Cmpass Critical Illness Insurance A limited benefit plicy Enrllment at a Glance An affrdable way t help prtect against the financial stress f a serius illness. Fr the emplyees f: City and Cunty f San Francisc Health Service System
What is Critical Illness Insurance? Critical Illness Insurance pays a lump-sum benefit if yu are diagnsed with a cvered illness r cnditin. Yu have the ptin t elect Critical Illness Insurance t meet yur needs. Critical Illness Insurance is a limited benefit plicy. It is nt health insurance and des nt satisfy the requirement f minimum essential cverage under the Affrdable Care Act. Features f Critical Illness Insurance include: Guaranteed Issue: N medical questins r tests required fr cverage. Flexible: Yu can use the benefit mney fr any purpse yu like. Payrll deductins: Premiums are paid thrugh cnvenient payrll deductins. Prtable: Shuld yu leave yur current emplyer r retire, yu can take yur cverage with yu. Fr what critical illnesses and cnditins are benefits available? Critical Illness Insurance prvides a benefit fr the fllwing illnesses and cnditins. Cvered illnesses/cnditins are brken ut int grups called mdules. Benefits are paid at 100% f the Maximum Critical Illness Benefit amunt unless therwise stated. Fr a cmplete descriptin f yur benefits, alng with applicable prvisins, cnditins n benefit determinatin, exclusins and limitatins, see yur certificate f insurance and any riders. Base Mdule Heart attack Majr rgan failure Strke Permanent paralysis Crnary artery bypass (25%) End stage renal (kidney) failure Cma Cancer Mdule Cancer Carcinma in situ (25%) Skin cancer (10%) Hw can Critical Illness Insurance help? Belw are a few examples f hw yur Critical Illness Insurance benefit culd be used (cverage amunts may vary): Medical expenses, such as deductibles and cpays Child care Hme healthcare csts Mrtgage payment/rent and hme maintenance Wh is eligible fr Critical Illness Insurance? Yu all active emplyees wrking 20+ hurs per week. Yur spuse* under age 70. Cverage is available nly if emplyee cverage is elected. Yur child(ren) t age 26. Cverage is available nly if emplyee cverage is elected. *The use f spuse in this dcument means a persn insured as a spuse as described in the certificate f insurance r rider. Please cntact yur emplyer fr mre infrmatin. What Maximum Critical Illness Benefit am I eligible fr? Fr yu Yu have the pprtunity t purchase a Maximum Critical Illness Benefit f $10,000, $20,000 r $30,000. Fr yur spuse Yu have the pprtunity t purchase a Maximum Critical Illness Benefit f $5,000, $10,000 r $15,000 fr yur spuse. Fr yur children Yu have the pprtunity t purchase a Maximum Critical Illness Benefit f $2,500, $5,000, r $10,000 fr each cvered child.
Hw many times can I receive the Maximum Critical Illness Benefit? Usually yu are nly able t receive the Maximum Critical Illness Benefit nce fr each cvered cnditin. Yur plan includes the Recurrence Benefit*, which prvides a ne-time restratin f 100% f the maximum benefit amunt in rder t pay a secnd benefit fr the same cvered cnditin. It s imprtant t nte that in rder fr the secnd ccurrence f the illness t be cvered, it must ccur after 12 cnsecutive mnths withut the ccurrence f any cvered critical illness named in yur certificate, including the illness frm the first benefit payment. If yu have reached the benefit limit by receiving the maximum benefit fr each cvered cnditin, yu may chse t end yur cverage; hwever, if yu have cverage fr yur spuse and/r child(ren), yu must cntinue yur cverage in rder t keep their cverage active. Please see yur certificate f cverage fr details. *This benefit des nt apply t the cancer mdule. Meet Julie When Julie lks at her life, she thinks she s in pretty gd health. Sure, she has a sedentary jb, but Julie feels she ffsets sitting 40 hurs a week by eating fairly well, getting enugh sleep and taking regular walks arund her neighbrhd. That s why the heart attack she suffered just three mnths after her 42 nd birthday came as such a shck. While Julie is expected t make a full recvery, her recuperatin culd have been mre challenging had it nt been fr the benefit paid by her Critical Illness Insurance. Expenses incurred ver tw mnths: $5,000 Out-f-pcket medical expenses $2,800 Mrtgage $1,500 Fd and utilities $800 Car payment $150 Car insurance $500 Other living expenses $10,750 Ttal ut-f-pcket expenses $10,000 Maximum Critical Illness Benefit paid under Julie s plicy The amunts shwn are fr illustrative purpses nly. Actual csts/results may vary. The benefit amunt assumes a Maximum Critical illness Benefit f $10,000 f base cverage. Yur emplyer may ffer/prvide different amunts r ptins. What des my Critical Illness Insurance include? The benefits listed belw are included with yur critical illness cverage. There may be sme variatin by state. Fr a list f standard exclusins and limitatins, please refer t the end f this dcument. Fr a cmplete descriptin f yur available benefits, alng with applicable prvisins, exclusins and limitatins, see yur certificate f insurance and any riders. Wellness Benefit: This prvides an annual benefit payment if yu cmplete a health screening test. Yu may nly receive a benefit nce per year, even if yu cmplete multiple health screening tests. Examples f health screening tests include but are nt limited t: Pap test, serum chlesterl test fr HDL and LDL levels, mammgraphy, clnscpy, and stress test n bicycle r treadmill. The annual benefit is $100 fr cmpleting a health screening test. If yur spuse and children are cvered fr Critical Illness Insurance, they are als cvered by the Wellness Benefit. Yur spuse s benefit amunt is als $100. The benefit fr child cverage is 50% f yur cverage with an annual maximum f $200 fr children s benefits. What ptinal benefits are available? Yu may chse t include the ptinal benefits belw with yur critical illness cverage. Fr a list f standard exclusins and limitatins, please refer t the end f this dcument. Fr a cmplete descriptin f yur available benefits, alng with applicable prvisins, exclusins and limitatins, see yur certificate f insurance and any riders. Spuse* Critical Illness Insurance: If yu have cverage fr yurself, yu may enrll yur spuse, as lng as yur spuse is under age 70 and is nt cvered under the Plicy as an emplyee.
Yur spuse will receive cverage fr the same cvered cnditins as yu. Yur spuse will be able t receive a benefit the same number f times as yu, as utlined abve. Guaranteed issue: N medical questins r tests required fr cverage *The use f spuse in this frm means a persn insured as a spuse as described in the certificate f insurance r benefit. Please cntact yur emplyer fr mre infrmatin. Children s Critical Illness Insurance: As lng as yu have critical illness cverage n yurself, yur natural child(ren), stepchild(ren), adpted child(ren) r child(ren) fr whm yu are a legal guardian are eligible t be cvered under yur emplyer s plan, up t the age f 26. Yur children are cvered fr the same cvered cnditins as yu are with the exceptin f carcinma in situ and crnary artery bypass; hwever, actual benefit amunts may vary. Yur child(ren) will be able t receive a benefit the same number f times as yu, as utlined abve. One premium amunt cvers all f yur eligible children. Guaranteed issue: N medical questins r tests required fr cverage. If bth yu and yur spuse are cvered under the plicy as an emplyee, then nly ne, but nt bth, may cver the same child(ren) under this benefit. If the parent wh is cvering the child(ren) stps being insured as an emplyee then the ther parent may apply fr children s cverage. Hw much des Critical Illness Insurance cst? See the chart belw fr the premium amunts. Rates shwn are guaranteed until January 1, 2020. Emplyee Cverage Mnthly Rates Nn-Tbacc User $10,000 $20,000 $30,000 Tbacc User $10,000 $20,000 $30,000 Under 30 $6.40 $10.20 $14.00 Under 30 $8.10 $13.60 $19.10 30-39 $7.40 $12.20 $17.00 30-39 $10.10 $17.60 $25.10 40-49 $12.70 $22.80 $32.90 40-49 $18.90 $35.20 $51.50 50-59 $24.40 $46.20 $68.00 50-59 $38.70 $74.80 $110.90 60-64 $35.70 $68.80 $101.90 60-64 $59.30 $116.00 $172.70 65-69 $45.20 $87.80 $130.40 65-69 $69.10 $135.60 $202.10 70+ $59.40 $116.20 $173.00 70+ $90.50 $178.40 $266.30 Nn-Tbacc User $5,000 $10,000 $15,000 Spuse Cverage* Mnthly Rates Tbacc User $5,000 $10,000 $15,000 Under 30 $4.60 $6.60 $8.60 Under 30 $5.50 $8.40 $11.30 30-39 $5.10 $7.60 $10.10 30-39 $6.55 $10.50 $14.45 40-49 $7.90 $13.20 $18.50 40-49 $11.15 $19.70 $28.25 50-59 $14.05 $25.50 $36.95 50-59 $21.55 $40.50 $59.45 60-64 $20.00 $37.40 $54.80 60-64 $32.35 $62.10 $91.85 65-69 $24.95 $47.30 $69.65 65-69 $37.50 $72.40 $107.30 70+ $32.40 $62.20 $92.00 70+ $48.75 $94.90 $141.05 Children Cverage Mnthly Rates Cverage Amunt Rate $2,500 $1.05 $5,000 $2.10 $10,000 $4.20 *Spuse rates are based n the age f the Spuse.
Exclusins and Limitatins Benefits are nt payable fr any critical illness caused in whle r directly by any f the fllwing*: Participatin r attempt t participate in a felny r illegal activity. Suicide, attempted suicide r any intentinally self-inflicted injury, while sane r insane. War r any act f war, whether declared r undeclared, ther than acts f terrrism. Lss that ccurs while n full-time active duty as a member f the armed frces f any natin. We will refund, upn written ntice f such service, any premium which has been accepted fr any perid nt cvered as a result f this exclusin. Alchlism, drug abuse, r misuse f alchl r taking f drugs, ther than under the directin f a dctr. Benefits reduce 50% fr the emplyee and/r cvered spuse n the plicy anniversary fllwing the 70 th birthday, hwever, premiums d nt reduce as a result f this benefit change. *See the certificate f insurance and any riders fr a cmplete list f available benefits, alng with applicable prvisins, exclusins and limitatins. Hw d I enrll? Yu can enrll fr benefits Octber 1, 2016 - Octber 31, 2016 by visiting www.wrkterra.net. Wh d I cntact with questins? Fr mre infrmatin, please call yur Custmer Service Team at 888-392-7597. This is a summary f benefits nly. A cmplete descriptin f benefits, limitatins, exclusins and terminatin f cverage will be prvided in the certificate f insurance and riders. All cverage is subject t the terms and cnditins f the grup plicy. If there is any discrepancy between this dcument and the grup plicy dcuments, the plicy dcuments will gvern. T keep cverage in frce, premiums are payable up t the date f cverage terminatin. Critical Illness Insurance is underwritten by ReliaStar Life Insurance Cmpany, a member f the Vya family f cmpanies. Plicy Frm #RL-CI3-POL-12; Certificate Frm #RL-CI3-CERT- 12; and Rider Frms: Spuse Critical Illness Rider Frm #RL-CI3-SPR-12, Children's Critical Illness Rider Frm #RL- CI3-CHR-12, Wellness Benefit Rider Frm #RL- CI3-WELL-12, and Recurrence Rider Frm #RL- CI3-REC-12 Frm numbers, prvisins and availability may vary by state. CN0208-21887-0217 City and Cunty f San Francisc Health Service System, Grup #69674-9, Acct #001 Date Prepared: 09/13/2016 172508-02/22/2016