2015 Benefits Enrollment Guide

Transcription

1 You can only enroll once a year, so don t miss your chance! 2015 Benefits Enrollment Guide To enroll by phone, call , Option 1, M F, 9 am - 5 pm EST Complete a paper application and fax to or scan it and send to enroll@myvba.biz Enroll online at questions to ask@myvba.biz or call , Option 1

2 Minimum Essential Coverage This coverage is required to satisfy the individual mandate under Health Care Reform. Minimum Essential Coverage (MEC) covers 100% of the 63 CMS-listed Preventative and Wellness benefits when you visit a network provider (40% out-of-network) including Pap smears, mammograms, contraception, well child visits and much more (See next page for details). As an Employee, you can prevent being taxed the Individual Mandate coverage penalty by purchasing Minimum Essential Coverage through your employer Penalty tax of 2% of adjusted household income or $325 per adult plus $ per child, whichever is greater 2016 and beyond - Penalty tax of 2.5% of adjusted household income or $695 per adult plus $ per child, whichever is greater First-dollar coverage that gives you access to one of the largest national provider networks available (simple web portal for member s local or out-of-town provider look up) with valuable discounts for MEC benefits. Network savings can be used for services not covered by MEC. Cost of Coverage Minimum Essential Coverage Monthly Rates EE Only $ EE + Spouse $ EE + Child(ren) $ EE + Family $ PPO Network The MEC plan utilizes the Multiplan PPO network for discounts on medical services. Multiplan provides access to over 525,000 healthcare professionals, 3,800 hospitals and more than 66,000 ancillary care facilities in every state. Multiplan is the largest independent primary PPO in the nation. The PPO discounts continue to apply to the member s medical bills even after your benefits have been exhausted. Information on accessing the network will be included in the fulfillment package that each insured employee will receive. To check if your provider is in the network, go to or speak to a representative at Important: This brochure contains a brief summary of benefits and services available to you for purchase through your employer. Limitations and exclusions apply. Refer to your policy, certificate and riders for complete details. If there should be a typo in this brochure, the policy certificate will always prevail. 2

3 Minimum Essential Coverage 15 Covered Preventive Services for Adults (ages 18 and older) 1. Abdominal Aortic Aneurysm one time screening for ages Alcohol Misuse screening and counseling 3. Aspirin use for men ages and women ages to prevent CVD when prescribed by a physician 4. Blood Pressure screening 5. Cholesterol screening for adults 6. Colorectal Cancer screening for adults starting at age 50, limited to one every 5 years 7. Depression screening 8. Type 2 diabetes screening 9. Diet counseling 10. HIV screening 11. Immunizations, vaccines (Hepatitis A & B, Herpes Zoster, Human Papillomavirus, influenza (flu shot), measles, mumps, rubella, Meningococcal, Pneumococcal, Tetanus, Diptheria, Pertussis, Varicella) 12. Obesity screening and counseling 13. Sexually Transmitted Infection (STI) prevention counseling 14. Tobacco use screening and cessation interventions 15. Syphilis screening Covered Preventive Services for Women, Including Pregnant Women 1. Anemia screening on a routine basis for pregnant women 2. Bacteriuria urinary tract or other infection screening for pregnant women 3. BRCA counseling and genetic testing for women at higher risk 4. Breast Cancer mammography screenings every year for women age 40 and over 5. Breast Cancer Chemo Prevention counseling for women 6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women 7. Cervical Cancer screening 8. Chlamydia infection screening 9. Contraception: Food and drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs 10. Domestic and interpersonal violence screening and counseling for all women 11. Folic Acid supplements for women who may become pregnant when prescribed by a physician 12. Gestational diabetes screening 13. Gonorrhea screening 14. Hepatitis B screening for pregnant women 15. Human Immunodeficiency Virus (HIV) screening and counseling 16. Human Papillomavirus (HPV) DNA test: HPV DNA testing every three years for women with normal cytology results who are 30 or older 17. Osteoporosis screening over age Routine prenatal visits for pregnant women 19. Rh Incompatibility screening for all pregnant women and follow-up testing 20. Tobacco Use screening and interventions and expanded counseling for pregnant tobacco users 21. Sexually Transmitted Infections (STI) counseling 22. Syphilis screening 23. Well-woman visits to obtain recommended preventive services Covered Preventive Services for Children 1. Alcohol and Drug Use assessments 2. Autism screening for children limited to two screenings up to 24 months 3. Behavioral assessments for children limited to 5 assessments up to age Blood Pressure screening 5. Cervical dysplasia screening 6. Congenital Hypothyroidism screening for newborns 7. Depression screening for adolescents age 12 and older 8. Developmental screening for children under age 3, and surveillance throughout childhood 9. Dyslipidemia screening for children 10. Fluoride Chemo Prevention supplements for children without fluoride in their water source when prescribed by a physician 11. Gonorrhea preventive medication for the eyes of all newborns 12. Hearing screening for all newborns 13. Height, Weight and Body mass index measurements for children 14. Hematocrit or Hemoglobin screening for children 15. Hemoglobinopathies or sickle cell screening for newborns 16. HIV screening for adolescents 17. Immunization vaccines for children from birth to age 18; doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis, Hepatitis A & B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Rotavirus, Varicella, Haemophilus influenzae type b 18. Iron supplements for children up to 12 months when prescribed by a physician 19. Lead screening for children 20. Medical History for all children throughout development Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years 21. Obesity screening and counseling 22. Oral Health risk assessment for young children up to age Phenylketonuria (PKU) screening in newborns 24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents 25. Tuberculin testing for children 26. Vision screening for all children under the age of 5 3

4 Minimum Value Plan Description of Covered Services New As outlined under the new healthcare law (ACA), all individuals must have coverage beginning January 2014 or pay a penalty tax. MVP is a 60%- equivalent bronze major medical policy and provides substantially more coverage than Minimum Essential Coverage (MEC). As an Employee, you can prevent being taxed the Individual Mandate coverage penalty by purchasing a Minimum Value Plan through your employer Penalty tax of 2% of adjusted household income or $325 per adult plus $ per child, whichever is greater 2016 and beyond - Penalty tax of 2.5% of adjusted household income or $695 per adult plus $ per child, whichever is greater The MVP plan offers strategically selected medical benefits including: a nationally acclaimed patented Chronic Disease Management (CDM) program, prescription drug coverage, online explanation of benefits, online plan summaries and much more. With copayments up to the $1,850 out-of-pocket maximum, MVP members receive 100% coverage after reaching their out-of-pocket maximum on covered services. For even more comprehensive MVP coverage, consider the MVP Preferred Plan. This Plan includes valuable hospital, surgical and other benefits not found in the MVP Plan. The MVP coverage also includes the 63 preventive services required per the government for Minimum Essential Coverage. This list includes diabetes and cholesterol screenings, prenatal visits for pregnant women, and more. These benefits are covered at 100% when you visit a network provider. The benefits drop to 40% if you use an out-of-network provider. A full list of the covered services is included in this package on page 3 of this guide. The MVP plan utilizes the same Multiplan PPO network for discounts on medical services that is used for the MEC. 4 This brochure contains a brief summary of benefits and services available to you for purchase through your employer. Limitations and exclusions apply. Refer to your policy, certificate and riders for complete details. If there should be a typo in this brochure, the policy certificate will always prevail.

5 Description of Covered Services MVP MVP Preferred MVP Covered Benefits Network Non-Network Network Non-Network Deductible $0 / $0 $500 / $1,000 $0 / $0 $500 / $1,000 Coinsurance 100% 40% 100% 40% Out of Pocket Maximum $1,850 / $12,700 N/A $1,850 / $12,700 N/A MVP Covered Benefits Network Non-Network Network Non-Network PPO Network Multiplan Multiplan Emergency Room Services $400 Copay Ded / Coins $400 Copay Ded / Coins Primary Care Visits to Treat an Injury or Illness $15 Copay Ded / Coins $15 Copay Ded / Coins Specialist Visit $25 Copay Ded / Coins $25 Copay Ded / Coins Imaging (CT, PET Scans, MRIs) $400 Copay Ded / Coins $400 Copay Ded / Coins Laboratory Outpatient and Professional Services $50 Copay Ded / Coins $50 Copay Ded / Coins X-rays and Diagnostic Imaging $50 Copay Ded / Coins $50 Copay Ded / Coins Preventive Care / Screenings / Immunization (MEC) 100% Covered Ded / Coins 100% Covered Ded / Coins Chronic Disease Management (CDM) Benefit 100% Covered Ded / Coins 100% Covered Ded / Coins Prescription Drugs Generic $15 Copay Ded / Coins $15 Copay Ded / Coins Preferred Brand Drugs $25 Copay Ded / Coins $25 Copay Ded / Coins Non-Preferred Brand Drugs $75 Copay Ded / Coins $75 Copay Ded / Coins Fully Insured Limited Indemnity Benefits Initial Hospital Admission Daily Indemnity Benefit Inpatient Hospital Daily Indemnity Benefit Intensive Care Daily Indemnity Benefit Inpatient Surgery & Anesthesia Daily Indemnity Benefit Outpatient Surgery & Anesthesia Daily Indemnity Benefit Accident Benefit Critical Illness Benefit Minimum Value Plan N/A $1,500 daily benefit 1 admission per year $500 per day 31 days per confinement $500 per day 31 days per confinement $1,000 daily benefit 1 day per year Includes a 20% Anesthesia Benefit $500 daily benefit 1 day per year Includes a 20% Anesthesia Benefit $300 per day for accident treatment 5 days per year $5,000 Benefit Life AD&D* $10,000 Benefit $10,000 Benefit * The Life AD&D benefit is included with all MVP offerings except for groups domiciled in CA, CT, NY, NJ and HI. This chart illustrates the full cost of the MVP plan. If you make less than $23,500 annually, you may qualify for an Employer Subsidy. Please call the VBA Call Center at Cost of Coverage for details. All other employees pay the listed rates. Minimum Value Plan Monthly Rates EE Only MVP $ EE + Spouse $ EE + Child(ren) $ EE + Family $ MVP Preferred $ $ $ $

6 Dental Insurance Insured through Security Life Insurance Company of America Choose any dentist! Routine, preventive and regenerative services are available from the first day of coverage. Access to responsive, professional customer care personnel for assistance with claims questions. Use the extensive network of highly qualified providers to enjoy significant savings on out-of-pocket costs associated with dental services. Automated claims processing results in an average turnaround time of less than four days! Preventive/Diagnostic Services: Pays 100%, No Deductible, No Waiting Period 2 Cleanings per year, X-rays, Periodic Exams, Fluoride Treatments & Sealants (under age 19) Basic Restorative Services: Pays 80%, $50 Deductible, No Waiting Period Simple Extractions, Fillings, Endodontics, Periodontics and Complex Oral Surgery Major Restorative Services: Pays 50%, $50 Deductible, No Waiting Period Bridges, Crowns, Implants*, Dentures *Implants (endosteal only), up to the allowance for the lowest cost covered traditional procedure. Annual Individual Benefit Maximum: $1,500 Per Person Per Calendar Year Monthly Rates Employee Only $ Employee + Spouse $ Employee + Child(ren) $ Family $ Vision Insured through VSP VSP is the largest vision network in the country with over 22,000 providers. Examinations: $15 Co-Pay Every 12 months Materials: $25 Co-Pay Lenses every 12 months Frames every 24 months Laser Vision Surgery: 15% Average Discount Participating Doctors: VSP will pay the cost of a comprehensive eye examination and prescribed materials purchased One set of frames up to $130 Elective contacts up to $130 less - any co-pay Non Participating Doctors: Benefits are paid upon a schedule of benefits. Monthly Rates Employee Only $ 8.50 Employee + Spouse $14.51 Employee + Child(ren) $16.60 Family $23.10 This brochure contains a brief summary of benefits and services available to you for purchase through your employer. Limitations and exclusions apply. Refer to your policy, certificate and riders for complete details. If there should be a typo in this brochure, the policy certificate will always prevail. 6

7 Group Term Life Insurance Group Term Life Insurance Underwritten by Lincoln Financial Group Group Term Life Insurance Policy Group Term Life Insurance coverage is available during your Enrollment period with NO medical questions asked! This Guaranteed Issue is only available for new hires. If you choose to elect the Life Insurance later, you will need to provide Evidence of Insurability. Employee Coverage: Coverage is available in $20,000 increments up to 5.00 x (times) your annual salary (rounded to the next higher $20,000) Minimum coverage is $20,000. Maximum coverage is $200,000 Spouse Coverage: Coverage is available in $10,000 increments, not to exceed 50% of the employee s benefit amount Minimum coverage is $10,000; Maximum coverage is $40,000. Spouse coverage is only available if the employee is insured for voluntary coverage Dependent Child(ren) Coverage: Dependent coverage is only available if the employee is insured for voluntary coverage This benefit provides coverage for all dependent children in the following amounts: From age 6 months to 19 years old: Choose between $5,000 and $10,000 coverage amounts. (Up to 26 years old age if unmarried and a full time student.) Voluntary Life Benefit features: Portability Employee Life Insurance Premium Waiver Accelerated Death Benefit (Living Benefit) - maximum of $200,000 or 75% of Insured person s Life Insurance coverage, whichever is less Conversion is available when insurance terminates Coverage reduces 35% upon the Insured s attainment of age 65, an additional 25% of the original amount at age 70. Insurance will terminate upon retirement. All permanent employees regularly scheduled to work at least 20 hours are eligible to participate. An employee must be actively at work on the date the coverage takes effect. Employees who work part-time, on-call or on a seasonal basis are not eligible to participate in the program. Retirees are not eligible. This is a brief summary of Group Term Life Insurance underwritten by Transamerica Life Insurance Company, Cedar Rapids, Iowa Policy form series CP and CC100400; Rider form series CR Forms and form numbers may vary. Coverage may not be available in all jurisdictions. Limitations and exclusions apply. Refer to the policy, certificate, and riders for complete details. This brochure contains a brief summary of benefits and services available to you for purchase through your employer. Limitations and exclusions apply. Refer to your policy, certificate and riders for complete details. If there should be a typo in this brochure, the policy certificate will always prevail. 7

8 Group Term Life Insurance Monthly Group Term Life Insurance Rates Employee Employee Benefit Amount Age $20,000 $40,000 $60,000 $80,000 $100,000 $120,000 $140,000 $160,000 $180,000 $200,000 <25 $0.90 $1.80 $2.70 $3.60 $4.50 $5.40 $6.30 $7.20 $8.10 $ $0.90 $1.80 $2.70 $3.60 $4.50 $5.40 $6.30 $7.20 $8.10 $ $0.98 $1.96 $2.94 $3.92 $4.90 $5.88 $6.86 $7.84 $8.82 $ $1.42 $2.84 $4.26 $5.68 $7.10 $8.52 $9.94 $11.36 $12.78 $ $2.38 $4.76 $7.14 $9.52 $11.90 $14.28 $16.66 $19.04 $21.42 $ $3.72 $7.44 $11.16 $14.88 $18.60 $22.32 $26.04 $29.76 $33.48 $ $5.64 $11.28 $16.92 $22.56 $28.20 $33.84 $39.48 $45.12 $50.76 $ $9.06 $18.12 $27.18 $36.24 $45.30 $54.36 $63.42 $72.48 $81.54 $ $15.14 $30.28 $45.42 $60.56 $75.70 $90.84 $ $ $ $ Age $13,000 $26,000 $39,000 $52,000 $65,000 $78,000 $91,000 $104,000 $117,000 $130, $15.83 $31.67 $47.50 $63.34 $79.17 $95.00 $ $ $ $ Spouse Spouse Benefit Amount Age $10,000 $20,000 $30,000 $40,000 <25 $0.45 $0.90 $1.35 $ $0.45 $0.90 $1.35 $ $0.49 $0.98 $1.47 $ $0.71 $1.42 $2.13 $ $1.19 $2.38 $1.80 $ $1.86 $3.72 $5.58 $ $2.82 $5.64 $8.46 $ $4.53 $9.06 $13.59 $ $7.57 $15.14 $22.71 $30.28 Age $6,500 $13,000 $19,500 $26,000 $32, $7.92 $15.83 $23.75 $31.67 $39.59 Child(ren) Child(ren) Benefit Amount Age $5,000 $10,000 <25 $1.00 $2.00 Benefits decrease 35% at age 65, and benefits are not available over age 69 *Amounts from age do not include the Waiver Riders For higher benefit amounts, please call Member Services at and Select Option 1. 8

9 Disability Income Insurance Underwritten by Lincoln Financial Group Short Term Disability Income Insurance $1,500 Maximum Monthly Benefit with No Medical Questions 60% of Weekly Salary up to $1, Weeks Maximum Disability Period 7 Day Accident and Sickness Elimination Period Optional Disability Income Protection Disabilities happen. When you cannot work, your ability to support your lifestyle and your family are at risk. Ask yourself these questions. If I become disabled, how will I pay the bills? Who will provide for my family? Savings? It may not last. The average 45 year old earning $50,000 per year only has about 4 months worth of income saved. Even if savings help sustain your way of life for a few months, what happens when they re gone? Spouses Income? Could only one income cover all the bills? What if additional medical expenses were piled on top of regular expenses? Fortunately, there is a way to help protect against the potentially devastating loss of livelihood resulting from disabling sicknesses and injuries. Income Replacement - Simply put, VBA s DI Plus helps replace up to 60% of your salary if you are unable to work due to total or partial Disability caused by illness or an off-the-job injury (maternity is covered). Benefits Include: Elimination Period Benefits begin after the 7th day for a covered illness, off-the-job injury or maternity. Monthly Benefits While you re totally disabled, you ll receive a fixed monthly income benefit that will not exceed 60% of your monthly income rounded to the nearest $100. Periods of disability of less than one month will be paid at 1/30th the monthly benefit for each day of total disability. Benefit Period Monthly benefits are payable for up to 13 weeks for each covered sickness or off-the-job injury. This coverage is Guaranteed issue for 2014 s Open Enrollment only. Any employee choosing to elect this coverage after Monthly Premium Calculator How to figure your rate: 1. Find your closest GROSS MONTHLY INCOME on the chart below without exceeding your monthly income. This represents how much you are paid monthly before taxes are deducted. 2. Scroll down to find your WEEKLYBENEFIT. This is the amount you qualify for and you would receive each week you are disabled. 3. Below that you will find your MONTHLY COST based on your AGE GROUP. Gross Monthly Income Weekly Benefit $723 - $1,444 $1,445 - $2,166 $2,167 - $2,888 $2,889 - $3,611 $3,612 - $4,333 $4,334 - $5,055 $5,056 - $5,777 $5,778 - $6,499 $6,500 - $7,222 $7,223 - $7,944 $7,945 - $8,666 $8,667 - $9,388 $ $10111 $10,112 - $10,834 - $10,833 $11,555 $100 $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 Monthly Cost Below Age < 29 $5.75 $11.50 $17.25 $23.00 $28.75 $34.50 $40.25 $46.00 $51.75 $57.50 $63.25 $69.00 $74.75 $80.50 $ $5.59 $11.18 $16.77 $22.36 $27.95 $33.54 $39.13 $44.72 $50.31 $55.90 $61.49 $67.08 $72.67 $78.26 $ $3.97 $7.94 $11.91 $15.88 $19.85 $23.82 $27.79 $31.76 $35.73 $39.70 $43.67 $47.64 $51.61 $55.58 $ $3.48 $6.96 $10.44 $13.92 $17.40 $20.88 $24.36 $27.84 $31.32 $34.80 $38.28 $41.76 $45.24 $48.72 $ $3.66 $7.32 $10.98 $14.64 $18.30 $21.96 $25.62 $29.28 $32.94 $36.60 $40.26 $43.92 $47.58 $51.24 $ $4.06 $8.12 $12.18 $16.24 $20.30 $24.36 $28.42 $32.48 $36.54 $40.60 $44.66 $48.72 $52.78 $56.84 $ $5.49 $10.98 $16.47 $21.96 $27.45 $32.94 $38.43 $43.92 $49.41 $54.90 $60.39 $65.88 $71.37 $76.86 $ $7.18 $14.36 $21.54 $28.72 $35.90 $43.08 $50.26 $57.44 $64.62 $71.80 $78.98 $86.16 $93.34 $ $ $7.18 $14.36 $21.54 $28.72 $35.90 $43.08 $50.26 $57.44 $64.62 $71.80 $78.98 $86.16 $93.34 $ $ $7.18 $14.36 $21.54 $28.72 $35.90 $43.08 $50.26 $57.44 $64.62 $71.80 $78.98 $86.16 $93.34 $ $

10 Frequently Asked Questions Who is eligible to enroll? All employees that work a minimum of 30 hours per week are eligible to enroll in the MVP plan. When I expect my Welcome Packet to arrive? The benefit kit will be mailed to you soon after you have enrolled and your first payment has been made. All employees who work more than 20 hours are eligible to enroll in all other coverages. Eligible dependents include spouses, domestic partners, and unmarried children or step-children under age 26. Can I enroll at any time? No, you must sign up for coverage during Open Enrollment during the first 30 days of your date of hire. If you do not elect coverage during these eligibility periods, you will not be able to enroll until the next open enrollment period, unless you experience a qualifying event. How will my premiums be paid? Premiums will be taken through payroll deductions. If you miss a payroll deduction as a result of absence or lack of work, you risk being terminated from the plan. If your policy is terminated, you will not be eligible to re-enroll until the next open enrollment period unless you experience a qualifying event. Can I cancel coverage at any time? Premiums are paid with pre-tax dollars through payroll deductions as part of a Section 125 Savings Plan. You will not be able to change these elections until the next annual enrollment period, unless you have an IRS approved qualifying event. Are there any Pre-Existing Condition Limitations? Only the Short Term Disability Insurance plan has Pre-Existing Condition Limitations. Are Medicare/Medicaid recipients eligible for this plan? If you have Medicare / Medicaid, it is NOT recommended that you enroll in coverage as Medicare / Medicaid regards this plan as Primary Coverage and may reduce or discontinue your Medicare/Medicaid benefits. Whom can I contact if I have questions about my plan? Contact Member Services at , Option 1, and a customer service representative will assist you. You can also questions to ask@myvba.biz. When will I receive my ID cards? You will receive your ID cards in two to three weeks of your first premium deduction. Can I use any doctor or hospital? Yes, you can go to any doctor. There are no network restrictions. Benefits are payable to any hospital that is accredited by JCAHO (Joint Commission on Accreditation of Healthcare Organizations) and meets the definition of a hospital. Most hospitals have received accreditation; however, if you choose to use a network provider you will save money! How do I use my MVP Benefits? To utilize your MVP Benefits, present your MVP Benefits ID card to your provider at the time of service. This brochure contains a brief summary of benefits and services available to you for purchase through your employer. Limitations and exclusions apply. Refer to your policy, certificate and riders for complete details. If there should be a typo in this brochure, the policy certificate will always prevail. 10

11 Employer: Cor-Tech Group Number: (For internal use only) MTA01016 Employee Information: First Name Middle Name Last Name Street Address (Include House # and Apartment #) City State Zip Code Date of Birth Social Security # Sex Phone Number - - Male Female ( ) - Date of Employment Annual Salary Hours Worked Per Week Work Location $ Beneficiary Name (First, Last) Beneficiary Relationship Address Mothers Maiden Name (for security purposes) Dependents You Are Enrolling: Spouse Name Social Security # Date of Birth Age Male - - Female Child Name Social Security # Date of Birth Age Male - - Female Child Name Social Security # Date of Birth Age Male - - Female Child Name Social Security # Date of Birth Age Male - - Female Child Name Social Security # Date of Birth Age Male - - Medical Plan (Check the plan(s) you wish to enroll in): MEC (Minimum Essential Coverage) Female Optional Benefits (Check the plan(s) you wish to enroll in): Dental Insurance Vision Insurance Employee $66.59 Monthly Employee + Spouse $99.19 Monthly Employee + Child(ren) $ Monthly Employee $29.86 Monthly Employee + Spouse $59.88 Monthly Employee + Child(ren) $73.54 Monthly Employee $8.50 Monthly Employee + Spouse $14.51 Monthly Employee + Child(ren) $16.60 Monthly Family $ Monthly MVP You may elect MEC OR one MVP Plan. (If enrolling in an MVP Plan, only choose ONE MVP Plan.) MVP Preferred Family $ Monthly Family $23.10 Monthly Please complete the application, scan it and it to enroll@myvba.biz or enroll online at cortechbenefits.com. Life Insurance Short Term Disability Employee $ Monthly Employee $ Monthly Employee Employee Employee + Spouse $ Monthly Employee + Child(ren) $ Monthly Family $ Monthly Employee + Spouse $ Monthly Employee + Child(ren) $ Monthly Family $ Monthly Coverage Amount $ Monthly Cost $ Spouse Coverage Amount $ Monthly Benefit Monthly Cost $ $ Monthly Cost $ Child(ren) Coverage Amount $ Monthly Cost $ I have read the benefits packet and understand its limitations and exclusions. I understand that I will not have any insurance coverage for plans I did not elect above and that open enrollment is ONLY available for a limited time. I also understand that I have to enroll by my eligibility date and making NO benefit elections is a declination of coverage. I also understand I will not be able to re-enroll, make changes or cancel my coverage without a qualifying event/change of family status until the next open enrollment period. I will also read my policy upon receipt for a complete listing of limitations and exclusions. SIGNATURE: DATE: / /

12 For more information: Call Member Services at & Select Option 1 Available Monday - Friday, 9:00am - 5:00pm EST Questions to ask@myvba.biz