January 1, 2019 to December 31, 2019 - 2019 Benefits Enrollment
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January 1, 2019 to December 31, 2019 2019 Benefits Enrollment
MISSION STATEMENT:
To consistently CONTENTS
deliver 2019 BENEFIT PLAN HIGHLIGHTS 4
exceptional ENROLL WITH EASE 5
health care by HOW TO LOG IN - FIRST TIME USER 5
demonstrating ENROLLMENT HAS NEVER BEEN EASIER 5
the values WHEN CAN I ENROLL IN BENEFITS? 6
of service, HEALTH SAVINGS ACCOUNT (HSA) 8
teamwork, TELEMEDICINE BY RELYMD 9
accountability, DENTAL 11
respect and BASIC LIFE, ACCIDENTAL DEATH AND DISMEMBERMENT
safe care. AND SUPPLEMENTAL LIFE INSURANCE 13
SHORT TERM AND LONG TERM DISABILITY 14
UNUM WHOLE LIFE 15
VISION STATEMENT: 401(K) 16
To be the best ROTH 401K 18
community EMPLOYEE ASSISTANCE PROGRAM 18
hospital in the EQUI-VEST 403(B) TSA 19
nation, with SUMMARY OF EMPLOYEE DISCOUNT PROGRAMS 20
service as our PAID TIME OFF (PTO) 21
guiding principle. WHO TO CONTACT 22
LEGAL NOTICES 23
Dear Hugh Chatham Memorial Hospital Employee: Life/AD&D, Disability
You are one of our most valuable assets and Hugh Chatham Memorial Life/AD&D and STD/LTD disability benefits continue to be available
Hospital is pleased to offer a competitive and comprehensive package of through Cigna.
benefits for 2019. The enrollment period for benefits coverage effective
January 1, 2019, is scheduled for November 5 - November 19, 2018. Voluntary Offerings
You may enroll anytime during that period using the online website Whole Life, Critical Illness, Hospital Indemnity and Accident products are
http://mybensite.com/hughchatham. available through Hugh Chatham Memorial Hospital Benefits.
As healthcare costs continue to rise due to inflation and increased An HSA (Health Savings Account) will be offered with your election of the
government regulation, the cost to provide healthcare coverage has also Medical Plan. As you may know premiums for traditional PPO plans are
increased. Additionally, Hugh Chatham Memorial Hospital has seen an notably higher than those of a High Deductible Health Plan. With this in
increase in the occurrence as well as the severity of claims of healthcare mind, you may consider setting aside some of the savings into your HSA
costs. This has been a common scenario across the market as costs account to assist with future medical costs.
increase in an effort to keep pace with healthcare trends. Hugh Chatham
Memorial Hospital is committed to providing a comprehensive benefits Below are important dates to put on your calendar:
package to its employees for the following year and has made the Q&A Sessions: October 29 MSCR at 2:30 p.m. and 8:30 p.m.
following changes to its 2019 offerings:
October 30 MSCR at 10:00 a.m.
Health Insurance – Vendor Change PowerPoint slides with voiceover narration will be on Quick Click,
2018 2019 covering the benefit information on all plans for 2019, should you not be
able to attend the meetings.
Cigna Allegiance – with the same Cigna network
Annual Enrollment
Pharmacy Benefit – Vendor Change November 5 - November 19 (All employees must elect for 2019)
2018 2019 Benefits Fair
November 1 Cardiac & Lung Rehab Area 7:30 am – 4:00 p.m.
Cigna Express Scripts
Human Resources staff will be available in the Computer Classroom at
the following times should you need assistance with your enrollment.
Dental Insurance – Vendor Change
November 5th: 9AM - 10:30AM
2018 2019 November 9th: 9AM - 10:30AM
MedCost Delta Dental of NC November 12th: 7:30AM - 9:30AM & 4PM - 5:30PM
Employee contributions for the medical plan will increase only for those November 14th: 7:30AM - 9:30AM
members who did not complete the three required wellness activities. November 16th: 11:30AM - 12:30PM & 2:30PM - 3:30PM
Employee contributions for the dental plan will be decreasing and will November 19th: 7:30AM - 3:30PM
remain for both the 2019 and 2020 plan years. The tobacco surcharge for
employee and spouse will remain the same for the 2019 plan year. You Please note enrollment deadlines so that you may select and use the
may attest to your current tobacco status via the on line enrollment site. benefits that are right for you.
Thank you for your continued dedication to providing exceptional care
Vision Coverage: and service to our patients, their loved ones, and for your efforts to
Vision coverage will continue to be available through Superior Vision improve the overall quality of life for our entire community.
with no changes in the rates.
Sincerely,
Wellness Program Hugh Chatham Executive Team
Hugh Chatham Memorial Hospital will be revealing an enhanced
wellness program for the 2019 plan year. Details for this program will be
available in January 2019.
(3 3 6) 527-7 0 0 0 • 180 Parkwood Drive • Elkin, NC 28621 • w w w.HughChatham.or g
2019 BENEFIT PLAN HIGHLIGHTS
Medical and Pharmacy/Rx Coverage Employee Eligibility
• NEW!! HCMH will be transitioning our Medical Administrative Services to Due to the Health Care Reform Act, Hugh Chatham has elected to allow
Allegiance. Members will still have access to the same Cigna network and employees who regularly work an average of 24 hours or more a week to
there are no changes to our medical plan design. be eligible for benefits. HCMH human resources will monitor, and will notify
• NEW!! HCMH will be transitioning to a new HSA bank, Healthcare Bank. employees who meet that criteria.
Telemedicine Dependent Eligibility
• HCMH continues to offers the benefit of accessing a doctor 24/7/365 via Your spouse, as defined by the State of North Carolina; unless you are
mobile app, web browser or phone call. Please see page 9 for more details. divorced or are legally separated with documentation.
Wellness Program Your dependent child(ren) up to the to the end of the month of which
• For 2019 HCMH will be expanding the Wellness Program to encompass a they turn 26 (regardless of marital status, financial dependence, residency,
more holistic approach. Please keep on the lookout for detailed information student status, employment status or access to employer sponsored health
coming in January 2019! insurance) under the medical, dental, vision and child life.
• The Tobacco Surcharge for Employee and Spouse will remain the same for the
2019 plan year. This year you will attest to your tobacco status via the online Required Documents
enrollment system.
For Spouse:
Working Spouse Provision • A copy of your marriage certificate
• As a reminder, Hugh Chatham Memorial Hospital does not allow working • Affidavit of Spousal Health Care Coverage must be completed during the
spouses with access to other health coverage to be enrolled in the medical enrollment process
plan. Spouses that do not have access to other coverage may enroll.
And one of the following:
You will need to complete an Affidavit concerning spousal coverage. This • A copy of the front page of your most recent federal tax return confirming
year you will complete this process via the online enrollment system. this dependent is your spouse
Remember that you are required to notify HR if you have a dependent that is • A document dated within the last 60 days showing current relationship status
no longer eligible within 30 days or you waive your rights to COBRA. such as a recurring monthly household bill or statement of account. The
Dental Coverage document must list your spouse’s name, the date and your mailing address.
HCMH will be transitioning the dental plan to Delta Dental of NC. Members For Children up to age 26:
will now have access to a tiered dental provider network. Accessing • A copy of the child’s birth certificate or adoption certificate naming you or
providers in the network will result in lower out of pocket costs for you. The your spouse as the child’s parent OR
change to Delta Dental of NC will result in lower employee contributions as
• A copy of the court document naming you or your spouse as the child’s
well. The dental contributions will remain the same for both the 2019 and
legal guardian
2020 plan years.
Vision Coverage For disabled Children age 26 or older:
• Documentation indicating that your child is legally disabled
There are no plan design changes or contribution changes for 2019.
• A copy of the child’s birth certificate or adoption certificate naming you or
Life/AD&D, Disability your spouse as the child’s parent OR
• Life/AD&D and STD/LTD disability benefits continue to be available • A copy of the court order naming you or your spouse as the child’s legal
through Cigna, for eligible employees. guardian AND
• A copy of the front page of your most recent federal tax return claiming this
Voluntary Offerings child as your dependent
• Universal Whole Life will remain with Unum. You may enroll with a • Note for a stepchild: If you are covering a stepchild you must also
counselor via the enrollment line. Please see page 15 for more details. provide documentation of your current relationship to your spouse as
• Specified Disease (Critical Illness), Hospital Indemnity and Accident products requested above
will be available through Voya. You may enroll or make changes to these
benefits via the online enrollment system without the need to meet with an Keep in mind employees will be required to provide the following information
enroller. by November 19th when adding/ enrolling new dependents on the medical
plan. (Spouse and/or Children). For new hires, and newly added dependents
New Hires: (through qualifying life event) employees must submit their documentation
within their 30 day enrollment deadline.
New hires are effective the 1st of the month after 30 days of benefit eligible
employment. However, dependent care FSA is effective immediately.
Please review your beneficiary information.
Beneficiary information recorded in the benefit enrollment system is for life
insurance provided by HCMH and supplemental life at your choice. If you
need to make 401K beneficiary changes, log into netbenefits.com and select
“Profile” on the top right hand side of the home page. You will then click on
beneficiaries and follow the prompts to make changes.
4 2019 Online Benefits Enrollment
ENROLL WITH EASE ENROLLMENT HAS NEVER BEEN EASIER
Welcome to your employee benefits website! Once Inside The Site, you will go through a series of screens, each screen
takes only a few moments to complete.
As you know, benefits are an important part of your overall compensation. We
are proud to offer our simple, convenient online benefits enrollment system Personal Information
that will make enrollment faster and easier than ever before! Please verify that all the information is accurate. If you see any blank fields or
Please visit your employee benefits website: need to make changes, please update the information on this screen.
www.mybensite.com/hughchatham Dependent Information
Inside the website you will find important information such as benefit If you have a spouse or children that you wish to cover, please enter their
summaries, forms, summary plan descriptions, provider search directories, information in this section. Remember that you will need correct names,
frequently asked questions, health and wellness resources and much more. dates of birth and social security numbers for all covered individuals.
Please review this information thoroughly before entering the enrollment
You are now able to upload dependent information directly onto the
section of the website. It is important that you understand your benefit
enrollment site. Below is a screen shot of where on the enrollment you will
options BEFORE starting the enrollment process.
be directed to upload the required documentation for dependents.
If at any point during this process you have questions or
require technical support, please call Tiffany Sparks at
(336) 527-7660.
Benefit Selections
The next few screens will present benefit selections by product (medical,
dental, vision, life insurance, etc.). Each page will show you the benefits you
are eligible for along with a cost “per paycheck”. If at any point in time you
would like to see more information, simply click on one of the menu items to
the right to see expanded benefit summaries, forms, provider links and more.
After you’ve made your selection, click “continue” to go to the next benefit.
HOW TO LOG IN - First time User Review and Submit Benefits
Step 1 This is the final step. Please review your benefit choices and costs. If you wish
Visit www.mybensite.com/hughchatham to make changes to your selections, click on the “edit” button to update your
information. Once you have completed your review, agree to the terms and
Step 2 hit “Continue”. Benefit Statement will be mailed to you.
You will be asked to register as a user on the system by clicking “create a new Beneficiary Information
user account”. When creating a new user account, you must enter your last
name, date of birth (mm/dd/yyyy), and last 4 digits of the employee’s SSN. It is important that you select a beneficiary for your life insurance benefits.
You may select a beneficiary from the dependents section, or you can
Step 3 designate any other person, organization or estate trust. We recommend
updating this information on an annual basis or after any major life event.
You will also be asked to enter an email address (this becomes your User
Name), along with your password. Once that has been completed, you will be You must complete enrollment in one session.
logged into the website with access to the enrollment system. Confirmation statements will be distributed the first week of December.
Step 4
Once logged in, select the “Enroll Now” tab. You will be guided through a
series of screens, each taking only a few moments to complete. All of your
benefit elections will be displayed on a cost “per paycheck” basis, based on
your specific benefit options.
January 1, 2019 to December 31, 2019 5
WHEN CAN I ENROLL IN BENEFITS?
New Hires
You must enroll within 30 days of your benefit eligibility date. If you fail
to enroll within your 30 day window, you will be required to wait until
open enrollment to enroll or make changes. Please complete your online
enrollment prior to your effective date.
Open Enrollment
You may enroll and make changes online during the open enrollment season.
Once open enrollment is closed, you may not make any changes to your
benefit elections unless you experience a qualifying event.
Qualifying Events
If you experience a “Qualifying Event,” during the plan year, you must Qualifying Events Include:
request the appropriate changes in the Online Enrollment system within 30 • Any change in your legal marital status which includes divorce, marriage
days of the event. If you fail to do so, you will be required to wait until open or annulment.
enrollment to enroll or make changes. • Any change in the number of dependents in your health insurance plan
including birth, death or adoption.
• Any change in your employment status or your spouse or any change in
the employment status of dependents will also trigger a qualifying event.
The change includes termination or commencement of a job. Change
or return from an unpaid leave of absence. Change in place of work or
situation (hourly or weekly salary changes). All this is also applicable to
your spouse’s employment or dependents employment conditions.
• Any dependent which does not satisfy eligibility requirements due to
attainment of age, student status or similar qualifying events.
• Significant changes in cost of coverage. FMLA
(Family Medical Leave Act) Leave.
• Judgments, orders and decree’s trigger a qualifying event for health
insurance changes.
• Any changes in the coverage of your spouse or dependent from another
employer plan.
• HIPAA (Health Insurance Portability and Accountability Act) special
qualifying events for dependents and due to loss of coverage in insurance.
We will discuss this in detail down below under qualifying events
under HIPPA.
• Qualifying events for health insurance under COBRA. Qualification under
Medicaid or Medicare.
• Loss of coverage under a group health plan of the federal government
like state sponsored health insurance programs, CHIP (Children Health
Insurance Program), state health risk pools etc.
6 2019 Online Benefits Enrollment
MEDICAL & PRESCRIPTION
Medical Plan Highlights
HCMH Tier is defined as Hugh Chatham owned and associated providers. In-Network refers to Cigna contracted providers.
Plan Features HCMH Cigna Out-of-Network
Deductibles
Single Deductible $1,500 $3,000 $5,000
Family Deductible (includes single + spouse or children) $3,000 $6,000 $15,000
Out-of-Pocket Maximum
Single $6,000 $6,450 $10,000
Family (includes single + spouse or children) $12,000 $12,800 $20,000
HCMH Tier and In-Network deductibles and Out-of-Pocket maximums count towards each other, but not towards Out-of-Network.
Coinsurance 80% 70% 40%
Lifetime Maximum Unlimited
Physician Office Visit
Primary Care Provider 80% after deductible 70% after deductible 40% after deductible
Specialist 80% after deductible 70% after deductible 40% after deductible
Preventive Care (including PPACA preventive drugs) 100% 100% 40% after deductible
Emergency Room 70% after deductible 70% after deductible 70% after deductible
Urgent Care 80% after deductible 70% after deductible 40% after deductible
Inpatient Hospital 80% after deductible 70% after deductible 40% after deductible
Mental/Nervous 80% after deductible 70% after deductible 40% after deductible
Outpatient Hospital 80% after deductible 70% after deductible 40% after deductible
Basic Radiology / Lab Services (Facility only, Professional, Imaging Services) 80% after deductible 70% after deductible 40% after deductible
Advanced Radiology (Facility only, MRI, CT Scan, PET Scan) 80% after deductible 70% after deductible 40% after deductible
Therapy Services 80% after deductible 70% after deductible 40% after deductible
Mental/Nervous 80% after deductible 70% after deductible 40% after deductible
Vision Care (Comprehensive Eye Exam Only) 100% 100% Not Available
Preventive 85%, no deductible.
Prescription All other prescriptions are 80%, after the HCHM In Network deductible
Hugh Chatham Memorial Hospital offers employees an additional discount on outpatient services for Imaging Services and Laboratory, processed and
completed at Hugh Chatham Memorial Hospital. This discount will be only for outpatient services for Imaging Services and Labs performed at Hugh Chatham
Memorial Hospital. The discount will be applied to the member responsibility. Employees will need to contact Hugh Chatham’s business office within 30 days
of the claims processing date to request the additional 50% discount on outpatient Imaging Services services and an additional 75% discount on outpatient
Lab services preformed at HCMH. The discount will now be applied before the deductible is met. Example: If you have an imaging procedure at Hugh
Chatham and the amount billed to Allegiance is $1,500, then Allegiance will discount the bill based on their allowable amount making your
responsibility $900 (this is the amount applied to your deductible), then you get 50% off the $900, so your total cost is $450. This can be paid
by using your HSA account, payroll deduct, PTO or your own personal funds.
All employees working on average 24 or more hours per week are eligible for this coverage, under ACA guidelines. HCMH human resources will monitor, and
will notify employees who meet that criteria.
Employee Wellness Tobacco Non- Wellness Tobacco
Wellness Non-Wellness Non-Wellness
Contributions Wellness Tobacco (if spouse is also (if spouse is also
Non-Tobacco Non-Tobacco Tobacco
(Bi-Weekly) tobacco user) tobacco user)
Employee Only $37.54 $77.54 $45.05 $85.05 N/A N/A
Employee & Spouse $112.62 $152.62 $135.14 $175.14 $192.62 $215.14
Employee & Child(ren) $67.57 $107.57 $81.09 $121.09 N/A N/A
Employee & Family $135.14 $175.14 $162.16 $202.16 $215.14 $242.16
Please refer to your booklet/certificate for a full description of plan provisions, exclusions, conditions and limitations. If information in this guide deviates
from that information in any way, the terms in the booklet/certificate/master contract will govern.
January 1, 2019 to December 31, 2019 7
HEALTH SAVINGS ACCOUNT (HSA)
A Health Savings Account (HSA) is an individually-owned, portable savings Account Holders aged 55 and older are eligible to make an additional catch-
account that allows employees to save for qualified medical and retiree up Contribution up to $1,000 in the calendar year. You will be able to make
health expense. contributions into an HSA if you meet the following criteria:
Contributions that you make into this account are done pre-tax. • You are not covered by any other non-HC Choice Fund Plan, such as a
spouse’s plan;
An HSA is designed to help you save and pay for your qualified healthcare
expenses. Healthcare expenses include deductibles and coinsurances, your • You are not enrolled in Medicare ;
out of pocket cost. • You do not receive health benefits under TRICARE;
You can contribute to your HSA through payroll deductions, post-tax • You have not received Veterans Administration (VA) benefits within the
deductions or a one-time lump sum contribution (post tax). Allegiance’s past three months;
current banking parter is Healthcare Bank. Once your HSA account is fully • You cannot be claimed as a dependent on another person’s tax return;
opened, you will be issued a debit card which can be used for qualified
medical, pharmacy, dental or vision expenses. However be advised if using • If your spouse is covered under Medicare:
the funds from the Health Saving Account for dental or vision expenses your • You may still contribute to the HSA;
health plan deductible or out-of-pocket expense will not be reduced. Only • You may still use your HSA funds to pay for your spouse’s qualified
Medical and Pharmacy expenses apply toward the health plan deductible medical expenses.
and out-of-pocket maximum.
There is a limit on how much may be contributed each year to these
accounts; this includes both the amount Hugh Chatham Memorial Hospital
contributes, and what the employee contributes for 2019.
Hugh Chatham Memorial Hospital - HSA Funding Schedule
Benefit Effective Date January 1 January 1, 2019 April 1, 2019 July 1, 2019 October 1, 2019 Total Annual HCMH Contribution
Employee Only $ 375 $ 375 $ 375 $ 375 $ 1,500
Employee + Dependent(s) $ 750 $ 750 $ 750 $ 750 $ 3,000
For new hires the HCMH HSA contribution will be pro-rated based on Benefit Start Date. Examples are illustrated below:
Start Date January 1, 2019 April 1, 2019 July 1, 2019 October 1, 2019 Total Annual HCMH Contribution
April 1, 2019 Employee Only N/A $ 375 $ 375 $ 375 $ 1,125
Employee + Dependent(s) N/A $ 750 $ 750 $ 750 $ 2,250
July 1, 2019 Employee Only N/A N/A $ 375 $ 375 $ 750
Employee + Dependent(s) N/A N/A $ 750 $ 750 $ 1,500
New Hires who start October 1st or later will not receive a HCMH contribution into their HSA.
Maximum Allowed HCMH will be transitioning to Healthcare Bank with Allegiance for the 2019
Maximum Allowable plan year. For the 2019 plan year, the HCMH employer HSA contributions
IRS after HCMH
HSA Contribution will be deposited into this account for you to access. Your current account
Contribution
with HSA Bank will remain in place through March. You may access your HSA
Employee Only $3,500 $2,000 Bank funds at any time until the transition date. Please note a new debit
Employee + Dependent(s) $7,000 $4,000 card will be issued by Healthcare Bank.
For new HSA holders, your account will be automatically opened by HCMH.
You may be contacted to validate your identification to complete setting up
this account. Funds will not be placed in to the HSA until the account has
HCMH contribution will be deposited been validated.
within the first 15 days of the month
that the quarter begins. For existing HCMH HSA Bank account holder, your account will remain open
through March 2019. During this time you will continue to use the same
HSA Debit card for any remaining balances (please do not throw away your
debit cards).
8 2019 Online Benefits Enrollment
TELEMEDICINE BY RELYMD January 1, 2019 to December 31, 2019 9
DEPENDENT CARE
FLEXIBLE SPENDING ACCOUNT
Hugh Chatham’s Dependent Care Flexible Benefit Plan allows payroll When are Dependent Care expenses reimbursed?
contribution to a “flexible spending account (FSA) to pay eligible dependent
care expenses with tax-free benefit dollars incurred during 2019. Dependent care expenses are payable after your account balance can cover
the actual expense. Any FSA funds not used for the 2019 plan year will not
Who is eligible to participate in the Dependent Care rollover, and will be forfeited.
Spending Account? Dependent Care FSA
• Active Full Time / Part Time ( with a FTE of .5 or higher) employees who If your spouse works or if you are a single parent, how much do you pay for
have a dependent: dependent care or babysitting service for children under age 13?
• Child or children under the age of 13 who attend(s) a child care facility so (Expenses must be incurred as a result of employment and may not be paid
you and your spouse can maintain gainful employment; or to a dependent.)
• Child under the age of 13 for whom, due to a court order, you are Total Dependent Care Expense $______________ Maximum
responsible for child care services; or $416.67/month ($5,000/year/household)
• Child, parent or spouse who is physically or mentally incapable of caring
for him/herself and requires day care services so you can maintain gainful
Qualified Dependent Care Expenses
employment. • Day Camp
• Nursery Schools
Dependent Care Spending Accounts • Day Care Centers
For the Dependent Care Spending Account, you can submit expenses related • After-School Programs
to the care of your dependent child or children (up to age 13) toward those
pre-tax dollars. An eligible provider of Dependent Care expense is one that Additional questions can be answered by Hugh Chatham’s benefit
can provide you with a Tax-ID number or a Social Security number for claim administrator or the plan service provider, Flores and Associates
filing purposes. Also, both you and your spouse must be gainfully employed 1-800-532-3327.
or your spouse must be actively looking for employment. The annual limit
you can put into your dependent care FSA is $5,000. If you are married and Please visit www.flores247.com for a complete listing.
filing separately, the annual limit would be $2,500.
10 2019 Online Benefits EnrollmentDENTAL
Delta Dental of NC will be the dental carrier for Hugh Chatham Memorial Hospital for the 2019 plan year. Members will now have access to
network providers at a discounted rate. Please go to www.deltadental.com to search for providers. Employees with an FTE of .5 or higher
are eligible for this coverage.
Network PPO Premier Out-of-Network
Smaller Dental Provider Network Larger Dental Provider Network No Dental Provider Network
Higher Provider Discounts Lower Provider Discounts Claims Reimbursed at 90th UCR
Lifetime Deductible $100
Annual Maximum
Per Person $1,300
Services
Preventive 100% 100% 100%
Basic 100% 100% 100%
Major 50% 50% 50%
Orthodontia Yes
Benefit Percentage 50%
Adult and/or Child(ren) Children Only
Lifetime Maximum $1,200
2019 Per Pay Period Rates
Employee Only $16.87
Employee/Spouse $33.75
Employee/Child(ren) $40.50
Your current deductible will carry over
Employee/Family $50.62 to the new dental plan. If you have met
your lifetime deductible your will not
Procedure Benefit Frequency have to satisfy a new one.
Bitewings X-Rays One (1) every 12 months
Full X-Rays One (1) every 60 months
Fluoride One (1) every year under 19
Note: These procedures follow ADA recommended guidelines
January 1, 2019 to December 31, 2019 11VISION - MATERIALS ONLY (Frames, Lenses and Contacts)
Remember: Routine eye exams are covered at 100% when using the Discount Features
domestic or in-network providers, no co-pay, under Allegiance medical.
Look for providers in the Provider Directory who accept discounts, as some
Your 2019 Vision Plan: Materials only do not; please verify their services and discounts (range from 10%-40%)
prior to service as they vary.
Superior Vision will remain our vision provider for 2019. Superior offers
cost savings to employees as well as deeper discounts. They have a network Discounts on Covered Materials
of providers that you can check at www.superiorvision.com. Superior’s
customer service # is 1-800-507-3800. • Frames: 20% off amount over allowance
• Lens options: 20% off retail
Eligibility • Progressives: 20% off amount over retail lined trifocal lens, including
Employees with an FTE of .5 or higher are eligible for this coverage. lens options
• The following options have out-of-pocket maximums4 on standard (not
Services/Frequency
premium, brand, or progressive) lenses.
Frames 12 months
Discounts on Non-Covered Exam and Materials
Contact Lens Fitting 12 months
• Exams, frames, and prescription lenses: 30% off retail
Lenses 12 months • Lens options, contacts, other prescription materials: 20% off retail
Contact Lenses 12 months • Disposable contact lenses: 10% off retail
Copays
1
Materials $10
2
Contact Lens Fitting (standard & specialty) $10
Maximum Member Out-of-Pocket (Single Vision)
Scratch coat $13
Ultraviolet coat $15
Tints, solid or gradients $25
Anti-reflective coat $50
Polycarbonate $40
High Index 1.6 $55
Photochromics $80 Notes:
1. Materials co-pay applies to lenses and frames only, not contact lenses
Per Pay Period Rates 2. See your benefits materials for definitions of standard and specialty
contact lens fittings
Employee Only $2.89
3. Covered to provider’s in-office standard retail lined trifocal amount; member pays
Employee/Spouse $4.84 difference between progressive and standard retail lined trifocal,
Employee/Child(ren) $6.48 plus applicable co-pay
Employee/Family $7.85 4. Discounts and maximums may vary by lens type. Please check with your provider.
Benefits In-Network Out-of-Network
Frames $100 retail allowance Up to $50 retail
Contact Lens Fitting (standard) Covered in full Not covered
Contact Lens Fitting (specialty) $50 retail allowance Not covered
Single Vision Lenses (standard) per pair Covered in full Up to $34 retail
Bifocal Lenses (standard) per pair Covered in full Up to $48 retail
Trifocal Lenses (standard) per pair Covered in full Up to $64 retail
Progressive Lens Upgrade See description3 Up to $64 retail
Contact Lenses (Contact lenses are in lieu of eyeglass lenses and frames benefit) $130 retail allowance Up to $100 retail
* Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements.
12 2019 Online Benefits EnrollmentBASIC LIFE, Supplemental Life Insurance
ACCIDENTAL DEATH AND DISMEMBERMENT In addition to the basic life insurance that Hugh Chatham Memorial Hospital
is providing to employees, eligible employees can purchase more coverage
AND SUPPLEMENTAL LIFE INSURANCE by enrolling in a Supplemental Group Term Life insurance program.
Program Basics:
As part of your benefits package, Hugh Chatham Memorial Hospital provides To Enroll
full time employees with Term Life/Accidental Death and Dismemberment Complete the online enrollment in the benefits enrollment system and then
(AD&D) Insurance at no cost to you. complete Evidence of Insurability (EOI) when applicable within the benefit
You may purchase additional coverage by enrolling in Supplemental Life election system. Premiums will be deducted from your paycheck (following
insurance for you and your family. These plans are underwritten by Cigna. any required approvals).
Basic Life Insurance Life Insurance Rate Information
Basic Term Life and AD&D Employer Paid The rate is based on your age at the time of initial enrollment. Any future
- Full Time Employees Only rate changes due to age will be effective on your employer’s plan anniversary
date (each January 1st) following the date you enter a new age bracket.
1 times your base salary rounded to the next higher
Benefit Amount Children’s monthly rate is $.50 for $2,500, $1.00 for $5,000, $1.50 for
$1,000
$7,500, and $2.00 for $10,000 of coverage.
Maximum $250,000
by 35% at age 65 How To Use This Chart
Age Reduction by 60% at age 75 To determine your payroll deduction:
by 75% at age 70
• Select the amount of supplemental life coverage you would like to elect
Basic Life Coverage is convertible. for you and your spouse
• Divide by 1,000
Supplemental Life Insurance Employee Paid • Multiply the rate shown on the chart for your age for amount elected on
- Employees with an FTE of .5 or higher yourself and your spouse’s age for amounts elected on your spouse
• Multiply this number by 12 (This is the yearly premium)
Benefit Amount $10,000 increments
• Divide the yearly premium by 26.(This is your payroll deduction)
the lesser of $500,000 or 5 times your basic annual
Maximum Benefit If you are enrolling Online, you will be able to click on the drop down arrow
earnings
and see your rate.
Guarantee Issue $100,000
by 35% at age 65 Voluntary Life Rate Chart
Age Reduction by 60% at age 75 Age of Employee Premium Age of Employee Premium
by 75% at age 70 or Spouse Rate or Spouse Rate
Employees who currently have Supplemental Life can increase their Less than 30 $0.11 50 – 54 $0.73
coverage by level of $10,000 up to the guarantee issue amount without 30 – 34 $0.14 55 – 59 $1.27
having to submit EOI.
35 – 39 $0.20 60 – 64 $1.95
40 – 44 $0.29 65 – 69 $3.95
Spouse Coverage
45 – 49 $0.45 70+ $6.09
Benefit Amount $10,000 increments This Supplemental Life coverage is portable.
the lesser of $250,000 (cannot exceed 100% of
Maximum Benefit Beginning on and after your 65th birthday, Cigna decreases the amount of
employee supplemental life election)
your Supplemental Life insurance. Cigna pays a percentage of the amount
Guarantee Issue $30,000 otherwise payable as follows:
Newly eligible employees can elect up to the guarantee issue without • From your 65th birthday to age 70, Cigna pays 65%
an EOI. Spouse must be at least 18 years old on the date of enrollment. • From your 70th birthday to age 75, Cigna pays 40%
Employees who currently have Supplemental Life can increase their
coverage by level of $10,000 up to the guarantee issue amount without • From your 75th birthday and after, Cigna pays 25%
having to submit EOI.
Example
Ann Smith is a 35-year-old and applies for $100,000 of Supplemental
Child Coverage Life coverage. She follows these steps to calculate her bi-weekly payroll
Benefit Amount $2,500 increments deduction.
the lesser of $10,000 or 100% of the $100,000 divided by 1,000 = $100 100 x .20 = $20 $20 x 12 = $240
Maximum Benefit
emplpoyee's benefit
$240 divided by 26 = $9.23 Her bi-weekly payroll deduction for $100,000 of
If you and your spouse are employees, only one of you may elect Supplemental Life coverage is $9.23
Supplemental Life Coverage for your children. Coverage for dependent
children ends at age 26.
You are eligible for Supplemental Life Insurance the first day of the month
on 30 days of continuous benefit eligible service. You may enroll during
your initial eligibility enrollment period, open enrollment, or if you have a
qualifying life event. Late entrants are not eligible for guaranteed issue and
must submit an EOI for approval. Supplemental Life coverage is portable
January 1, 2019 to December 31, 2019 13SHORT TERM AND LONG TERM DISABILITY
Program Basics Long Term Disability (Full Time Employees only)
Long Term Disability (LTD) is a monthly income benefit to help you with
As part of your benefits package, HCMH provides full time employees with
financial support when an illness or injury occurs and prevents you from
Long Term Disability at no cost to the employee. You may also purchase
working for an extended period of disability.
additional coverage by enrolling in Short Term Disability. These plans are
underwritten by Cigna.
Long Term Disability Employer Paid
Elimination Period 180 Days
Benefit Percentage 60%
Maximum Weekly Benefit up to $7,000 per month
To age 65 0r SSNRA (Social Security
Maximum Period of Payment
Normal Retirement Age)
Minimum Benefit $100
You are eligible for LTD the first day of the month on 30 days of continuous
benefit eligible service. Hospital provided but need to elect in benefit system
Age at Disability Maximum Benefit Period
Age 62 or under The Employee’s 65th birthday or the date the
42nd Monthly Benefit is payable, if later.
Age 63 The date the 36th Monthly Benefit is payable.
Short Term Disability Age 64 The date the 30th Monthly Benefit is payable.
(Employees with an FTE of .5 or higher) Age 65 The date the 24th Monthly Benefit is payable.
Age 66 The date the 21st Monthly Benefit is payable.
Short Term Disability (STD) is a weekly income benefit to help you with
financial support when an illness or injury occurs and prevents you from Age 67 The date the 18th Monthly Benefit is payable.
working for a period of weeks. Age 68 The date the 15th Monthly Benefit is payable.
Short Term Disability Employee Paid Age 69 or older The date the 12th Monthly Benefit is payable.
Elimination Period
Sickness 14 Basic Short Term/Long Term Disability Earnings
Accident 14 The base rate earnings you received on the last day you worked for HCMH,
Benefit Percentage 60% before becoming disabled. It does not include bonuses, commission,
overtime pay, or shift differentials.
Maximum Weekly Benefit up to $1,000 per week
Maximum Period of Payment
26 weeks (includes two week Value Added Benefits for all employees
elimination period) • Travel Assistance
Rate Information $.645 per $10 of Benefit • ID Theft Protection
You are eligible for STD the first day of the month on 30 days of continuous • Estate Guidance
benefit eligible service. You may enroll during your initial eligibility • Will Preparations
enrollment period, open enrollment, or if you have a qualifying life event.
Late entrants are not eligible for guaranteed issue and must submit an EOI • Funeral Planning
for approval. • Concierge Services
How to determine what you will pay for • Concierge Services
Weekly Income Benefits coverage:
Beneficiary Assistances program
Per Pay Period Premium for an Employee
Information about these services can be found at HC QuickClick.
Employee Base Rate Salary $2,000 Monthly
This is a summary of benefits only. A complete description of benefits and
60% of salary to a maximum benefit of limitations will be provided in the certificate of coverage.
Weekly Benefit
$1,000. $2,000 x 12 months =
Please note that “Other Income” will be subtracted from your basic monthly earnings
$24,000/ 52 weeks x60%
when calculating your monthly income benefit. “Any Other Assumed Income” includes
= $277.00 weekly benefit
unemployment benefits, workers’ compensation benefits, social security benefits,
Monthly Rate $.645 per $10 of benefit and others. For a full list of income sources that reduce your monthly income benefit,
Monthly Premium $277 / 10 = 27.7 x $.645 = $17.86 please reference your Life & Disability Summary Plan Description. You must be disabled
for at least 180 days before you can receive a benefit payment.
Bi-weekly premium $8.24
When you are enrolling Online, you will be able to click on the drop down
arrow and see your rate.
14 2019 Online Benefits EnrollmentVOLUNTARY BENEFITS
Voya will continue to be our provider for our Specified Disease (Critical
Illness), accident and Hospital Indemnity Plans. Your coverage is guaranteed
when you enroll.
Voya Compass Specified Disease Insurance
Voya Compass Specified Disease Insurance pays a lump-sum benefit if you
are diagnosed with a covered disease or condition1. You can use this money
however you like, for example: to help pay for expenses not covered by your
medical plan, lost wages, child care, travel, home health care costs or any of
your regular household expenses. Voya Compass Specified Disease Insurance
is a limited benefit policy. This is not health insurance and does not satisfy the
requirement of minimum essential coverage under the Affordable Care Act.
During this open enrollment period you may elect up to $20,000 for yourself
and $10,000 for your spouse and children without having to answer any
medical questions.
If you enroll in Voya Compass Specified Disease Insurance coverage, you
and your covered dependents will have access to the Wellness Benefit. UNUM WHOLE LIFE
The Wellness Benefit provides an annual benefit if you complete a health
screening test, whether or not there were any out-of-pocket costs. This Why individual Whole Life Insurance coverage?
benefit is designed to encourage you to maintain a healthy lifestyle as the Whole Life Insurance is designed to provide a base of life insurance coverage
tests can help screen for a wide range of potential illnesses and diseases. for your lifetime. It offers you life insurance protection, tax-deferred cash
Rates for Specified Disease are based on age and amount of coverage accumulation (based on current tax laws), and cash value loan privileges – all
selected. This information is included within the benefit enrollment system. in one policy.
The premium you pay is based on the death benefit you select and the
Voya Compass Accident Insurance optional riders you choose as well as your age and tobacco status. The
Accident insurance pays you benefits for specific injuries and events insurance coverage, premium amounts, and cash value are guaranteed as
resulting from a covered accident1. You can use this money however you long as you meet the required premium payments.
like, for example: deductibles, child care, housecleaning, groceries or
utilities. Compass Accident Insurance is a limited benefit policy. This is not Term Life Insurance Whole Life Insurance
health insurance and does not satisfy the requirement of minimum essential Only covered during the life of the policy Coverage for entire life
coverage under the Affordable Care Act.
Less expensive than whole life for Acquire cash value
Rates per pay period: comparable death benefit
Employee $6.15
You can only enroll in the Whole Life during open enrollment.
Employee & Spouse $9.99
Employee & Children $11.81 You may elect by meeting with an enroller or calling the enrollment line at
Family $15.65
(877) 275-0016.
Voya Compass Hospital Confinement
Indemnity Insurance
Hospital Confinement Indemnity Insurance pays a daily benefit if you have
a covered stay in a hospital, critical care unit or rehabilitation facility1.
You can use this money for any purpose you like, for example: to help pay
for expenses not covered by your medical plan, lost wages, child care,
travel, home health care costs or any of your regular household expenses.
Compass Hospital Confinement Indemnity Insurance is a limited benefit
policy. This is not health insurance and does not satisfy the requirement of
minimum essential coverage under the Affordable Care Act. There are no
pre-existing condition restrictions.
Rates per pay period
Employee $8.35
Employee + Spouse $16.97
Employee + Children $12.80
Family $21.42
1 See the product brochure, certificate of coverage and any applicable riders for the
definition of covered facilities, along with complete provisions, exclusions and limitations.
Insurance products issued by ReliaStar Life Insurance Company, a member of the Voya®
family of companies. Home and Administrative Office: 20 Washington Avenue South,
Minneapolis, MN 55401. Policy provisions and product availability may vary by state.
January 1, 2019 to December 31, 2019 15401(k)
This Plan is intended to be a participant-directed Plan as described in Section 404(c) of the Employee Retirement Income Security Act of 1974 (ERISA),
which means that fiduciaries of the Plan are ordinarily relieved of liability for any losses under ERISA that are the direct and necessary result of investment
instructions given by a participant or beneficiary. What follows is an introduction to the investment options you can choose for your plan account. You
can spread your investments among several options to take advantage of what each has to offer and help balance different types of risk. Reviewing this
information can help you understand and compare your options.
Spectrum Category Fund Name
More Conservative Money Market Prime Fund – Daily Money class
Stable Value Putnam Stable Value Fund 75
Potentially less Government Diversified Municipal Inflation High Yield International
investment ▪ JP Morgan ▪ Fidelity Advisor Protected BlackRock High
risk and more ▪ Gov’t Bond Strategic Income Yield Bond
inflation risk Bond Fund Class A Fund Portfolio
– Class A Investor A
PIMCO TotalReturn Fund Shares
Class A
Balanced / Hybrid
Large Value Large Blend Large Growth
BlackRock Equity Dividend Fund Dreyfus S&P 500 Fidelity Advisor New
Investor A Shares Index Fund Insights Fund Class A
Mid Value Mid Blend Mid Growth
MFS Mid Cap Value Fund Class R3 Fidelity Advisor Mid Cap II Fund Class A
More Small Value Small Growth Small Growth
Aggressive Domestic Equity Fidelity dvisor Small
Invesco Small Cap Value Fund Class A
Potentially Cap Fund Class A
more Diversified:
International / Emerging Markets
investment AllianzGI NFJ International Value Fund Class A
Global Equity Oppenheimer Developing Markets Fund Class A
risk and less Oppenheimer International Growth Class A
inflation risk Specialty
Company Stock
Stock values fluctuate in response to the activities of individual companies and general market and economic conditions. In general, bond prices rise when
interest rates fall and vice versa. This effect is usually more pronounced for longer-term securities LLC or an affiliate.
This spectrum, with the exception of the Domestic Equity category, is based on Fidelity’s analysis of the general investment categories and not on the
actual investment options and their holdings., which can change frequently. Investment options in the Domestic Equity category are based on the options’
Morningstar categories as of the most recent calendar quarter. Morningstar categories are based on a fund’s style as measured by its underlying portfolio
holdings over the past three years and may change at any time. These style calculations do not represent the investment options’ objectives and do not
predict the investment options’ future styles. Investment options are listed in alphabetical order within each investment category. Risk associated with the
investment options may vary significantly within each category, and the relative risk of categories may change under certain conditions. For a complete
discussion of risk associated with the mutual fund options, please read the prospectuses before making your investment choices. The spectrum does not
represent actual or implied performance.
The 401(k) Plan provides our employees with a simple, cost effective way to save for retirement. The Plan provides the convenience of automatic payroll
deduction and the power of tax deferred savings. All contributions and earnings are tax-deferred until withdrawn from the Plan. The Hospital provides even
more incentive for you to save for your retirement by making a matching contribution on a portion of your contributions.
Eligibility Catch-up Contributions and Contributions Limits
All employees meet the following criteria: One (1) month of service Employees that are 50 or will be 50 by the end of the current calendar year
and age 21. will be automatically enrolled in the “catch-up contribution that allows an
additional $6,000 each calendar year. (please refer to full plan information for
Entry Dates maximum allowable contributions). The maximum contribution is $19,000
Monthly after fulfilling one month of eligibility. a year, unless your income is $270,000 or greater. Once your income has
reached $275,000, contributions will need to cease.
Auto-Enrollment Feature
Company Matching Contribution
Eligible employees automatically enrolled at 4% when eligible.
$.50 on $1.00 up to 4% of Contribution. Employees must be employed 1 year,
Contribution Amount Changes Allowed and have worked 1000 hours within a year (on their anniversary date) to be
eligible for the Company Matching. Once you become eligible, you will not
Monthly need to satisfy the 1,000 every year.
Employee Contributions
May range from 1 to 90% of Compensation (please refer to full plan
information for maximum allowable contributions). Your contribution will
automatically increase 1% each year up a maximum of 10% unless
you opt-out.
16 2019 Online Benefits EnrollmentEmployer Matching & Profit Sharing Vesting Schedule The Fidelity Advisor Freedom Funds are represented on a separate investment
spectrum because each fund (except the Fidelity Advisor Freedom Income
fund) will gradually adjust its asset allocation to be more conservative as the
100% fund approaches its target retirement date. Approximately ten to fifteen years
after the target date, the asset allocation of each Freedom fund will match the
75% allocation of the Freedom Income fund. The spectrum illustrates the relative
risk and return of each fund as compared with the other funds in the Freedom
family. This spectrum does not represent actual or implied performance.
50% The Advisor Freedom Funds are subject to the risks of their underlying funds,
including the volatility of the financial markets in the U.S. and abroad, as well
as the additional risks associated with investing in high yield, small-cap, and
25%
foreign securities. Principal invested is not guaranteed at any time, including
0% at or after each fund’s target date.
0% Strategic Advisers, Inc., a subsidiary of FMR LLC., manages the Fidelity Advisor
< 2 years Year 2 Year 3 Year 4 Year 5 Freedom Funds.
Important Information: This document provides only a summary of the main
Rollovers Permitted from Other Plans features of Hugh Chatham Memorial Hospital, Inc. 401(k) Plan, and the Plan
document will govern in the event of any discrepancy. This document is not a
Employees are eligible to rollover balances from previous retirement plans. Summary Plan Description.
Please refer to full plan information for rules regarding permitted rollovers.
Loan Provision: Plan permits you to take a loan from your account, which you Unless otherwise noted, transaction requests confirmed after the close of the
repay through payroll deductions. market, normally 4 p.m. Eastern time, or on weekends or holidays, will receive
the next available closing prices.
Distributions from the Plan: The investment options available through the Plan reserve the right to modify
In-Service withdrawals available for Hardship reasons, and at age 59 1/2. At or withdraw the exchange privilege.
termination of employment or retirement, balances can be rolled to an IRA This Plan is intended to be a participant-directed Plan as described in Section
or another employer’s retirement plan. You will receive more detailed Plan 404(c) of the Employee Retirement Income Security Act of 1974 (ERISA),
information when you become eligible to enroll in the Plan. For a Summary Plan which means that fiduciaries of the Plan are ordinarily relieved of liability for
Description for the Plan, please contact the Human Resources Department. any losses under ERISA that are the direct and necessary result of investment
instructions given by a participant or beneficiary.
Contact Information
The Fidelity Advisor Freedom Funds offer a blend of stocks, bonds and short-
Fidelity website: www.netbenefits.com term investments within a single fund. The funds are designed for investors
Fidelity Retirement Benefits Line: 1.800.294.4015 expecting to retire around the year indicated in each fund’s name. Consider
an appropriate Fidelity Advisor Freedom Fund that matches your needs.
Financial Advisor Contact Information:
Non-Fidelity mutual funds are managed by non-Fidelity entities. Please
Scott Graham, Susan Eisenman consult the prospectus for more information. Class of shares may vary.
AXA Advisors, LLC Please consult your Summary Plan Description for the specific class of shares
4000 Piedmont Parkway, Suite 205 available through your Plan.
High Point, NC 27265
336.812.8001 Fidelity Management & Research Company manages Fidelity Advisor mutual funds.
All trademarks and service marks appearing herein are the property of FMR LLC or an
How do I access my account? affiliate. Not NCUA or NCUSIF insured. May lose value. No credit union guarantee.
You can access your account virtually at any time through NetBenefits. Log in Keep in mind that investing involves risk. The value of your investment will fluctuate over
to netbenefits.com and you will have access to your account information and time, and you may gain or lose money.
retirement planning tools. You also can call the Retirement Benefits Line at An investment in a money market fund is not insured or guaranteed by the Federal
1.800.294.4015 between 8:30 a.m. and 8:30 p.m. ET on any business day* for Deposit Insurance Corporation or any other government agency. Although the fund
more information on your account. seeks to preserve the value of your investment at $1.00 per share, it is possible to lose
money by investing in the fund. Interest rate increases can cause the price of money
How do I change my investment options? market securities to decrease.
You may request investment changes (exchanges) or redirect future
Before investing, consider the funds’ investment objectives, risks, charges, and expenses.
contributions among investment options available to you any business day*
Contact your investment professional for a prospectus or visit netbenefits.com for a
online through Fidelity at netbenefits.com or by calling the Retirements
Fidelity Advisor fund prospectus containing this information. Read it carefully before you
Benefits Line at 1.800.294.4015.
make your investment choices.
*Available on days when the NYSE is open. It is important that you elect your Beneficiary
NOT FDIC INSURED • MAY LOSE VALUE • NO BANK GUARANTEE
when you enroll in the 401(k) program. If you are currently enrolled, and have not elected
a beneficiary, you need to log into NetBenefits.com and provide that information.
January 1, 2019 to December 31, 2019 17ROTH 401k
In 2018, a Roth 401k option was added to the Fidelity 401k Plan. Roth
deferrals are deducted on an after tax basis, any growth of value is tax
deferred, but distributions can be income tax free upon retirement.
It should be noted that employees can elect both pretax and Roth
contributions if they choose and are not limited to one or the other.
Changes to deferral amounts or types can be made online at Netbenefits.
com or by calling Fidelity directly.
EMPLOYEE ASSISTANCE PROGRAM
REACH EAP & Workplace Solutions (REACH) is proud to partner with your
employer to provide integrated employee assistance program (EAP), Work-
life, and Wellness services to help you and your family with interests and
concerns ranging from significant life problems to everyday challenges.
These services are prepaid by your employer at no cost to you and are very
confidential. To help you gain and maintain balance in your home and work
life, prevent further problems, and enhance your quality of life, we can help.
REACH OFFERS:
• 24-hour access to services
• Professional consultation in person or by phone
• Work-life Services
• Connections and referrals to additional supports and services as needed
REACH SERVICES ADDRESS:
• job stress
• family and parenting issues
• depression
• alcohol and drug abuse
• financial worries
• legal stressors
• stress and anxiety
• marital and relationship problems
• grief and loss
• other life stressors
To schedule an EAP appointment or to get more information about your
EAP benefits:
Call toll-free 24/7: 800-950-3434
Email: info@reach-eap.com
Visit our website: www.reach-eap.com
WEB-BASED SERVICES
To help you make the time for what matters most, your Work-life service
provides online access to a wide range of resources available by self-
search for work and life topics of interest to you and your family including
childcare, eldercare, and healthful living tips for all ages. Also available
are monthly online seminars and a comprehensive library of health and
wellness articles and self-assessments. Just log on with your company’s
username and password, and navigate through articles, links, interactive
content, financial calculators, and more.
To access, go to: http://reachworklife.powerflexweb.com
Username: reach-hcmh Password: reacheap
18 2019 Online Benefits EnrollmentEQUI-VEST 403(b) TSA Guaranteed Interest Option (GIO)3,4
A 403(b) Tax-Sheltered Annuity (TSA) is a Offers a guaranteed rate of interest and a guarantee of principal. The value of variable investment
tax-deferred retirement plan. EQUI-VEST®, a options within annuities will fluctuate and is subject to market risk, including the possible loss of
variable deferred annuity, offers you a way principal. Contribution limits are indexed to inflation.
to help build and enhance your retirement You may incur higher costs with these portfolios than if you were to invest directly in the underlying
savings. It also offers death benefit protection portfolios. Guarantees are based on the claims-paying ability of AXA Equitable Life Insurance
and a number of payout options. Your 403(b) Company. The GIO is part of AXA Equitable’s general account. AXA Equitable reserves the right to limit
TSA plan and EQUI-VEST® can be a lifelong allocations to the GIO. No more than 25% of any transfer request and contribution can be allocated
resource as you save for retirement. to the Guaranteed Interest Option (GIO). Therefore, we will not process any transfer requests and
contribution that would result in more than 25% of your account value in the GIO. These transfer
Market & Issue Ages restrictions are currently waived in all states. We will notify you 45 days in advance if the transfer
Eligible employees of public schools, colleges restrictions are reimposed.
and universities, hospitals and 501(c)(3) Features are subject to availability and your employer’s plan.
nonprofit organizations:
Ages 18 – 79 Important Considerations
Variable annuities are long-term financial products designed for retirement purposes. In essence, an
Investment Amounts annuity is a contractual agreement in which payment(s) are made to an insurance company, which
Initial Minimum: $20 agrees to pay out an income or a lump sum amount at a later date. There are fees and charges associated
with variable annuities, which include, but are not limited to, mortality and expense risk charges, sales
Contribution Limits1 and surrender charges, administrative fees, and charges for optional benefits. For costs and complete
• Maximum: $18,000 in 2019 or 100% of details of coverage, speak to your financial professional. The variable investment portfolios offered in this
compensation, whichever is less. There is a contract will fluctuate in value and are subject to market risk, including loss of principal.
salary cap of 265,000. All guarantees described herein are subject to the claims paying ability of AXA Equitable Life Insurance
• Catch-Up: $6,000 in 2019 if you are at least Company. Guarantees do not apply to variable investment portfolios.
age 50; this is in addition to the maximum Because this EQUI-VEST® annuity contract would be used to fund a 403(b) TSA plan, you should be
amount shown above. aware that such annuities do not provide tax-deferral benefits beyond those already provided by the
Internal Revenue Code. Before purchasing, you should consider whether its features and benefits
Investment Options beyond tax deferral meet your needs and goals. You may also want to consider the relative features,
An EQUI-VEST® account provides a wide variety benefits and costs of this annuity with any other investment that you may use in connection with your
of equity and guaranteed investment options, retirement plan or arrangement.
including options that offer one-step investing. Certain types of contracts, features and benefits may not be available in all jurisdictions. This fact card
Based on your retirement planning needs, you does not cover all material provisions of the EQUI-VEST® contract. This fact card must be preceded
can select: or accompanied by a current applicable EQUI-VEST® prospectus and any applicable supplements,
which contain detailed information about the EQUI-VEST® contract, including risks, charges, expenses,
Asset Allocation Portfolios2 investment objectives, limitations and restrictions. You should carefully read the prospectus, and any
Invest according to your risk tolerance, prospectus supplements included in this kit, before purchasing a contract.
with choices ranging from conservative to
aggressive. Features5 at No Additional Charge: (See prospectus for details)
• Special Dollar Cost Averaging • Loans
Target Date Allocation Portfolios2
• Investment Simplifier • Systematic Withdrawal Option (SWO)
Select a portfolio closest to your retirement
date. These portfolios offer a one-step • Asset Rebalancing • Standard Death Benefit
investment strategy that adjusts with you as • Transfers among Investment Options • Beneficiary Continuation Option
you move through the phases of your life. (may be subject to restrictions)
Your Own Asset Mix
Choose from among all of our investment
options.
1. Contribution limits are indexed to inflation. 4. No more than 25% of any transfer request and contribution can
be allocated to the Guaranteed Interest Option (GIO). Therefore,
2. You may incur higher costs with these portfolios than if you
we will not process any transfer requests and contribution that
were to invest directly in the underlying portfolios.
would result in more than 25% of your account value in the GIO.
3. Guarantees are based on the claims-paying ability of AXA These transfer restrictions are currently waived in all states. We
Equitable Life Insurance Company. The GIO is part of AXA will notify you 45 days in advance if the transfer restrictions are
Equitable’s general account. AXA Equitable reserves the right to reimposed.
limit allocations to the GIO.
5. Features are subject to availability and your employer’s
Please be advised that this document is not intended as legal or tax advice. Accordingly, any tax information provided in this document is not intended or written to be used, and
cannot be used, by any taxpayer for the purpose of avoiding penalties that may be imposed on the taxpayer. The tax information was written to support the promotion or marketing
of the transaction(s) or matter(s) addressed, and you should seek advice based on your particular circumstances from an independent tax advisor. AXA Equitable Life Insurance
Company and AXA Advisors, LLC do not provide tax or legal advice. Guarantees described herein are subject to the claims-paying ability of AXA Equitable Life Insurance Company.
EQUI-VEST® is a registered service mark of AXA Equitable Life Insurance Company (AXA Equitable), New York, NY 10104. EQUI-VEST® is issued by AXA Equitable and distributed by
an affiliate, AXA Advisors, LLC, New York, NY 10104. Contract form #s: 2006BASE-A, 2006BASE-B, 2006BASE-1A, 2006BASE-1B and any state variations ©2009 AXA Equitable Life
Insurance Company. All rights reserved. 1290 Avenue of the Americas, New York, NY 10104, (212) 554-1234 Visit our Web site at www.axa.com
January 1, 2019 to December 31, 2019 19You can also read
