Benefits Enrollment Guide - 2021 Bloomington Schools ISD #271 - DigitalOcean
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2021 Benefits Enrollment Guide Bloomington Schools ISD #271
TABLE OF CONTENTS
Enrollment and Eligibility
Package Overview & HR Contact
Medical Plan
Health Savings Account
Dependent Care Flexible Spending Account
Dental Plans
Voluntary Vision Plan
Life Insurance Plans
Long Term Disability Plan
Employee Assistance Program (EAP)
Telemedicine
Medical & Dental Rates and Contributions
Required Notices
The following descriptions of available benefit elections options, are purely informational
Carriers Vendors and Contacts and have been provided to you for illustrative purposes only. Payment of benefits will vary
from claim to claim within a particular benefit option and will be paid at the sole discretion
of the applicable insurance provider for each benefit option. The terms and conditions of
each applicable policy or certificate of coverage will provide specific details and will govern
in all matters relating to each particular benefit option described in this summary. In no
case will any information in this summary amend, modify, expand, enhance, improve or
Presented by: otherwise change any term, condition or element of the policies or certificates of coverage
that govern the benefit options described in this summary.
2
ENROLLMENT AND ELIGIBILITY
Offering a comprehensive and competitive benefits package is one way we recognize your contribution to the success of the organization and our role in helping you and your family to be healthy,
feel secure and maintain work/life balance. This enrollment guide has been designed to provide you with information about the benefit choices available to you. Remember, open enrollment is your
only opportunity each year to make changes to your elections, unless you or your family members experience an eligible "change in status."
How to Enroll in the Plans Change in Status
Read your materials and make sure you understand all of the options available. Generally, you may enroll in the plan, or make changes to your benefits, when you are first
• Locate your enrollment/change forms. eligible. However, you can make changes/enroll during the plan year if you experience a
• Fill out any necessary personal information. change in status. As with a new enrollee, you must submit your paperwork within 30 days of
the change or you will be considered a late enrollee.
• Make your benefit choices.
• If you have questions or concerns, please contact your HR department.
Examples of changes in status:
• You get married, divorced or legally separated
Whom Can You Add to Your Plan? • You have a baby or adopt a child
Eligible:
• You or your spouse takes an unpaid leave of absence
• Legally married spouse
• You or your spouse has a change in employment status
• Natural or adopted children up to age 26, regardless of student and marital status
• Your spouse dies
• Children under your legal guardianship
• You become eligible for or lose Medicaid coverage
• Stepchildren
• Significant increase or decrease in plan benefits or cost
• Children under a qualified medical child support order
• Disabled children 19 years or older
• Children placed in your physical custody for adoption
Ineligible:
• Divorced or legally separated spouse
• Common law spouse, even if recognized by your state
• Domestic partners, unless your employer states otherwise
• Foster children
Open Enrollment is the only chance to make changes,
• Sisters, brothers, parents or in-laws, grandchildren, etc.
unless you experience a “change in status.”
3
PACKAGE OVERVIEW & CONTACT INFORMATION
Bloomington Schools ISD #271 offers eligible employees a comprehensive benefit
package that provides both financial stability and protection. Our offering provides
flexibility for employees to design a package to meet their unique needs.
Effective July 1, 2021:
• Medical benefit plans with PreferredOne
• Dental benefit plan with Delta Dental of MN
• Voluntary Vision benefit plan with EyeMed
• Basic Life / AD&D and Long Term Disability benefit plans with The Hartford
• Accident and Critical Illness benefit plans with Voya
• Health Savings Account with Health Equity
• Dependent Care Flexible Spending Account with Benefit Extras
• Employee Assistance Program with Fairview
• Healthy Savings Plan
After you have enrolled in insurance coverage, you will receive additional information
in the mail from the insurance carriers. This information will contain your personal
identification cards. In the meantime, you can look up providers for your plans on the
internet.
HR at Bloomington Schools ISD #271:
Yoojin Woodward, Benefit Specialist
952-681-6444
ywoodward@isd271.org
4
MEDICAL PLAN
For this plan year, you can choose from the following medical options. Refer to the carrier benefits summaries for the exact benefit levels associated with your plan choice.
Carrier Name PreferredOne
Type of Plan PPO/HDHP
Office Visits In Network Out of Network
Primary Deductible then 0% Deductible then 20%
Specialist Deductible then 0% Deductible then 20%
Pharmacy
Deductible Integrated with Medical Deductible
Retail Standard Covered at out of network benefit level.
Retail Specialty Deductible then 0% Please see plan design.
Mail Order (90 days - Standard)
Common Services
In-Patient Facility Deductible then 0% Deductible then 20%
Out-Patient Facility Deductible then 0% Deductible then 20%
Urgent Care Deductible then 0% Deductible then 20%
Emergency Room Deductible then 0%
Annual Deductible
Individual $1,400
Family $2,800
Coinsurance 0% 20%
Annual Out of Pocket
Individual $1,400 $7,000
Family $2,800 $14,000
Maximum Benefits Unlimited - LTM
The benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the
plans of insurance described in this guide, the underlying insurance documents will govern in all cases.
5
HEALTH SAVINGS ACCOUNT (HSA)
Option for High Deductible Health Plan (HDHP)
For employees who elect the HDHP, you have the option of opening a Health Savings
Account (HSA). The HSA-eligible plan provides a way to save money that becomes
available in future years for health care expenses.
• In 2021, individuals can contribute up to $3,600 and families can contribute up to $7,200
to their HSA (these totals represent the total of employee and employer contributions).
• If you are 55 or older, you can make a $1,000 catch-up contribution.
• Contributions to an HSA can be made on a pre-tax or post-tax basis, and funds within the
HSA grow without incurring taxes. Funds are withdrawn tax-free for healthcare related
needs without having to file receipts, although you should keep your receipts in case you
are ever audited.
• Money deposited in the HSA by the employee AND employer immediately become the
employee’s asset and is portable.
Can money in
What is this account Maximum
Pre-Tax Plan accounts be “rolled
and how does it work? Contribution Allowed
over”?
Employee only
coverage: $3,600
An HSA account can be Yes, amounts left in
funded with pre-tax your HSA account can
Family coverage:
Health Savings Account dollars by you, your be rolled over year to
$7,200
(HSA) employer or both to year and is portable if
help pay for eligible you leave employment
Catch up contribution
medical expenses. of the company
(55 year of age or
older): $1,000
The benefit plan information shown in this guide is illustrative only. This information is not intended to be exhaustive nor should any discussion
or opinions be construed as professional advice.
6
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS (FSA) WITH BENEFIT EXTRAS
Who is Eligible and When
All Benefit Eligible Employees. Please check with your HR representative for specific eligibility requirements.
Benefits You Receive
FSAs provide you with an important tax advantage that can help you pay dependent care expenses on a pretax basis. By anticipating your
family’s dependent care costs for the next year, you can actually lower your taxable income.
Dependent Care FSA
The Dependent Care FSA lets employees use pretax dollars toward qualified dependent care such as caring for children under the age 13 or
caring for elders. The annual maximum amount you may contribute to the Dependent Care FSA is $5,000 (or $2,500 if married and filing
separately) per calendar year. Examples include:
• The cost of child or adult dependent care
• The cost for an individual to provide care either in or out of your house
• Nursery schools and preschools (excluding kindergarten)
The benefit plan information shown in this guide is illustrative only. This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice.
7
DENTAL PLANS
For this plan year, you can choose from the following dental options. Refer to the carrier benefits summaries for the exact benefit level associated with your plan choice.
Carrier Name Delta Dental of MN
Name of Plan Comprehensive Plan Preventive Plan
Type of Plan PPO PPO
Class In Network Premier & Out of Network In Network Premier & Out of Network
Preventive 0% 0% 0% 20%
Basic Restorative 0% Deductible then 15% 0% 20%
Major Services 40% Deductible then 50% Not Covered Not Covered
Orthodontia 50% Not Covered Not Covered Not Covered
Plan Details
Deductible applies to Preventive No No No No
Endodontics/Periodontics:
Basic Basic Not Covered Not Covered
Basic or Major
Orthodontics (Adult/Children) Adults & Children Adults & Children Not Covered Not Covered
Waiting Periods Applied NA NA NA NA
Deductible
Person - Calendar Year $50
Not Applicable Not Applicable Not Applicable
Family - Calendar Year $150
Plan Maximums
Calendar Year Max $1,500 $1,500 $500 $500
Ortho Lifetime Max $1,000 $1,000 Not Covered Not Covered
The benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the
plans of insurance described in this guide, the underlying insurance documents will govern in all cases.
8
VOLUNTARY VISION PLAN
For this plan year, you can choose from the following voluntary vision option. Refer to the
carrier benefit summary for the exact benefit level associated with your plan.
Carrier EyeMed
Network Select
Exam In Network Out of Network
Copay $10 Copay Reimbursed to $35
Frequency 12 Months
Lenses
Frequency 12 Months
Single $10 Copay Reimbursed to $25
Bifocal $10 Copay Reimbursed to $40
Trifocal $10 Copay Reimbursed to $50 Research has linked smoking to an increased
Contacts Elective $120 Allowance Reimbursed to $100 risk of developing age-related macular
degeneration, cataract, and optic nerve damage.
Contacts Medically Necessary Covered in Full Reimbursed to $210
Frames -National Eye Institute* https://nei.nih.gov/health/healthyeyes
Frequency 12 Months
Frames $120 Allowance Reimbursed to $50
The benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases.
9
LIFE AND AD&D INSURANCE PLAN
Basic Life / AD&D with The Hartford Dependent Group Life with The Hartford
All Eligible Active Employees Who DO NOT Opt Out of the Portion of Their Benefit
Exceeding $50,000
Life and AD&D Benefit 2x Annual Salary Spouse $2,000
Maximum Benefit Refer to Contract
All Eligible Active Employees Who Opt Out of the Portion of Their Benefit Exceeding
$50,000 Child: Birth – 21, 26 if FT Student $2,000
Life and AD&D Benefit $50,000
The benefit plan information shown in this guide is illustrative only. To the extent the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance
described in this guide, the underlying insurance documents will govern in all cases.
10LONG TERM DISABILITY INSURANCE
Carrier Name The Hartford
Benefit 66.67%
Maximum Monthly Benefit Refer to Contract
Minimum Monthly Benefit $100
Elimination Period 90 Days
Own Occupation Definition 24 Months
Benefit Duration SSNRA
Earnings Definition Base Pay
41% of people with arthritis are forced to limit their physical activity, making it the
leading cause of disability in the US.
- Illinois Department of Public Health. “Arthritis and Disability.” 2007. Web Accessed November 10, 2014.
The rates and benefit plan information shown in this guide are illustrative only. To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases.
11EMPLOYEE ASSISTANCE PROGRAM (EAP) WITH FAIRVIEW
Bloomington Schools ISD #271 provides these services at no cost to employees or their
families. No referrals are needed to see an EAP counselor, and you never have to
worry about finding a provider who is in your network. And unlike insurance-covered
care, you never have a co-pay. In addition, all household family members are covered
regardless if they are covered by other benefits.
The call center is open 24 hours a day, 7 days a week. All operators have clinical
backgrounds and at minimum a bachelor's degree in the field. You can also talk to a
licensed counselor at any time. Instead of waiting weeks to be seen by a counselor, you
can contact one anytime.
We offer short-term counseling to help people work through any problems they may
be having. Some counseling sessions are done over the phone, while in other instances
the employee visits the counselor.
Call Fairview at 612-672-2195
• Stress Management • Feeling Depressed
• Divorce/Marital Problems • Family Issues
• Grief • Feeling Stuck
• Feeling Unmotivated • Drug and Alcohol Issues
The benefit plan information shown in this guide is illustrative only. This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice.
12TELEMEDICINE
What is Telemedicine?
• Telemedicine uses technology to facilitate communication, between a doctor and
patient who are not in the same physical location for medical evaluation, diagnosis
and treatment.
• Speak to a real live doctor 24/7/365.
• All doctors are US Board Certified, licensed to practice medicine and write
prescriptions in the state the caller is located in.
• Experienced doctors are here to help.
• 100% HIPAA Compliant.
• Designed for non-emergency care; 71 % of all medical visits today are non-
emergency.
Benefits
✓ Remote Access
✓ Specialist Availability
✓ Cost Savings
✓ Convenient Care
For more information on how Telemedicine benefits may affect your HDHP plan with an HSA, please
contact your Human Resources representative.
The benefit plan information shown in this guide is illustrative only. This information is not intended to be exhaustive nor should any discussion or opinions be construed as professional advice.
13MEDICAL & DENTAL PREMIUMS and CONTRIBUTIONS
Bloomington Schools ISD #271 contributes to the cost of the medical and dental plans for you.
Coverage Tier FULL-TIME PART-TIME
Coverage Tier Monthly Premium District Contribution Employee Share Per 24 Paychecks District Contribution Employee Share Per 24 Paychecks
Medical Plan with PreferredOne - High Deductible Health Plan (HDHP)
Single $852.00 $852.00 $0.00 $0.00 $598.0 $256.00 $128.00
Employee + 1 $1,792.00 $1,253.00 $539.00 $269.50 $879.00 $913.00 $456.50
Family $1,960.00 $1,372.00 $588.00 $294.00 $960.00 $1,000.00 $500.00
Medical Plan with PreferredOne – H.S.A. Contribution
Full-Time Part-Time Full-Time Part-Time
Single
$700.00 $350.00 Employee + 1 & Family $1,400.00 $700.00
($58.34 per month) ($29.17 per month) ($116.67 per month) ($58.34 per month)
Coverage Tier Monthly Premium Paid by District Employee Cost/Month Per Paycheck (24)
Dental Plan with Delta Dental – Part Time Employees
Single Preventive $24.50 $24.50 $0.00 $0.00
Buy up to Single Comprehensive $37.70 $24.50 $13.20 $6.60
Buy up to Family Comprehensive $111.45 $24.50 $86.95 $43.48
Dental Plan with Delta Dental – Full Time Employees
Single Comprehensive $37.70 $37.70 $0.00 $0.00
Family Comprehensive $111.45 $37.70 $73.50 $36.88
The rates shown in this guide are illustrative only. To the extent the rates contained herein differ from those in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the rates in the underlying insurance documents will govern in all cases.
14REQUIRED NOTICES
Newborn and Mothers’ Health Protection Act
• Group health plans and health insurance issuers generally may not, under
federal law restrict benefits for any hospital length of stay in connection with
childbirth for the mother or newborn child to less than 48 hours following
vaginal delivery, or less than 96 hours following a cesarean section. However,
federal law generally does not prohibit the mother’s or newborn’s attending
provider, after consulting with the mother, from discharging the mother or
newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans
and issuers may not, under federal law, require that a provider obtain
authorization from the plan or the issuer for prescribing a length of stay not in
excess of 48 hours (or 96 hours).
Women’s Health and Cancer Rights Act
• In October 1998, Congress enacted the Women’s Health and Cancer Rights
Act of 1998. This notice explains some important provisions of the Act.
Please review this information carefully. As specified in the Women’s Health
and Cancer Rights Act, a plan participant or beneficiary who elects breast
reconstruction in connection with a covered mastectomy is also entitled to
the following benefits: 1. All stages of reconstruction of the breast on which
the mastectomy has been performed: 2. Surgery and reconstruction of the
other breast to produce a symmetrical appearance; and 3. Prostheses and
treatment of physical complications of the mastectomy , including
lymphedemas. Health plans must provide coverage of mastectomy related
benefits in a manner to determine in consultation with the attending
physician and the patient. Coverage for breast reconstruction and related
services may be subject to deductibles and insurance amounts that are
consistent with those that apply to other benefits under the plan.
15REQUIRED CHIP NOTICE
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage,
using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy
individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or
CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-
sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you
aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions
about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2020. Contact your State
for more information on eligibility –
ALABAMA – Medicaid COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+)
Health First Colorado Website: https://www.healthfirstcolorado.com/
Health First Colorado Member Contact Center:
1-800-221-3943/ State Relay 711
Website: http://myalhipp.com/
CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus
Phone: 1-855-692-5447
CHP+ Customer Service: 1-800-359-1991/ State Relay 711
Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/health-insurance-buy-program
HIBI Customer Service: 1-855-692-6442
ALASKA – Medicaid FLORIDA – Medicaid
The AK Health Insurance Premium Payment Program
Website: http://myakhipp.com/
Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html
Phone: 1-866-251-4861
Phone: 1-877-357-3268
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx
ARKANSAS – Medicaid GEORGIA – Medicaid
Website: http://myarhipp.com/ Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp
Phone: 1-855-MyARHIPP (855-692-7447) Phone: 678-564-1162 ext 2131
CALIFORNIA – Medicaid INDIANA – Medicaid
Healthy Indiana Plan for low-income adults 19-64
Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx Website: http://www.in.gov/fssa/hip/
Phone: 916-440-5676 Phone: 1-877-438-4479
All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584
16REQUIRED CHIP NOTICE (CONT)
IOWA – Medicaid and CHIP (Hawki) MONTANA – Medicaid
Medicaid Website:
https://dhs.iowa.gov/ime/members
Medicaid Phone: 1-800-338-8366 Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Hawki Website: Phone: 1-800-694-3084
http://dhs.iowa.gov/Hawki
Hawki Phone: 1-800-257-8563
KANSAS – Medicaid NEBRASKA – Medicaid
Website: http://www.ACCESSNebraska.ne.gov
Website: http://www.kdheks.gov/hcf/default.htm Phone: 1-855-632-7633
Phone: 1-800-792-4884 Lincoln: 402-473-7000
Omaha: 402-595-1178
KENTUCKY – Medicaid NEVADA – Medicaid
Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website:
https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx
Phone: 1-855-459-6328
Medicaid Website: http://dhcfp.nv.gov
Email: KIHIPP.PROGRAM@ky.gov
Medicaid Phone: 1-800-992-0900
KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx
Phone: 1-877-524-4718
Kentucky Medicaid Website: https://chfs.ky.gov
LOUISIANA – Medicaid NEW HAMPSHIRE – Medicaid
Website: https://www.dhhs.nh.gov/oii/hipp.htm
Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp
Phone: 603-271-5218
Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)
Toll free number for the HIPP program: 1-800-852-3345, ext 5218
MAINE – Medicaid NEW JERSEY – Medicaid and CHIP
Medicaid Website:
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html http://www.state.nj.us/humanservices/dmahs/clients/medicaid/
Phone: 1-800-442-6003 Medicaid Phone: 609-631-2392
TTY: Maine relay 711 CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid
Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Website: https://www.health.ny.gov/health_care/medicaid/
Phone: 1-800-862-4840 Phone: 1-800-541-2831
MINNESOTA – Medicaid NORTH CAROLINA – Medicaid
Website:
https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/medical- Website: https://medicaid.ncdhhs.gov/
assistance.jsp [Under ELIGIBILITY tab, see “what if I have other health insurance?”] Phone: 919-855-4100
Phone: 1-800-657-3739
MISSOURI – Medicaid NORTH DAKOTA – Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 573-751-2005 Phone: 1-844-854-4825
17REQUIRED CHIP NOTICE (CONT)
OKLAHOMA – Medicaid and CHIP UTAH – Medicaid and CHIP
Medicaid Website: https://medicaid.utah.gov/
Website: http://www.insureoklahoma.org
CHIP Website: http://health.utah.gov/chip
Phone: 1-888-365-3742
Phone: 1-877-543-7669
OREGON – Medicaid VERMONT– Medicaid
Website: http://healthcare.oregon.gov/Pages/index.aspx
Website: http://www.greenmountaincare.org/
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-250-8427
Phone: 1-800-699-9075
PENNSYLVANIA – Medicaid VIRGINIA – Medicaid and CHIP
Website: https://www.coverva.org/hipp/
Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspx
Medicaid Phone: 1-800-432-5924
Phone: 1-800-692-7462
CHIP Phone: 1-855-242-8282
RHODE ISLAND – Medicaid and CHIP WASHINGTON – Medicaid
Website: http://www.eohhs.ri.gov/ Website: https://www.hca.wa.gov/
Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line) Phone: 1-800-562-3022
SOUTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid
Website: https://www.scdhhs.gov Website: http://mywvhipp.com/
Phone: 1-888-549-0820 Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
SOUTH DAKOTA - Medicaid WISCONSIN – Medicaid and CHIP
Website:
Website: http://dss.sd.gov
https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
Phone: 1-888-828-0059
Phone: 1-800-362-3002
TEXAS – Medicaid WYOMING – Medicaid
Website: http://gethipptexas.com/ Website: https://wyequalitycare.acs-inc.com/
Phone: 1-800-440-0493 Phone: 307-777-7531
To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special enrollment rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/agencies/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and
Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently
valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any
other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See
44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of
Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
OMB Control Number 1210-0137 (expires 1/31/2023)
18HIPAA Notice
HIPAA Privacy Notices
HIPAA requires group health plans to provide a notice of current privacy practices regarding protected
personal health information (PHI) to enrolled participants. All employers must distribute HIPAA Privacy
Notices if the plan is self-funded or if the plan is fully- insured and the employer has access to PHI. If the
employer maintains a benefits website, the HIPAA Privacy Notice must be included on the website.
The HIPAA Privacy Notice must be written in plain language and must describe three things: (1) the use
and disclosures of PHI that may be made by the group health plan; (2) plan participants’ privacy rights; and
(3) the group health plan’s legal responsibilities with respect to the PHI.
The Department of Health and Human Services (HHS) has developed three different model Privacy Notices
for health plans to choose from: booklet version, layered version, and full-page version.
More information can be found at: https://www.hhs.gov/hipaa/for-
professionals/privacy/guidance/privacy-practices-for-protected-health-information/index.html
Link to OneDigital’s privacy policy: https://www.onedigital.com/privacy-policy/
Model Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other
health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in
this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops
contributing toward your or your dependents’ other coverage). However, you must request enrollment
within the appropriate time period that applies under the plan after you or your dependents’ other coverage
ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new
dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll
yourself and your dependents. However, you must request enrollment within the appropriate time period
that applies under the plan after the marriage, birth, adoption, or placement for adoption. To request special
enrollment or obtain more information, contact the appropriate plan representative.
More information can be found at: https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-
center/faqs/hipaa-compliance
For additional information on your employer’s privacy policy, please contact your HR department.
19CONFIDENTIALITY NOTICE
Digital Insurance LLC dba OneDigital Health and Benefits does not sell or share any information we learn about our clients and understands you may have to answer
sensitive questions about your medical history, physical condition and personal health habits as required by our insurance carrier partners.
We collect nonpublic personal information from the following sources:
• Information from you, including data provided on applications or other forms, such as name, address, telephone number, date of birth and Social Security number
• Information from your transactions with us and/or our partners such as policy coverage, premium, claim, and payment history.
OneDigital Health and Benefits recognizes the importance of safeguarding the privacy of our clients and prospective clients, and we pledge to protect the confidential
nature of your personal information. We understand our ability to provide access to affordable health insurance to businesses and individuals can only succeed with
an environment of complete trust.
In the course of business, we may disclose all or part of your customer information without your permission to the following persons or entities for the following
reasons:
• To an insurance carrier, agent or credit reporting agency to detect, prevent or prosecute actual or potential criminal activity, fraud, misrepresentation, unauthorized
transactions, claims or other liabilities in connection with an insurance transaction.
• To a medical care institution or medical professional to verify coverage or benefits, to inform you of a medical problem of which you may or may not be aware or to
conduct an audit that would enable us to verify treatment.
• To an insurance regulatory authority, law enforcement or other governmental authority to protect our interests in detecting, preventing or prosecuting actual or
potential criminal activity, fraud, misrepresentation, unauthorized transactions, claims or other liabilities in connection with an insurance transaction.
• To a third party, for any other disclosures required or permitted by law. We may disclose all of the information that we collect about you, as described above.
Our practices regarding information confidentiality and security: We restrict access to your customer information only to those individuals who need it to provide you
with products or services, or to otherwise service your account. In addition, we have security measures in place to protect against the loss, misuse and/or
unauthorized alternation of the customer information under our control, including physical, electronic and procedural safeguards that meet or exceed applicable
federal and state standards.
20CARRIERS, VENDORS & CONTACTS
Program Vendor Contact Information
763-847-4477 or 1-800-997-1750 (7am-7pm M-F)
Medical/Rx PreferredOne
www.preferredone.com
1-800-553-9536
Dental Delta Dental of MN
www.deltadentalmn.org
1-8669EYEMED (1-866-939-3633)
Voluntary Vision EyeMed
www.eyemed.com
1-888-563-1124
Basic Life / AD&D and Long-Term Disability The Hartford
www.thehartford.com
952-681-6444, Please see Yoojin Woodward, Human Resources
Accident and Critical Illness Voya Employee Benefit Resource Center:
https://presents.voya.com/EBRC/BloomingtonSchools
1-866-346-5800 (24/7)
Health Savings Account (H.S.A.) Health Equity
www.healthequity.com
952-435-6858
Dependent Care Flexible Spending Account Benefit Extras
www.benefitextras.com
Employee Assistance Program (EAP) Fairview 612-672-2195
Healthy Savings Healthy Savings www.myhealthysavings.com
Know Where to Go!
24Additional
Benefit
Information
2021Compass Accident Insurance
Enrollment at a glance
For the employees of: Bloomington Independent School District #271
Group #65768-9
What is Accident Insurance?
Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident that occurs while
you are not at work, on or after your coverage effective date. The benefit amount depends on the type of injury and care
received. You have the option to elect Accident Insurance to meet your needs. Accident Insurance is a limited benefit
policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable
Care Act.
Features of Accident Insurance include:
Guaranteed issue: No medical questions or tests are required for coverage.
Flexible: You can use the benefit payments for any purpose you like.
Portable: If you leave your current employer or retire, you can take your coverage with you.
How can Accident Insurance help?
Below are a few examples of how your Accident Insurance benefits could be used:
Medical expenses, such as deductibles and copays
Home healthcare costs
Lost income due to lost time at work
Everyday expenses like utilities and groceries
What Accident benefits are available?
The following list is a summary of the benefits provided by Accident Insurance. You may be required to seek care for your
injury within a set amount of time. Note that there may be some variations by state. For a list of standard exclusions and
limitations, go to the end of this document. For a complete description of your available benefits, exclusions and
limitations, see your certificate of insurance and any benefits.
Event Benefit
Accident hospital care
Surgery open abdominal, thoracic $1,000
Surgery exploratory or without repair $100
Blood, plasma, platelets $300
Hospital admission $900
Hospital confinement
$225
per day up to 365
Critical care unit confinement
$450
per day, up to 15 days
Rehabilitation facility confinement per day for 90 days $125
Coma duration of 14 or more days $5,000
Transportation
$300
per trip, up to three per accident
Lodging per day, up to 30 days $100
Family care
$20
per child, up to 45 days
Follow-up care
Medical equipment $100
Physical therapy
$25
per treatment, up to six
Prosthetic device (one) $500
Prosthetic device (two or more) $1,000Common injuries
Burns second degree, at least 36% of the body $750
Burns third degree, at least nine but less than 35 square inches of the body $1,500
Burns third degree, 35 or more square inches of the body $10,000
Skin grafts 25% of the burn benefit
Emergency dental work
$150 crown, $50 extraction
while hospital confined
Eye injury removal of foreign object $50
Eye injury surgery $200
Torn knee cartilage surgery with no repair or if cartilage is shaved $100
Torn knee cartilage
$500
surgical repair
1
Laceration treated no sutures $25
Laceration1 sutures up to 2” $50
Laceration1 sutures 2” – 6” $200
Laceration1 sutures over 6” $400
Ruptured disk surgical repair $400
Tendon/ligament/rotator cuff
$400
one, surgical repair
Tendon/ligament/rotator cuff
$600
two or more, surgical repair
Tendon/ligament/rotator cuff
$100
exploratory arthroscopic surgery with no repair
Concussion $100
Paralysis quadriplegia $10,000
Paralysis paraplegia $5,000
Dislocations Closed/open reduction2
Hip joint $2,000/$4,000
Knee $1,000/$2,000
Ankle or foot bone(s)
$800/$1,600
other than toes
Shoulder $300/$600
Elbow $300/$600
Wrist $300/$600
Finger/toe $100/$200
Hand bone(s) other than fingers $300/$600
Lower jaw $300/$600
Collarbone $300/$600
Partial dislocations
25% of the closed reduction amount
Fractures Closed/open reduction3
Hip $1,500/$3,000
Leg $800/$1,600
Ankle $300/$600
Kneecap $300/$600
Foot excluding toes, heel $300/$600
Upper arm $350/$700
Forearm, hand, wrist except fingers $300/$600
Finger, toe $50/$100
Vertebral body $800/$1,600
ReliaStar Life Insurance Company, a member of the Voya® family of companiesFractures Closed/open reduction3
Vertebral processes $300/$600
Pelvis except coccyx $800/$1,600
Coccyx $200/$400
Bones of face except nose $350/$700
Nose $100/$200
Upper jaw $350/$700
Lower jaw $300/$600
Collarbone $300/$600
Rib or ribs $250/$500
Skull – simple except bones of face $1,000/$2,000
Skull – depressed
$2,500/$5,000
except bones of face
Sternum $300/$600
Shoulder blade $300/$600
Chip fractures
25% of the closed reduction amount
Emergency care benefits
Ground ambulance $100
Air ambulance $500
Emergency room treatment $150
Initial doctor visit $50
Follow-up doctor visit $50
1
Laceration benefits are a total of all lacerations per accident.
2
Closed Reduction of Dislocation = Non-surgical reduction of a completely separated joint. Open Reduction of Dislocation = Surgical reduction of a
completely separated joint.
3
Closed Reduction of Fracture = Non-surgical. Open Reduction of Fracture = Surgical.
Who is eligible for Accident Insurance?
You—All active employees classified as teachers working 17.5+ hours per week and active employees classified as
non-teachers working 20+ hours per week.
Your spouse*—If you have coverage on yourself, you may enroll your spouse, as long as your spouse is under age
70 and is not covered under your employer’s plan as an employee. Your spouse will be covered for the same
Accident benefits as you are.
Your children**—If you have coverage on yourself; your natural children, stepchildren, adopted children or children
for whom you are a legal guardian; are eligible to be covered under your employer’s plan, up to the age of 26. Your
children will be covered for the same Accident benefits as you are and one premium amount covers all of your eligible
children. If both you and your spouse are covered under this policy as an employee; then only one, but not both, may
cover the same children under this benefit. If the parent who is covering the children stops being insured as an
employee, then the other parent may apply for children’s coverage.
*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. Please contact your
employer for more information.
**The definition of “child” may vary by state. Please contact your employer for more information.
ReliaStar Life Insurance Company, a member of the Voya® family of companiesWhat does my Accident Insurance include?
The benefits listed below are included with your Accident Insurance coverage. For a list of standard exclusions and
limitations, please refer to the end of this document. For a complete description of your available benefits, exclusions and
limitations, see your certificate of insurance and any benefits.
Wellness Benefit: This provides an annual benefit payment if you complete a health screening test.
o The annual benefit amount is $100 for completing a health screening test.
o Your spouse’s benefit amount is $100.
o The benefit for child coverage is 50% of your benefit amount per child with an annual maximum of $200
for all children.
When is my coverage effective?
The effective date of coverage is the date your coverage is active and you are eligible to begin filing claims. The specific
injury and event must occur on or after the coverage effective date.
Annual enrollment
Your coverage becomes effective on the July 1st following the election of coverage. Coverage for your spouse
and/or children becomes effective on the same date as your coverage.
How much does Accident Insurance cost?
All employees pay the same rate, no matter their age. See the chart below for the premium amounts.
Monthly Rates
Employee Employee and Spouse Employee and Children Family
$9.36 $15.58 $17.64 $23.86
Exclusions and limitations
Exclusions for the Certificate, Spouse Accident Insurance, and Children’s Accident Insurance are listed below. (These
may vary by state.) Benefits are not payable for any loss caused in whole or directly by any of the following*:
Participation or attempt to participate in a felony or illegal activity.
An accident while the covered person is operating a motorized vehicle while intoxicated. Intoxication means the
covered person’s blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of
the state where the accident occurred.
Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane.
War or any act of war, whether declared or undeclared, other than acts of terrorism.
Loss that occurs while on full-time active duty as a member of the armed forces of any nation. We will refund,
upon written notice of such service, any premium which has been accepted for any period not covered as a result
of this exclusion.
Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.
Riding in or driving any motor-driven vehicle in a race, stunt show or speed test.
Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any
aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not
excluded.
Engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting, kite surfing or any
similar activities.
Practicing for, or participating in, any semiprofessional or professional competitive athletic contests for which any
type of compensation or remuneration is received.
Any sickness or declining process caused by a sickness.
*See the certificate of insurance and riders for a complete list of available benefits, exclusions and limitations.
ReliaStar Life Insurance Company, a member of the Voya® family of companiesQuestions?
Where do I get more information?
For more information or to access the certificate of insurance, please call the Voya Employee Benefits Customer Service
Team at (877) 236-7564
This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be
provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is
any discrepancy between this document and the group policy documents, the policy documents will govern. To keep coverage in
force, premiums are payable up to the date of coverage termination. Accident Insurance is underwritten by ReliaStar Life Insurance
Company (Minneapolis, MN), a member of the Voya® family of companies. Policy Form #RL-ACC2-POL-12; Certificate Form #RL-
ACC2-CERT-12; and Rider Forms: Spouse Accident Rider Form #RL-ACC2-SPR-12, Children's Accident Rider Form #RL-ACC2-
CHR-12 and Wellness Benefit Rider Form #RL-ACC2-WELL-12. Form numbers, provisions and availability may vary by state.
CN0209-30894-0218 Bloomington Independent School District #271, Group #65768-9 Date Prepared: 4.5.19 177544-
04/01/2017
ReliaStar Life Insurance Company, a member of the Voya® family of companiesCompass Critical Illness Insurance
Enrollment at a glance
For the employees of: Bloomington Independent School District #271Group
#65768-9
What is Critical Illness Insurance?
• Pays a lump-sum benefit if you are diagnosed with a covered illness or condition on or after your coverage
effective date.
• You have the option to elect Critical Illness Insurance.
Critical Illness Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of
minimum essential coverage under the Affordable Care Act.
Features of Critical Illness Insurance include:
• Guaranteed Issue: No medical questions or tests are required for coverage.
• Flexible: You can use the benefit payments for any purpose you like.
• Portable: If you leave your current employer or retire, you can take your coverage with you.
What benefits are available?
Critical Illness Insurance provides a benefit payment for the following illnesses and conditions. Covered
illnesses/conditions are broken out into groups called “modules”. Benefits are paid at 100% of the Maximum Critical
Illness Benefit amount unless otherwise stated. For a complete description of your benefits, along with applicable
provisions, conditions on benefit determination, exclusions and limitations, see your certificate of insurance and any
riders.
Base Module
• Heart attack* • Major organ failure
• Stroke • Permanent paralysis
• Coronary artery bypass (25%) • End stage renal (kidney) failure
• Coma
*Cardiac arrest is not a heart attack.
Cancer Module
• Cancer • Carcinoma in situ (25%)
• Skin cancer (10%)
Who is eligible for Critical Illness Insurance and what is the Maximum Critical Illness Benefit?
• You -All active employees classified as teachers working 17.5+ hours per week and active employees classified as
non-teachers working 20+ hours per week.
o Employer-paid: Your employer provides you with a $2,000 Maximum Critical Illness Benefit at no cost to
you.How many times can I receive a benefit?
Usually you are only able to receive the Maximum Specified Disease Benefit once for each covered condition, but:
• Your plan includes the Recurrence Benefit*, which allows you to receive a benefit for the same condition a second
time.
• In order for the second occurrence of the illness to be covered, it must occur after 6 consecutive months without the
occurrence of any covered critical illness named in your certificate, including the illness from the first benefit payment.
If you have reached the benefit limit by receiving the maximum benefit for each covered condition, you may choose to end
your coverage; however, if you have coverage for your spouse and/or children, you must continue your coverage in order
to keep their coverage active. Please see your certificate of coverage for details.
*This benefit does not apply to the cancer module.
When is my coverage effective?
If you are working for the Employer in an eligible class, the date you are eligible for coverage is the later of the following:
• The Policy effective date
• The day after you complete Your Eligibility Waiting Period.
Exclusions and Limitations
Benefits are not payable for any critical illness caused in whole or directly by any of the following*:
• Participation or attempt to participate in a felony or illegal activity.
• Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane.
• War or any act of war, whether declared or undeclared, other than acts of terrorism.
• Loss that occurs while on full-time active duty as a member of the armed forces of any nation. We will refund,
upon written notice of such service, any premium which has been accepted for any period not covered as a result
of this exclusion.
• Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.
th
Benefits reduce 50% for the employee and/or covered spouse on the policy anniversary following the 70 birthday,
however, premiums do not reduce as a result of this benefit change.
*See the certificate of insurance and any riders for a complete list of available benefits, along with applicable provisions, exclusions and
limitations.
Questions?
Where do I get more information?
For more information or to access the certificate of insurance, please call the Voya Employee Benefits Customer Service
Team at (877) 236-7564
This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be
provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is
any discrepancy between this document and the group policy documents, the policy documents will govern. To keep coverage in
force, premiums are payable up to the date of coverage termination. Critical Illness Insurance is underwritten by ReliaStar Life
®
Insurance Company (Minneapolis, MN), a member of the Voya family of companies. Policy Form #RL-CI3-POL-12; Certificate Form
#RL-CI3-CERT-12; and Rider Forms: Recurrence Rider Form #RL- CI3-REC-12 Form numbers, provisions and availability may vary
by state.
CN0129-39809-0218
Bloomington Independent School District #271, Group #65768-9 Date Prepared: 04/06/2018
177620-02/01/2018
®
ReliaStar Life Insurance Company, a member of the Voya family of companies.Wellness Benefit
At a glance
For employees of Bloomington Independent School District #271 enrolled in Accident Insurance.
What is the Wellness Benefit?
The Wellness Benefit is a rider that is included with your Accident coverage. It provides an annual benefit payment if you
complete a health screening test on or after your coverage effective date, whether or not there is any out-of-pocket cost to
you. You only need to complete one health screening test. Note that you may only receive a benefit payment once per
year, even if you complete multiple health screening tests. If your spouse and or children are covered for Accident
Insurance, they are also covered for this benefit.
What types of health screening tests are eligible?
Health screening tests include but are not limited to:
• Blood test for • Serum Protein • Fasting blood glucose • Annual Physical Exam –
triglycerides Electrophoresis test adults
• Pap smear or thin prep (myeloma) • Thermography • CA 125 (ovarian cancer)
pap test • Breast ultrasound, • PSA (prostate cancer) • Tests for sexually
• Flexible sigmoidoscopy sonogram, MRI • Hearing test transmitted infections
• CEA (blood test for colon • Chest x-ray • Routine eye exam (STIs)
cancer) • Mammography • Routine dental exam • Ultrasound screening for
• Bone marrow testing • Colonoscopy • Well child/preventative abdominal aortic
• Serum cholesterol test • CA 15-3 (breast cancer) exams through age 18 aneurysms
for HDL & LDL levels • Stress test on bicycle or • Biometric screenings • Hemoglobin A1C
• Hemoccult stool analysis treadmill • Electrocardiogram (HbA1c)
(EKG) • Bone density screening
What is my Wellness Benefit amount?
The annual benefit for you and your covered spouse is $100 each for completing a health screening test. The annual
benefit for any covered child is $50 up to a maximum of $200 for all children per calendar year.
How do I file a claim?
You can quickly and easily file your Wellness Benefit claim online.
1. Go to Voya.com/claims.
2. Scroll down to the “Have a Wellness Benefit Claim?” section and click the “Submit your claim” button.
3. Check all products that apply – Accident Insurance.
4. Click “Continue” and follow the screen prompts. Once all questions are answered, click “Submit”.
Your Group Name is: Bloomington Independent School District #271
Your Group Number is: 0065768-9
Our Compass insurance products pay a fixed benefit amount upon the occurrence of specified events that occur on or after the insured
person's coverage effective date. They are not health insurance and do not satisfy the requirement of minimum essential coverage
under the Affordable Care Act.
This is a summary of benefits only. A complete description of benefits, limitations, exclusions, and termination of coverage will be
provided in the certificate of insurance and riders. All coverage is subject to the terms of the group policy. If there is any discrepancy
between this document and the group policy documents, the policy documents will govern. Insurance products are issued and
®
underwritten by ReliaStar Life Insurance Company (Minneapolis, MN), a member of the Voya family of companies. Accident Insurance
Policy form # RL-ACC3-POL-16; Certificate form # RL-ACC3-CERT-16; Wellness Benefit Rider form # RL-ACC3-WELL-16 Form
numbers, provisions and availability may vary by state. ©2018 Voya Services Company. All rights reserved. CN0208-40038-0219
175518-03/01/2018
ReliaStar Life Insurance Company (Minneapolis, MN), a member of the Voya® family of companiesYou can also read
