for all lines of coverage listed in guide please call ShawHankins. ShawHankins and Polk School District reserves the right to modify, change, revise, amend or terminate these benefit plans at any time.

New for 2015

Benefit Current New

Dental – Low Plan

(Rate Change)

Employee Only:

Family:

$18.50

$59.13

Employee Only:

Family:

$18.87

$60.31

Dental – High Plan

(Rate Change)

Employee Only:

Family:

$29.96

$99.24

Employee Only:

Family:

$30.56

$101.22

Long Term Disability

(Plan & Rate Change) Please see plan document for full details.

Eligibility

Active employees of Polk School District are classified as: o Full Time

Eligible Dependents are classified as: o Your legal spouse who resides in the United States o Child/stepchild/legal dependent child less than 19 years of age or full time

student until age 26 If your dependent child is approaching 19 and is disabled, an

application for continuation of dependent status must be made within 30 days of the child’s 19th birthday.

Page 2

Benefits Enrollment

BEFORE YOU ENROLL - THINGS TO KNOW

You are REQUIRED to provide the below information/documentation for all dependents/beneficiaries: - First and Last Name - Social Security Number - Date of Birth Please Note: Eligible Dependents are classified as your legal spouse who resides in the United States and/or your biological children/stepchildren/legal dependent children.

HOW TO ENROLL Go to www.polkschooldistrict.bswift.com.

At this time, make sure to disable your pop up blocker.

At the enrollment website enter your Username and Password.

• Username is the first letter of your first name, your last name, last 4 of Social Security Number (ex. jdoe4567).

• Password is the last 4 digits of your Social Security number (ex. 4567).

You will then be prompted to create a permanent password.

Annual Enrollment Period: Begins Monday, October 27, 2014 and ends at midnight on Friday, November 14, 2014.

Enrollment is required. You must go online or contact the ShawHankins Service Center to elect or decline coverage for the new plan year by the deadline noted. • Please contact ShawHankins at 800-994-7429 to speak with a Benefit Consultant if you need

assistance with your annual enrollment. Qualifying Events (refer to your 2015 Summary Plan Description - Special Enrollment Rights): • Once your new plan year elections become effective (January 1st of each year ), you will not be

able to change your elections until the next annual enrollment period unless you experience an eligible qualifying event.

• Examples of qualifying events include: a change in marital status; a change in the number of dependents due to birth, adoption, placement for adoption or death of a dependent; a change in employment status for myself or my spouse; loss or gain of coverage through my spouse; a change in dependents eligibility.

• You must enroll within 30 days from the effective date of a qualifying event. • Please contact ShawHankins at 800-994-7429 to speak with a Benefit Consultant regarding enrollment due to a Qualifying Event. Failure to enroll within the above time period will result in the forfeiture of your eligibility for enrollment

until the beginning of the next plan year.

How To Enroll

NOTE: You are required to enroll in all Benefits. You must add any Dependents you wish to cover to the system at this year’s annual enrollment. To Begin: 1) From the “Home Page” click on the “Enroll Now” link, to begin the election process. 2) On the “Personal & Family Page”, verify your information is accurate and “Add” all eligible dependents you wish to cover under any benefits.

3) To make a plan selection, select the button beside the newly elected plan. If you are covering dependents, make sure to “Select” them by checking off next to their name under Select who to cover with this plan. Then press “Next” at the bottom of the screen.

4) Once you have reviewed and completed your enrollment, click on “I Agree and I am finished with my enrollment”, then click on “Save My Enrollment”.

5) You will now be taken to the final confirmation page to either print or email.

Note: The enrollment images within this guide are for illustrative purposes only. Page 4

Low Dental Plan

Page 5

Polk School District offers dental coverage through MetLife.

Benefit In-Network Out-of-Network Annual Deductible Single Family

$75.00

3 Individual Deductibles

$75.00


Annual Benefit Max $750.00 $750.00

Preventive Services (Type A) 100% of Negotiated Fee* (no deductible)

100% R&C Fee** (no deductible)

Basic Treatment (Type B) 80% of Negotiated Fee* (subject to deductible)

80% R&C Fee** (subject to deductible)

Major Treatment (Type C) Not Covered Not Covered

Orthodontia (Type D) Not Covered Not Covered

*Negotiated Fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated Fees are subject to change. **R&C refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of (1) the dentist’s actual charge, (2) the dentist’s usual charge for the same or similar services, or (3) the charge of most dentists in the same geographical area for the same or similar services as determined by MetLife.

Type A Type B

Routine Exam (2 per benefit period) Fillings

Bitewing X-Rays (1 per benefit period) Sealants for age 16 & under

Cleaning (2 per benefit period) Simple Extractions

Full Mouth X-rays (1 per 60 months) General Anesthesia

Fluoride for children 18 or younger (1 per benefit period) Oral Surgery

Space Maintainers for children up to 17th birthday

Low Plan Sample Procedure Listing:

Pretreatment: While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed.

Tier of Coverage Monthly Cost

Employee Only $18.87

Family $60.31

Late Enrollment Waiting Period: If You do not enroll for Dental Insurance within 31 days of becoming eligible, for the first year that You are covered for Dental Insurance, You will only be covered for oral exams, cleaning of teeth (oral prophylaxis) and fluoride treatment. After the first year of continuous coverage, You will be covered for all Covered Services.

High Dental Plan

Page 6

Polk School District offers dental coverage through MetLife.

Benefit In-Network Out-of-Network Annual Deductible Single Family

$75.00


$75.00


Annual Benefit Max $1,000.00 $1,000.00

Preventive Services (Type A) 100% of Negotiated Fee* (no deductible)

100% R&C Fee** (no deductible)

Basic Treatment (Type B) 80% of Negotiated Fee* (subject to deductible)


Major Treatment (Type C) 50% of Negotiated Fee* (subject to deductible)


Orthodontia (Type D) 50% of Negotiated Fee* (subject to deductible)

50% of Negotiated Fee* (subject to deductible)

Orthodontia Lifetime Maximum $1,500 $1,500

*Negotiated Fee refers to the fees that participating dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated Fees are subject to change. **R&C refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of (1) the dentist’s actual charge, (2) the dentist’s usual charge for the same or similar services, or (3) the charge of most dentists in the same geographical area for the same or similar services as determined by MetLife.

Pretreatment: While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed.

Late Enrollment Waiting Period: If You do not enroll for Dental Insurance within 31 days of becoming eligible, for the first year that You are covered for Dental Insurance, You will only be covered for oral exams, cleaning of teeth (oral prophylaxis) and fluoride treatment. After the first year of continuous coverage, You will be covered for all Covered Services.


Employee Only $30.56

Family $101.22

Type A (100%) Type B (80%) Type C (50%) Routine Exam (2 per benefit period) Fillings Implants

Bitewing X-Rays (1 per benefit period) Sealants for age 16 & under Crowns/Inlays/Onlays (1 in 10

years per tooth)

Cleaning (2 per benefit period) Simple Extractions Bridges and Dentures

Fluoride for children 18 or younger (1 per benefit period) General Anesthesia Endodontics

Space Maintainers for children up to 17th birthday Oral Surgery

Periodontal scaling and root planing (once per quadrant, every 2 years)

Full Mouth X-rays (1 in 60 months) Periodontal surgery (once per quadrant, every 3 years)

High Plan Sample Procedure Listing:

Vision Benefits

Page 7

Polk School District offers the vision plan through Avesis as summarized below.

Benefit In-Network Out-of-Network Frequency

Vision Exam $10 Copay Up to $35 Once every 12 months

Contact Lenses* Allowance Max Amount

Once every 12 months Conventional

Medically Necessary

Up to $130 allowance

$0 Copay; Paid-in-Full

Up to $130

Up to $250

Standard Plastic Lenses

Copayment Max Amount

Once every 12 months Single Vision

Bifocal

Trifocal

$25

$25

$25

Up to $25

Up to $40

Up to $60

Frames $50 Allowance Wholesale, which can be $100 - $150

Retail Up to $65 maximum amount Once every 24 months

Lasik Surgery 5% - 25% Discount on Retail 5% - 25% Discount on Retail 1 per Lifetime

Please note: This plan covers either contact lenses or lenses for your glasses once every 12 months.

Additional Discounts and Features: Progressive Lenses are discounted up to 20% off retail in addition to a $50 allowance Lens Options, Non Covered Items, and Additional Purchases are discounted up to 20% off

retail Specialty Lenses are discounted up to 20% off retail in addition to the corresponding

standard lens allowance


Employee Only $5.21

Family $13.27 Note: Participating Wal-Mart locations cover frames up to a $68 retail value.

Vision Providers

Page 8

SOUTHERN OPTOMETRICS, INC 306 S. COLLEGE ST CEDARTOWN GA (770) 748-5651

RAY POPHAM OD 206 MAIN ST CEDARTOWN GA (770) 748-2443

BRUCE K. BELL, OD 530 HUNTER STREET ROCKMART GA (770) 684-5650

GARY L SMITH, O.D. 1013 NORTH 5TH AVE. ROME GA (706) 232-6767

COOSA EYE CLINIC 2110 SHORTER AVE. ROME GA (706) 290-0098

SOUTHERN OPTOMETRICS, INC. 402 COURTHOUSE SQUARE BUCHANAN GA (770) 646-9100

VILLA RICA EYE CARE 104-C SOUTH CARROLL RD VILLA RICA GA (678) 941-4307

HUFFMAN FAMILY EYE CARE 80 SEVEN HILLS BLVD. DALLAS GA (678) 324-4211

TOTAL EYE CARE 837 JOE FRANK HARRIS PARKWAY CARTERSVILLE GA (770) 382-2020

EYEWORKS 837 JOE FRANK HARRIS PKWY. CARTERSVILLE GA (770) 382-2020

PEARLE VISION 239 MARKET PLACE BLVD CARTERSVILLE GA (770) 607-1449

WAL-MART VISION CENTER #0727 1585 ROME HWY CEDARTOWN GA (770) 748-7406

WAL-MART VISION CENTER #5151 825 CARTERSVILLE HIGHWAY SE ROME GA (706) 292-0838

WAL-MART VISION CENTER #0658 2510 REDMOND CIRCLE ROME GA (706) 236-9595

OPTIKS INC 207 CHESTNUT ST. BREMEN GA (770) 537-5246

WAL-MART VISION CENTER #0856 404 HIGHWAY 27 NORTH BYPASS BREMEN GA (770) 537-5531

WAL-MART VISION CENTER #2732 600 HIGHWAY 61 VILLA RICA GA (770) 459-6601

WAL-MART VISION CENTER #5126 1950 WEST MAIN STREET CENTRE AL (256) 927-9900

WAL-MART VISION CENTER #0615 101 MARKET PLACE BLVD. CARTERSVILLE GA (770) 382-3185

19 VISION PROVIDER SEARCH RESULTS FOR:

POLK SCHOOL DISTRICT Cedartown, GA

A RADIUS OF 30 MILE(S) FROM ZIP CODE 30125

Basic & Voluntary Life Insurance

Page 9

You are eligible to enroll in the Voluntary Term Life and AD&D Insurance program underwritten by UNUM. This enrollment period is an annual opportunity to increase coverage or elect life insurance if you do not already have coverage. Your premium will be based on the coverage amount you elect and your age. Premiums will be paid through the convenience of payroll deduction. If you are currently enrolled in the voluntary term life with Unum, your coverage will automatically rollover unless you complete a new application changing the coverage.

Benefit Coverage

Employee Voluntary Life You can purchase coverage in increments of $10,000 up to the lesser of $500,000 or 5 Times Annual Salary. New Hires: You will have a guarantee issue amount of $200,000. Current Employees: If you are currently enrolled with minimum coverage, you will be allowed to increase coverage to Guarantee Issue amount with no EOI, not to exceed $200,000.

Spouse Voluntary Life You can purchase coverage in increments of $5,000 up to a maximum of $250,000. New Hires: Spouse elections over $25,000 will require Evidence of Insurability. Current Employees: If you are currently enrolled with minimum coverage, you will be allowed to increase coverage to Guarantee Issue amount with no EOI, not to exceed $25,000.

Child(ren) Voluntary Life You can purchase coverage in increments of $5,000 up to a maximum of $10,000. The benefit amount for child(ren) between age 15 days and age 6 months is $1000. Child(ren) age 6+ months are covered to age 19, or 25 if full time student.

You will be considered a Late Entrant if you do not elect minimum coverage when initially eligible or as part of this year’s annual enrollment opportunity. If you later elect coverage, you will be required to complete an Evidence of Insurability (EOI) form that is satisfactory to the insurance carrier before the coverage can become effective.

Term Life Insurance provides valuable financial protection for your family. Polk School District is pleased to offer $20,000 for Administrators, $10,000 for Teachers/Clerical, and $5000 for All Others of Basic Life Insurance & AD&D.

Your policy has an Accelerated Benefit Option which allows you up to 75% of your life insurance coverage in the case of a terminal illness.

Portability – You may be eligible to take coverage with you at group rates in the event that you terminate employment.

Plan includes Waiver of Premium benefit if the insured becomes disabled prior to age 60; following a 9 month waiting period, coverage continues to age 65.

Your benefits reduce by 35% at age 65; 50% at age 70; and 65% of the original amount at age 75.

Voluntary Life and AD&D Insurance Rates

Page 10

Age Employee Rate Age Spouse Rate <25 0.052 <25 0.065

25 – 29 0.052 25 – 29 0.065 30 – 34 0.053 30 – 34 0.066 35 – 39 0.070 35 – 39 0.069 40 – 44 0.098 40 – 44 0.122 45 – 49 0.148 45 – 49 0.185 50 – 54 0.226 50 – 54 0.283 55 – 59 0.364 55 – 59 0.470 60 – 64 0.484 60 – 64 0.710 65 – 69 0.822 65 – 69 1.206 70 – 74 1.460 70 – 74 2.143

75 + 5.537 75 + 8.125 Dependent Child Rate

$0.75 for $5000 $1.50 for $10,000

Note: The premium paid for child coverage is based on the cost of coverage for one child, regardless of how many children you have.

AD&D Coverage Rate Employee: 0.031 Spouse: 0.031

Voluntary Life Insurance Premium Calculation Worksheet

Step 1: Amount of Voluntary Life Insurance _____________________ Desired Amount Step 2: Divide amount of Voluntary Life Insurance in Step 1 by $1000 _____________________ Step 3: Rate from table _____________________ Step 4: Multiply Step 2 by Step 3 _____________________ Monthly Premium

Important Terms to Understand Evidence of Insurability (EOI): Evidence of Insurability is a request to verify good health and is often in the form of a questionnaire. This is required when you are requesting insurance that is over the guarantee issue amount or if you are enrolling after your initial enrollment. Guarantee Issue: Guarantee Issue is the amount of life insurance that you can elect without having to provide evidence of insurability. The guaranteed issue period is 31 days from the date you first become eligible for the plan from your date of hire. If you choose not to enroll when you are first eligible and enroll at a later date, the entire amount of insurance will be subject to evidence of insurability.

Monthly Rates per $1,000

Steps to Calculate Voluntary Life Insurance Premium Per Paycheck

Group Dependent Life Insurance

Spouse Child Rate per Unit $1000 $1000 $0.59 Per Unit

Disability

Page 11

PROVIDED THROUGH UNUM

Benefits Option A

Percentage of Income You may elect a monthly benefit amount in $100 increments not to exceed 60% of your monthly earnings.

Benefits Begin After (Elimination Period)

Injury Sickness

0 Days 14 Days 30 Days 60 Days 90 Days

7 Days 14 Days 30 Days 60 Days 90 Days

Maximum Benefit Duration SS ADEA

Less Than Age 60 To age 65, but not less than 5 years

Age 60 Age 61 Age 62 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68

Age 69+

60 Months 48 Months 42 Months 36 Months 30 Months 24 Months 21 Months 18 Months 15 Months 12 Months

Contributions See Rate Chart on next page

Pre-Existing Condition 3/12*

*Pre-Existing: Benefits will not be paid for disabilities caused by, contributed to by, or resulting from a pre-existing condition. You have a pre-existing condition if you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage, and the disability begins 12 months after the effective date of coverage.

Guarantee Issue:

Coverage is available to you without answering any medical questions or providing evidence of insurability. You may apply for coverage within 60 days after your eligibility date. If you do not apply within 60 days after your eligibility date, you can apply only during an annual enrollment period. Benefits are subject to the pre-existing condition exclusion referenced. Employees who enroll during annual enrollment period, but later decide to increase coverage or change elimination period during a subsequent annual enrollment period will be subject to the pre-existing conclusion for the increased /change benefit amount.

Benefit Reductions:

Your benefits may be reduced if you are receiving benefits from any of the following sources: - Social Security Disability Insurance (please see section for exceptions in policy) - Workers’ Compensation - Other employer-based Insurance coverage you may have - Unemployment benefits - Settlements or judgments for income loss - Retirement benefits that your employer fully or partially pays for (such as a pension plan).

Disability Rates

Page 12


Benefit Duration: SS ADEA

Injury/Sickness Elimination Period (cost per month)

Annual Earnings

Monthly Earnings

Monthly Disability Benefit 0-7 14-14 30-30 60-60 90-90

4000 333 200 8.80 7.32 5.34 3.42 2.74 6000 500 300 13.20 10.98 8.01 5.13 4.11 8000 667 400 17.60 14.64 10.68 6.84 5.48

10000 833 500 22.00 18.30 13.35 8.55 6.85 12000 1000 600 26.40 21.96 16.02 10.26 8.22 14000 1167 700 30.80 25.62 18.69 11.97 9.59 16000 1333 800 35.20 29.28 21.36 13.68 10.96 18000 1500 900 39.60 32.94 24.03 15.39 12.33 20000 1667 1000 44.00 36.60 26.70 17.10 13.70 22000 1833 1100 48.40 40.26 29.37 18.81 15.07 24000 2000 1200 52.80 43.92 32.04 20.52 16.44 26000 2167 1300 57.20 47.58 34.71 22.23 17.81 28000 2333 1400 61.60 51.24 37.38 23.94 19.18 30000 2500 1500 66.00 54.90 40.05 25.65 20.55 32000 2667 1600 70.40 58.56 42.72 27.36 21.92 34000 2833 1700 74.80 62.22 45.39 29.07 23.29 36000 3000 1800 79.20 65.88 48.06 30.78 24.66 38000 3167 1900 83.60 69.54 50.73 32.49 26.03 40000 3333 2000 88.00 73.20 53.40 34.20 27.40 42000 3500 2100 92.40 76.86 56.07 35.91 28.77 44000 3667 2200 96.80 80.52 58.74 37.62 30.14 46000 3833 2300 101.20 84.18 61.41 39.33 31.51 48000 4000 2400 105.60 87.84 64.08 41.04 32.88 50000 4167 2500 110.00 91.50 66.75 42.75 34.25 52000 4333 2600 114.40 95.16 69.42 44.46 35.62 54000 4500 2700 118.80 98.82 72.09 46.17 36.99 56000 4667 2800 123.20 102.48 74.76 47.88 38.36 58000 4833 2900 127.60 106.14 77.43 49.59 39.73 60000 5000 3000 132.00 109.80 80.10 51.30 41.10 62000 5167 3100 136.40 113.46 82.77 53.01 42.47

Flexible Spending Accounts

Maximum Annual Contribution Please see below the annual maximum contribution you may be eligible to elect under the Flexible Spending Account:

Healthcare Reimbursement: $2,500 Dependent Daycare: Single $2500 Family $5,000

*Note: Annual Minimum contribution is $50 annually for both.

The Flexible Spending Account is provided through TASC/FlexSystem. This plan offers you a choice to contribute pre-tax dollars to pay for certain qualified benefits. You must make a new election for the FSA plan every year. Your current elections will not roll-over. You will be able to roll-over up to $500 of unused funds in your Healthcare Reimbursement FSA account to be used for the following Plan Year. However, it is still important to be conservative in making elections because any unused funds over the $500 threshold left in your FSA at the close of the Plan Year are not refundable to you.

PROVIDED THROUGH TASC

Whole Life Insurance with Long Term Care (LTC)


Group Critical Illness with Cancer

CRITICAL ILLNESS INSURANCE PROVIDED THROUGH UNUM Many people believe they will be covered by their medical policies should a critical condition arise. Unaware of the many hidden costs involved, they find out too late that their needs exceed the terms of their standard medical plan. How can critical illness insurance help? Critical illness insurance can pay a lump sum benefit at the diagnosis of a covered illness. You choose the level of coverage — from $5,000 to $50,000 — and you can use the money any way you see fit. Three reasons to buy this coverage at work 1. You get affordable rates when you buy this coverage through your employer, and the premiums are conveniently

deducted from your paycheck.

2. Coverage is portable. You may take the coverage with you if you leave the company or retire without having to answer new health questions. Unum will bill you directly for the same premium amount.

3. Coverage becomes effective on the first day of the month in which payroll deductions begin.

Wellness benefit This benefit can pay $75 per calendar year per insured individual if a covered health screening test is performed, including: • Blood tests • Chest X-rays • Stress tests • Mammograms • Colonoscopies A full list of covered tests will be provided in your certificate. To Claim your wellness benefit simply call UNUM at 800-635-5597.

Covered Conditions Heart attack Blindness

Major organ failure End-Stage renal (kidney) failure

Occupational HIV Coronary artery bypass surgery; pays 25% of lump sum benefit

Benign brain tumor

Covered Conditions with Time Limitations Stroke Evidence of persistent neurological

deficits confirmed by a neurologist at least 30 days after the event

Coma Coma resulting from severe traumatic brain injury lasting for a period of 14 or more consecutive days

Permanent paralysis

Complete and permanent loss of the use of two or more limbs for continuous 90 days as a result of a covered accident

Optional Cancer Options If selected by your employer, you may choose to select this benefit for an additional premium.

Cancer Carcinoma in situ pays 25% of lump sum benefit

Group Accident


Group Accident

PROVIDED THROUGH UNUM Schedule of Benefits:

Disclosure Notices

Unless otherwise noted, these Notices are available on the web at: www.polkschooldistrict.bswift.com. A paper copy is also available, free of charge, by calling ShawHankins at 800-994-7429. NOTICE OF YOUR HIPAA SPECIAL ENROLLMENT RIGHTS: If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards you or your dependents’ other coverage). However, you must request enrollment within 30 days after you or your dependents’ other coverage ends (or after the employer stops contribution toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself or your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. SECTION 125 PRE-TAX BENEFIT AUTHORIZATION NOTICE: Before-tax deductions will lower the amount of income reported to the federal government. This may result in slightly reduced Social Security benefits. If you do not enroll eligible dependents at this time, you may not enroll them until the next open enrollment period. You may not drop the coverage you elected until the next open enrollment period. You may only make a change or drop coverage elections before the next open enrollment period under the following circumstances: • A change in marital status, or • A change in the number of dependents due to birth, adoption, placement for adoption or death of a

dependent, or • A change in employment status for myself or my spouse, or • Open enrollment elections for my spouse, or • A change in dependents eligibility, or • A change in residence or worksite. Any change being made must be appropriate and consistent with the event and must be made within 30 days of when the event occurred. All changes are subject to approval by your Employer/Plan. NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION: This Notice describes how the Plan(s) may use and disclose your protected health information ("PHI”) and how you can get access to your information. The privacy of your protected health information that is created, received, used or disclosed by the Plan(s) is protected by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). This Notice is available on the web at: wwwpolkschooldistrict.bswift.com. A paper copy is also available, free of charge, by calling your Employer or ShawHankins at 800-994-7429. Please note the participant is responsible for providing a copy to their dependents covered under the group health plan." GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS: On April 7, 1986, a federal law was enacted (Public Law 99272, Title X) requiring that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health coverage (called "continuation coverage") at group rates in certain instances where coverage under the plan would otherwise end. If you or your eligible dependents enroll in the group health benefits available through your Employer you may have access to COBRA continuation coverage under certain circumstances. Therefore, your plan makes available to you and your dependents the General Notice Of COBRA Continuation Coverage Rights. This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. The full Notice is available on the web at: wwwpolkschooldistrict.bswift.com. A paper copy is also available, free of charge, by calling your Employer or ShawHankins at 800-994-7429. Please note the participant is responsible for providing a copy to their spouse/dependents covered under the group health plan.

Page 19

http://www.jonescountyschoolsys.bswift.com/



Plan Contact Phone Number

Benefit/Enrollment Questions ShawHankins

www.shawhankins.com 800-994-7429

Human Resources Main Number 770-748-3821

Dental Benefits MetLife

www.metlife.com 800-275-4638

Vision Benefits Avesis

www.avesis.com 800-828-9341

Life Insurance UNUM

www.unum.com 866-679-3054

Flexible Spending Accounts TASC

www.tasconline.com 800-422-4661

Whole Life with LTC UNUM


Group Critical Illness with Cancer UNUM


Group Accident UNUM


About this Guide

This guide describes the benefit plans available to you as an eligible Employee of Polk School District. The details of these plans are contained in the official Plan Documents, including some insurance contracts. This guide is meant only to cover the major points of each plan. It does not contain all of the details that are included in your Summary Plan Descriptions (SPD) (as described by the Employee Retirement Income Security Act).

If there is ever a question about one of these plans, or if there is a conflict between the information in this guide and the formal language of the Plan Documents, the formal wording in the Plan Documents will govern.

Please note the benefits described in this guide may be changed at any time and do not represent a contractual obligation on the part of Polk School District.

Contacts

Need additional information? Have a question about your benefits? Keep this brochure handy for a quick reference for all of your benefit needs.

http://www.shawhankins.com/

http://www.metlife.com/

http://www.avesis.com/

http://www.unum.com/

http://www.tasconline.com/


