Sample Employee Benefits Newsletter-JS Clark Agency-Employee Benefits Consultants - [PDF Document] (2024)

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EmployeeEmployeeEmployee BenefitBenefitBenefit

InformationInformationInformation

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

ABCABCABCCompanyCompanyCompany

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Employee Benefit News

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

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

The medical plan you select is the plan inwhich you will remainuntil the next openenrollment period with an effective dateofJanuary 1, 2010.

Please submit all forms to HumanResources no later than November7, 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 availablefor this plan year provides a generaloverview of the benefits.Actual provisions contained in the insurance contracts andplandocuments will be relied upon solely, in administration andinterpretations of the plans.

R ising healthcare costs affect almosteveryone. Factorsimpacting theseincreases include technology, costshifting,prescription drug costs, lifestyle choices, and anagingpopulation. As health plan premiumscontinue to rise, we maintain acommitment toyou and your family by offering an excellentbenefitpackage.

The ABC Company (ABC) is pleased to giveyou the opportunity toparticipate in one of thefollowing medical plans effective January1,2009:

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

During the open enrollment period you may:

Enroll in the medical plan of your choice (if you havepreviously waived coverage, you may only enroll in coverage duringopen enrollment ).

Enroll eligible dependents previously notenrolled.

Some things to remember

You and your eligible dependents must eachenroll in the sameplan.

You must complete a ABC Election Formand a BCBSM / BCNEnrollment-Change ofStatus Form if you would like to participateinone of the medical plans.

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

Page 3ABC Employee Benefits Plan 2009

IN THIS ISSUE:

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

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

ABCABCABCCompanyCompanyCompany

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The chart above highlights those areas in which your PCP willevaluate you on the Qualification Form. Each area ofconcern isassigned a possible point value ranging from 15 to 25 points. Froma beginning value of 100 points, yourPCP will subtract thecorrelating points if he/she determines a certain area needsattention. If your overall point valuefalls below 80 points, youmust 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 BlueLiving HMO

High-Impact HealthMeasures Wellness Targets

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

Alcohol Use(15 Points)

Pass a physicianadministered screening exam

Agree to follow treatment plan. Physicianfollow-up visitrequired.

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

Agree to follow treatment plan. Physicianfollow-up visitrequired.

Diabetes Management(15 Points)

Blood sugar at or belowtarget

Agree to follow treatment plan. Physicianfollow-up visitrequired.

Cholesterol Management(15 Points)

LDL-C below target (basedupon risk factors)

Agree to follow treatment plan. Physicianfollow-up visitrequired.

Smoking Status

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

smoking cessation program.

Weight(15 Points)

Body Mass Index at or below30

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

How Points are Scored on the Qualification Form

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

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

The information contained in the QualificationForm and HealthRisk Appraisal is confidential

and available only to healthcoaches.

While your doctor maycomplete the Qualification Form,

it is ultimately your responsibilityto ensure it is mailed orfaxed toBCN before the 90 day deadline.Late entries are notconsidered.Keep copies of all documentation.

If you smoke, you must

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

If your doctor requires a follow-up visit, you musthave him/hercomplete another QualificationForm at that follow-up visit. Failureto submit acompleted Qualification Form for each follow upvisitwill result in being moved to the StandardBenefit Level. Keepcopies of your form.

If a BCN Health Coach phones, you mustcooperate and return anycalls. They are anintegral part of the HBL plan and are theretooffer you support and resources.

Do not complete your Health Risk Appraisal ormake yourappointment for the QualificationForm until you have your BCN card.Once youhave your card, your enrollment information islogged withBCN and you may complete theHRA and Qualification Formrequirements.

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A Description of Your Medical BenefitsThe BCN Healthy BlueLiving 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 automaticallyenrolled in the Enhanced Benefit Level

for the first 90 days of the plan.If a Renewal: You remain inyour 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 db 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 eb 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 31 s t ) .

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7/24Page 7ABC Employee Benefits Plan 2009

The BCBSM Community Blue PPO Plan

A Description of Your Medical Benefits

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

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

Blue Preferred members do not haveto notify BCBSM whenchangingphysicians. When you choose toreceive services from aprovider whois not a member of the PPO network,the copayment,deductible andcoinsurance amount for which you areresponsibleincreases.

In addition to increasedcopayment amounts, someservices are notpayable whenrendered by non-PPO providers.However, if a PPOmembergoes to a non-PPO provider witha referral from a PPOprovider,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 andAlwaysCare Vision are available tohelp you. If you have questionsregarding your benefit coverage, need a claim issue resolved, orhavean eligibility question, call your carrier at one of thenumbers shown below for assistance.

Calling Member Services should be your first step in resolvingany problems you may have. If you feelMember Services has notresolved your issue, contact Human Resources for further direction.Be sure tohave the name of the Member Services representative withwhom you spoke, what they told you regardingthe issue, and anynecessary documentation ( i.e., copies of EOBs and bills, patientand subscriber information ) before contacting Human Resources.

You are the one to determine the best providerfrom whom toreceive care, regardless ofwhether that provider is in the BluePreferred

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

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

Be aware you may still be responsible forcharges which exceedthe BCBS approved

amount if you do not use participatingproviders.

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

It should be noted Preventive Services under theCommunity BluePPO are subjected to a $500 perperson calendar year maximum. Anyexpensesoutside of this amount will be thesubscribersresponsibility.

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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 upto a 30-day supply with acopayment of $10 for generic drugs and a$20copayment for brand name drugs if you areenrolled in theEnhanced Benefit Level .

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

When you use your BCBS Community Blue PPO prescription drug cardat the pharmacy, youreceive up to a 30-day supply of medication foracopayment of $10 for generic drugs and $40 forbrand name drugsunder 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 andyour

prescription orders are mailed directlyto your home.

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

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

If you have the HBLStandard Benefit Level,a three month supplyofa b r a n d n a m emaintenance medicationcould cost you $150atthe 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 ClassMail. Reorder information willbe included in your prescriptionshipment.

Go to www.medcohealth.com for more informationon the Blue CrossBlue Shield and Blue CareNetwork mail order prescription programwithMedco.

To participate in the mail order plan, have yourdoctor write youa 90-day prescription and requestan enrollment form from HumanResources.Complete the form and mail it, with yourcopayment andoriginal prescription, in theenvelope provided. Your prescriptionwill bemailed directly to your home and you will savemoney on thecopayments required.

Maintenance medication is taken ona regular or long-termbasis.For example, the followingconditions may be treatedwithmaintenance medication: High blood pressure Ulcers, ArthritisHeart Conditions Thyroid conditions Emphysema, and Diabetes.

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B CBSM and BCN monitor the use of certainmedications to ensuremembers receive themost appropriate and cost-effective drugtherapy.Physicians are required to get Prior Authorization on somemedications. This means certain clinicalcriteria must be met beforecoverage is provided.

Depending on the medication, previous treatmentwith formularydrugs may be required. Theformulary is a list of medicationsidentified byBCBSM and BCN as being therapeutically effectiveandoffering the best value.

Your physician can contact the BCBSM and BCNMedImpact help deskto request prior authorizationfor these drugs. You may be requiredto pay forthe full cost of the drug if your physician doesnotobtain prior authorization.

For more information regarding step therapy andpriorauthorization, and a list of medications on theformulary list, goto www.bcbsm.com if enrolled inthe BCBSM Community Blue PPO planorwww.mibcn.com if enrolled in the BCNHealthy Blue Living HMOplan.

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

Heres a Tip!

K eep the MedImpact Customer Service number handy! Call800.788.2949 if you are at thepharmacy and the pharmacy staff tellsyou a prescription is not covered or you are chargedmore than yourprescription copayment. Call MedImpact immediately, without leavingthepharmacy, and MedImpact can tell you if your physician failed toreceive prior authorization or ifyour medication is not coveredunder your plan. If you need prior authorization, you cancontactyour physicians office right from the pharmacy and remindthem to call in for prior authorizationor request an equivalentalternative prescription covered by your plan.

the BCBSM and BCN prescription drug formulariesrespectively andprovide you with specificinformation regarding your plans drugprogram.

MedImpact is contracted with BCBSM and BCN toadminister yourretail prescription program. If youever experience difficultygetting a prescriptionfilled at a retail pharmacy, call MedImpactat800.788.2949 and follow the prompts to speak witha MemberServices representative. TheMedImpact representative can advise youon why

your prescription may not be authorized or whatneeds to be doneto 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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11/24Page 11ABC Employee Benefits Plan 2009

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 hospitaland MH/SAFor an Individual You Pay 20% to $1,000 40% to $3,000 None20% to $1,500For a Family You Pay 20% to $2,000 40% to $6,000 None20% to $3,000

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

Does not include In-patient Mental Healthcoinsurance anddeductible

Does not include In-patient Mental Healthcoinsurance anddeductible

For an Individual You Pay $1,250 $3,500 None $2,000For a FamilyYou 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 toinsured Required Required

Hospital Room & Board 20% after deductible 40% afterdeductible $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

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 MaximumsApply

50% after deductibleCombined max of 60 days per

calendar year with lifetimemax of 120 days per member

50% after deductibleCombined max of 60 days per

calendar year with lifetimemax of 120 days per member

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 providerused

$50 copayment $75 copayment afterdeductible

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

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

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

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

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

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

deductible

Allergy Testing & Therapy $0Covered 100% 50% afterdeductible50% - 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% afterdeductible$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 MaximumsApply

50% after deductibleUp to state mandated dollar

amount

50% after deductibleUp to state mandated dollar

amount

50%up to state mandated dollar

limitation, 1 program per year

50%up to state mandated dollar

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 givingsubscribers the freedomto choose the provider that is rightforthem.

A national network with more than 61,000 PPOdentists isavailable with the PPO plan. While youwill save more out-of-pocketmoney with the DeltaPPO plan, this dental plan also allows accesstoDelta Dental Premier Network dentists.

Because this is a passive PPO plan, enrollees

may go to any licensed dentist anywhere, but theywill save moneyby choosing a Delta Dental PPOdentist. Delta Dental PPO dentistsagree to acceptour fee determination as full payment forcoveredservices. This guaranteed acceptance of paymentreduces groupclaims costs while protectingenrollees from balance-billingproblems.

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

Delta Dental provides members with resources tomake managingyour dental benefits easy. Go towww.deltadentalmi.com and click onthe Members tab. You will be directed to the Members pagewhere youmay access provider directories,download claim forms, andresearchdental related topics, such as OralHealth and Wellness.

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

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

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

indicated above.To see if your dentist participates, or to finda DeltaDental PPO dentist, please call 800.482.8915 orgo towww.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 forhelpful information .

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ITEM Delta Dental PPO Plan

Your out-of-pocket cost will dependupon which provider youchoose.

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

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A Description of Your Vision Coverage

AlwaysCare Vision Plan

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

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

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

Members may choose different providers for visionexams andvision supplies. Visit www.

DescriptionIn-Network

Member CostNon-Network

Reimbursem*ntNetwork* 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 tobifocal) 20% discount** N/A**

Contact Lenses

Conventional $120 allowance Up to $100

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

Lasik Preferred Pricing - see Provider for details.

AlwaysCareElite Vision Plan B Option

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

Members should log in to AlwaysAssistatwww.alwayscarebenefits.com to see the providersthat accept theirplan. We encourage you tocontact AlwaysCare or your selectedprovider priorto visiting their location.

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

For information on how to use your benefits atCostco Opticallocations please login as a currentmember atwww.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 fixedcopays.Other AlwaysCare providers,such as Service PlusProviders,offer a 20% discount for theseadd-on services.

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

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

Your Basic Life and AD&D insurance provides youwith onetimes 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&Dinsurance at your own expense. Thereare two options available:

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

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

to a maximum benefit of the lesser of $500,000 or5 times yourBasic Annual Salary, in increments of$10,000. AD&D amount isequal 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 theseplans cancelupon your retirement.

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

Optional Supplemental Life/AD&D InsuranceA Group LifeInsurance Enrollment card must becompleted in order for you topurchase thisadditional coverage. In addition, you will berequiredto complete an Evidence of Insurability (proof of good health) formif you increase theamount of insurance which you havepreviouslypurchased, or elect any amount greater than$100,000.

Long Term Disability Insurance

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

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

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

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

Insurability Form .Your LTD payment is subject toreductions ofyour employmentearnings.

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

Life and Disability Benefits

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17/24Page 17ABC Employee Benefits Plan 2009

support.

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

Your amount of DependentOptional Life may notexceed 50% of yourOptional Life Insuranceamount.

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

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

Please see your Mutual of Omaha employeecertificate for moreinformation.

Insurance for yourself in order to purchase it for yourspouse.

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

Evidence of Insurability is required for your OptionalSupplemental or Optional Dependent Life for anyof the followingreasons:

You, on your initial Eligibility Date, elect no Dependent Lifecoverage and subsequently electDependent Optional Life Insurance ata later date;

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

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

You elect an increase in your amount of Optional LifeInsurance.

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 LifeInsurance in $5,000 increments up toa maximum benefit of $10,000,not to exceed 50%of your amount of Optional Life Insurance. Ifyouwish to purchase coverage in excess of $10,000 toa maximum of$50,000, an Evidence of Insurability Form must be completed foryour dependent.

You must purchase additional Supplemental Life

Optional Dependent Child Life

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

For children under the age of 19 you may purchaseDependent ChildOptional 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 ifyour child is afull-time enrolled studentand depends on you for50%or more of their

Life and Disability Benefits

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18/24Page 18ABC Employee Benefits Plan 2009

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 $12.71EstimatedTax 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

Twice Monthly Contribution $1.47 $2.94 $7.31 $0.00

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

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

Twice Monthly Contribution $0.25 $1.40 $1.97 $0.00

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

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 taxbracket - Assumes the lowest federal income tax bracket which iscurrently 15%, 4.4% state income tax and7.65% FICA tax. If you arein a higher tax bracket your savings will be greater.2. Fam. Cont.- Family Continuation is an additional rate charged for dependentsage 19 to age 25 if a full time student or meet theIRS definitionof a dependent. See page 19 for more information on the FamilyContinuance rider.

P ayroll contributions are required for employees to participatein either of the BCBSM and BCN medicalplans, Delta Dental and theAlwaysCare vision coverage. If you have elected voluntarycoveragethrough Mututal of Omaha for optional employee life anddependent life insurance, you will find those rateson the carriersage-banded rate table. You must complete an ABC Election Form toacknowledge yourunderstanding of the payroll deductions taken on atwice monthly basis for the premium.

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Eligibility and Waiving Coverage

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

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

Delta Dental defines eligible dependents as yourspouse andunmarried children until the end of thecalendar year in which theyreach age 19.Coverage may be extended to the age of 25 iftheylegally reside with and are a member of thehousehold anddependent upon the subscriberwithin the meaning of the IRS personalexemption

code.AlwaysCareAlwaysCareAlwaysCare Vision Care defineseligibledependents as spouse and unmarried children tothe age of19. Coverage may be extended to theage of 25 if a dependent isunmarried, and a fulltime student.

Children over 19 who are physically or mentallyhandicapped mayalso be eligible for coverage.Contact Human Resources if you have aspecialsituation. Note: You must notify BCBSM and BCNof thissituation before the end of the year in which

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

Same gender domestic partners may be added tothe plans, providedcertain criteria is met. Thedomestic partner must be 18 years orolder andneither domestic partner may be legally marriednorrelated.

BCBS requires proof the subscriber and domesticpartner havelived together for the past 12consecutive months in the form of adriver's

license, voter registration, student ID, etc. Also, asigned andnotarized affidavit of domesticpartnership must be submitted toBCBS.

BCN requires proof of financial interdependency ofthe subscriberand domestic partner by submission

of proof of joint bank accounts, joint homeownership or someother specified documentedproof. BCN requires proof the subscriberanddomestic partner have lived together for the past12 consecutivemonths in the form of a driver'slicense, voter registration,student ID, etc. Also asigned and notarized affidavit ofdomesticpartnership is required. Delta and AlwaysCarealso requiredocumentation.

You and your eligible dependents will becomeeligible toparticipate in any or all of the selectedplan benefits uponcompletion of your waitingperiod. Human Resources will advise youof yourwaiting period and effective date of coverage.

Keep in mind you mustenroll your eligible

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

In the case of legal separation or divorce, coveragefor yourformer spouse will terminate on that date.Do not assume coveragewill automatically continuesimply because you are required toprovidecoverage under the terms of a divorce decree.

When enrolling in the medical plan, completetheenrollment/change of status form for the plan andthe ABCElection Form and turn it into HumanResources.

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

the plan until the next openenrollment of January 2010unlessspecific circ*mstancesapply ( e.g. a qualifying event such asinvoluntary loss of spouses employment, divorce,etc .).

If you should lose coverage inthis way, you may enroll intheplan 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, yourmarriage, etc. ).

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Your Plan Status

W hen you enroll in a benefit plan, your planstatus is asfollows:Individual Coverage:Provides coverage for the employeeonly.

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

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

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

dependent child turns age 25, if they are unmarriedand a fulltime student, or earning a gross incomeof less than four times thecurrent IRS personalexemption.

The Family Continuance is an additional rideradded to thesubscribers BCBS or BCN contract toallow coverage for 19-25 yearold childdependents. If you have a dependent child age 19who meetsthis criteria, be sure to contact HumanResources before the end ofthe year to have yourdependent childsstatus changed tothat ofFamilyC o n t i n u a n c e .Failure to do so willresult in BCBSMorBCN removing yourdependent fromyour plan effectiveJanuary1st.

The Blues Discount Services and Programs

W hen you become a BCBSM or BCNcustomer, there are severalwellnessprograms available to members and theirdependents. Designedto improve health and

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

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

Naturally Blue Members can obtaincomplementary health servicesat a discount. This

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

Quit the Nic! A free smoking cessation program,Quit the Nic! ,has a proven track record of helpingmembers give up tobacco forgood. Participantsreceive telephone support, educationalmaterials,and opportunities to speak with a health coachabout howto kick the habit. Our health coacheshelp develop a plan of actionand establish a quit

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

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

BlueHealth Connection The BlueHealthConnection Health Coach HotLine provides youwith access to registered nurses and otherhealtheducation materials. Supported by board-certifiedphysicians,their nurses assist individuals who maybe uncertain about whetherto seek medical care.

If you are enrolled in the BCN Healthy Blue Living

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

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

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Womens and Childrens Rights

The Womens Health and Cancer Right Act (WHCRA) of 1998 was apart of the omnibusappropriations bill passed by Congress andsigned

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

Under WHCRA, mastectomy benefits must includecoverage for:

Reconstruction of the breast upon which themastectomy has beenperformed,

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

Prostheses (or breast implant), and

Physical complications at all stages ofmastectomy, includinglymphedema.

Coverage for reconstructive breast surgery maynot be denied orreduced on the grounds that it iscosmetic in nature or that itotherwise does notmeet the coverage definition ofmedicallynecessary. Benefits must be provided on the

The Newborns Act Group health plans and health insuranceissuers

generally may not, under Federal law, restrictbenefits for anyhospital length of stay inconnection with childbirth for the motherornewborn child to less than 48 hours following avagin*l delivery,or less than 96 hours following acesarean section. However, Federallaw generallydoes not prohibit the mother's or newborn'sattendingprovider, after consulting with themother, from discharging themother or hernewborn earlier than 48 hours (or 96 hoursasapplicable).

same basis as for any otherillness or injury under themedicalplan.

Mastectomy benefits mayhave yearly deductibles andcoinsurancelike thoseestablished for other benefitsunder the plan orcoverage.

The WHCRA will not allow:

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

Plans and insurance issuers to provideincentives to, or penalizedoctors to cause them toprovide care in a manner not supportivewithWHCRA.

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

Coverage for reconstructive breast surgery may not be denied orreduced on the grounds that it is cosmetic in nature or that itotherwise does not meet the coverage definition of medicallynecessary. Benefits must be provided on the same basis as for anyother 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 theinsurance issuerfor prescribing a length of stay not in excess of48hours (or 96 hours).

Newborns & Mothers Health Protection Act

Womens Health and Cancer Rights Act

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authorizing payment fortreatment only inemergencysituations.

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

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

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

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

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

threatening change in the condition, orsymptoms the attendingphysician agreesappeared life threatening.

Follow up visits after treatment for the originalemergency.

Physicians and hospitals use insurance guidelinesto determinewhat services qualify as medicalemergencies.

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

O ne of the most frequently asked questions is,When areemergencies covered under theplan? To avoid unnecessary expenses,you needto know what qualifies as an emergency, and thebenefitsavailable 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; andattemptedsuicide.

A medical emergency is an internal condition thatthreatens lifeor bodily functions, or one that couldresult in serious bodily harmunless 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 ahospital,where ambulatory patients can be treated on awalk-in basiswithout an appointment, andreceive immediate, non-routine, urgentcare.This does not include primary care physiciansorspecialists.

Urgent Care is for those times when yourcondition is not seriousenough to be anemergency but you need urgent medicalattention. Yourcopayment is lower in anurgent care facility than in theemergencyroom.

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

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

Phone: 248.355.9600 Fax: 248.355.3145www.jsclarkagency.com