Benefit Plans Arranged by Stynchula, Herbert & Associates, Inc. www.stynherb.com (703)273-0222 Subsystem Technologies, Inc. Employee Benefits Program 2013-2014 Plan Year
Our employees are our most valuable asset. That s why at Subsystem Technologies, Inc. we are committed to a comprehensive employee benefit program that helps our employees stay healthy, feel secure, and maintain a work/life balance. Stay Healthy Medical Dental Vision Flexible Spending Accounts Feeling Secure Disability Insurance Life and Accidental Death & Dismemberment Voluntary Life Work/Life Balance Employee Assistance Program 2
Contact Information: Refer to this list when you need to contact one of your benefit vendors. For general information Contact Human Resources. Medical, Dental & Vision Insurance (Pages 6-9) Member Services Medical (800)357-0978 Pre-certification (800)638-7204 Member Services Dental (877)816-3596 Member Services Vision (800)638-3120 Online Account Information: www.myuhc.com If you haven t registered please visit www.uhc.com to set up an account. Disability & Life Insurance (Pages 11-13) Customer Service (800)769-7159 Short Term Disability (Policy #GUG-494I) Long Term Disability (Policy #GLTD-494I) Life and Accidental Death & Dismemberment (Policy #GLUG-494I) Voluntary Life (Policy #GVTL-494I) Claims (800)877-5176 STD/LTD (800)775-8805 Life and AD&D/Voluntary Life www.mutualofomaha.com 3
Contact Information (continued): Refer to this list when you need to contact one of your benefit vendors. For general information Contact Human Resources.. Health Reimbursement Account (HRA medical plan deductibles) Flexible Spending Account (FSA) COBRA Customer Service (877)797-7475 For Claims and documentation you can send via email to custservice@uhcservices.com For general questions or assistance, once registered on the www.uhcservices.com website you can utilize the AskAnExpert link to send inquiries via email. 4
Welcome to Open Enrollment for your 2013 Benefits! Elections you make during open enrollment will become effective May 1, 2013. Subsystem Technologies, Inc. offers you and your eligible family members a comprehensive and valuable benefits program. We encourage you to take the time to educate yourself about your options and choose the best coverage for you and your family. 5
Medical Insurance Who is Eligible and When This coverage is offered to all employees on the first day of the month following your full time date of hire or with a qualifying event. Benefits You Receive Subsystem Technologies, Inc. is pleased to offer you a choice of three medical plans through UnitedHealthcare. You can choose between a National EPO with or without a deductible and a PPO plan. The National EPO plans use the UnitedHealthcare Choice network of physicians and referrals are NOT necessary. The PPO plan uses the UnitedHealthcare Choice Plus network and this plans also does not require referrals. Please refer to your Certificate of Coverage from UnitedHealthcare for complete information regarding these plans. Employees will pay the first 50% of In Network deductibles and Subsystems will pay last 50% of In Network deductibles. Employees are responsible for any remaining amounts of the Out of Network deductibles. Plan Features Network Utilization Deductible Individual Family EPO VB8/2V In Network Only EPO HRA DGN/H9 In Network Only None $1000 $3000 PPO HRA DFP/H9 In Network $2000 $6000 Out of Network $3000 $9000 Your Coinsurance 0% (plan pays 100%) 10% (plan pays 90%) 10% (plan pays 90%) 30% (plan pays 70%) Out-of-Pocket Maximum $2000 Ind. $6000 Fam. $2000 ind. $6000 Fam $4000 Ind. $12,000 Fam. $8000 Ind. $16,000 Fam. Office Visit $25/$50 copay 90% after ded. 90% after ded. 70% after ded. Emergency Services Inpatient Services Prescription Drug Coverage $150 copay 90% after ded 90% after ded. 70% after ded. $500 copay per admission $10 generic $35 Brand Formulary $60 Brand Non Formulary 90% after ded. 90% after ded. 70% after ded. NO Deductible $10 generic $30 Brand Formulary $50 Brand Non Formulary NO Deductible $10 generic $30 Brand Formulary $50 Brand Non Formulary N/A 6
Medical Insurance Healthy Options This is a discount program provided to members of UnitedHealthcare. Because this is a discount program and not a covered benefit, there are no claim forms referrals or paperwork. To receive these discounts, simply show your UnitedHealthcare ID card. The Healthy Options program offers discounts on weight loss assistance programs, fitness club memberships, laser vision correction, and alternative health and wellness services such as acupuncture, chiropractic care, and massage therapy. To learn more about this program, go to www.myuhc.com and link into the health discount program on the bottom left-hand corner of the Health & Wellness page. My Account You can manage your health plan online through UnitedHealthcare My Account. This portal gives you access to check the status of a claim, view your out-of-pocket costs, order a new ID card and much more. Just visit www.myuhc.com and set up an account using the information from your ID card. Your Cost in 2013 Employee Premiums per Pay Period: Type of Coverage EPO No Deductible Choice VB8/2V EPO w/deductible Choice HRA DGN/H9 PPO w/deductible Choice Plus HRA DFP/H9 Employee Cost Employee Cost Employee Cost Employee $83.50 $68.00 $61.00 Employee/Children $214.00 $179.50 $161.50 Employee/Spouse $266.00 $223.00 $200.50 Family $322.00 $270.50 $243.50 7
Dental Insurance Who is Eligible and When This coverage is offered to all employees on the first day of the month following your full time date of hire or with a qualifying event. Benefits You Receive Our dental plan is also offered through UnitedHealthcare. This plan offers dental benefits for preventive, basic and major services. See chart below. Dental Option P2660 Type of Service In Network Out of Network Deductible (Ind/Fam) -Applies to basic and major services only $25/$75 $25/$75 Preventive Services -Exams, cleanings, x-rays Basic Services -Fillings, simple extractions Major Services -Oral surgery, root canal, crowns Orthodontia (children up to 19) Lifetime Maximum $2000 per member 100% 100% 90% 80% 60% 50% 50% 50% Annual Maximum $2000 $2000 Type of Coverage Dental Option P2660 Employee Cost Employee $18.50 Employee/Children $30.00 Employee/Spouse $26.00 Family $34.00 8
Vision Insurance Who is Eligible and When This coverage is offered to all employees on the first day of the month following your full time date of hire or with a qualifying event. Subsystem Technologies, Inc. provides full-time employees with vision coverage, and pays the full cost of this coverage through UnitedHealthcare. Healthy eyes are an important part of your overall health. Routine eye examinations not only keep your eyewear current, they can also detect high-risk health issues such as diabetes and glaucoma before symptoms occur. Vision Plan V1004 Type of Service In Network Out of Network Reimbursement Exams $10 Copay Up to $45 allowance Frames Plan pays up to $130 allowance Up to $45 allowance Standard Plastic Lenses Single, Bifocal, Trifocal Lenticular Contact Lenses Elective Medically Necessary Benefit Frequency Exam Frames Standard Lenses or Contacts 100% 100% Plan pays up to $97 allowance 100% Once every 12 months Once every 24 months Once every 12 months Up to $40/$60/$80 allowance Up to $181 allowance Up to $97 allowance Up to $285 allowance Type of Coverage Plan V1004 Employee Cost Employee Employer pays 100% Employee/Children Employer pays 100% Employee/Spouse Employer pays 100% Family Employer pays 100% 9
Flexible Spending Accounts (FSA) Who is Eligible and When This coverage is offered to all employees on the first day of the month following the date of employment, or with a qualifying event. Benefits You Receive FSA s provide you with an important tax advantage that can help you pay health care and dependent care expenses on a pre-tax basis. By anticipating your family s health care and dependent care costs for the next year, you can actually lower your taxable income. Health Care Reimbursement FSA This program lets Subsystem Technologies, Inc. employees pay for certain IRS-approved medical care expenses not covered by their insurance plan with pre-tax dollars. The annual maximum you may contribute to the Health Care FSA is $2,500. Some examples include: Hearing services, including hearing aids and batteries Vision services, including contact lenses, lens solution, eye examinations, and eyeglasses Dental services and orthodontia Chiropractic services Acupuncture Prescription contraceptives Dependent Care FSA The Dependent Care FSA lets Subsystem Technologies, Inc. employees use pre-tax dollars towards qualified dependent care such as caring for children under the age of 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) 10
Disability Insurance Who is Eligible and When This coverage is offered to all employees on the first day of the month following date of hire of employment, or with a qualifying event. Disability Income Benefits Subsystem Technologies, Inc. provides full-time employees with short and long-term disability income benefits, and pays the full cost of this coverage. In the event you become disabled from a non work-related injury or sickness, disability income benefits are provided as a source of income. You are not eligible to receive short-term disability benefits if you are receiving workers compensation benefits. Short Term Disability Long Term Disability Benefits Begin 15 th Day Accident 15 th Day Sickness 91 st Day of Disability Benefits Payable Weekly Earnings Monthly Earnings Percentage of Income Replaced 60% 66 2/3% Maximum Benefit Up to $1,000 Up to $7,500 11
Life and AD&D Insurance Who is Eligible and When This coverage is offered to all employees on the first day of the month following date of hire of employment, or with a qualifying event. Basic Life Insurance Subsystem Technologies, Inc. provides full-time employees with group life and accidental death and dismemberment (AD&D) insurance, in the amount of $100,000 and pays the full cost of this benefit. Contact Human Resources to update your beneficiary. Voluntary Life Insurance Employees who want to supplement their group life insurance benefits may purchase additional coverage. When you enroll yourself and/or your dependents in this benefit, you pay the full cost through payroll deductions. You can purchase coverage on yourself in $10,000 increments, $5,000 increments for your spouse and $1,000 increments for your dependent child(ren). Minimum coverage amount for an employee is $10,000 to a maximum of 5 X annual salary not to exceed $250,000. Employee coverage has a Guaranteed Issue* amount of $50,000. Semi-Monthly Cost for Each $10,000 of Employee Life Insurance Coverage $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 < 24 $0.42 $0.83 $1.25 $1.66 $2.08 $2.49 $2.91 $3.32 $3.74 $4.15 25-29 $0.30 $0.59 $0.89 $1.18 $1.48 $1.77 $2.07 $2.36 $2.66 $2.95 30-34 $0.32 $0.64 $0.96 $1.28 $1.60 $1.92 $2.24 $2.56 $2.88 $3.20 35-39 $0.46 $0.91 $1.37 $1.82 $2.28 $2.73 $3.19 $3.64 $4.10 $4.55 40-44 $0.75 $1.49 $2.24 $2.98 $3.73 $4.47 $5.22 $5.96 $6.71 $7.45 45-49 $1.26 $2.51 $3.77 $5.02 $6.28 $7.53 $8.79 $10.04 $11.30 $12.55 50-54 $2.05 $4.10 $6.15 $8.20 $10.25 $12.30 $14.35 $16.40 $18.45 $20.50 55-59 $3.49 $6.97 $10.46 $13.94 $17.43 $20.91 $24.40 $27.88 $31.37 $34.85 60-64 $4.30 $8.60 $12.90 $17.20 $21.50 $25.80 $30.10 $34.40 $38.70 $43.00 65-69 $6.47 $12.93 $19.40 $25.86 $32.33 $38.79 $45.26 $51.72 $58.19 $64.65 70-74 $17.04 $34.07 $51.11 $68.14 $85.18 $102.21 $119.25 $136.28 $153.32 $170.35 75-79 $29.62 $59.24 $88.86 $118.48 $148.10 $177.72 $207.34 $236.96 $266.58 $296.20 80+ $60.00 $120.00 $180.00 $240.00 $300.00 $360.00 $420.00 $480.00 $540.00 $600.00 12
Life and AD&D Insurance (continued) Semi-Monthly Cost for Each $5,000 of Spouse Life Insurance Coverage $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 < 24 $0.21 $0.41 $0.62 $0.82 $1.03 $1.23 $1.44 $1.64 $1.85 $2.05 25-29 $0.15 $0.29 $0.44 $0.58 $0.73 $0.87 $1.02 $1.16 $1.31 $1.45 30-34 $0.16 $0.32 $0.48 $0.64 $0.80 $0.96 $1.12 $1.28 $1.44 $1.60 35-39 $0.23 $0.45 $0.68 $0.90 $1.13 $1.35 $1.58 $1.80 $2.03 $2.25 40-44 $0.38 $0.75 $1.13 $1.50 $1.88 $2.25 $2.63 $3.00 $3.38 $3.75 45-49 $0.63 $1.26 $1.89 $2.52 $3.15 $3.78 $4.41 $5.04 $5.67 $6.30 50-54 $1.03 $2.05 $3.08 $4.10 $5.13 $6.15 $7.18 $8.20 $9.23 $10.25 55-59 $1.74 $3.48 $5.22 $6.96 $8.70 $10.44 $12.18 $13.92 $15.66 $17.40 60-64 $2.15 $4.30 $6.45 $8.60 $10.75 $12.90 $15.05 $17.20 $19.35 $21.50 65-69 $3.24 $6.47 $9.71 $12.94 $16.18 $19.41 $22.65 $25.88 $29.12 $32.35 Minimum coverage amount for a Spouse is $5,000 to a maximum of $50,000 not to exceed 50% of the Employee elected amount. Spouse coverage has a Guaranteed Issue* amount of $25,000. Semi-Monthly Cost for Each $1,000 of Dependent Child Life Insurance Coverage $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 Rate $0.10 $0.20 $0.30 $0.40 $0.02 $0.60 $0.70 $0.80 $0.90 $1.00 Semi-Monthly Cost for Each $10,000 of Employee AD&D Insurance Coverage Employee $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $0.115 $0.23 $0.345 $0.46 $0.575 $0.69 $0.805 $0.92 $1.035 $1.15 Spouse $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $0.06 $0.12 $0.18 $0.24 $0.30 $0.36 $0.42 $0.48 $0.54 $0.60 Children $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000 $0.01 $0.02 $0.03 $0.04 $0.05 $0.06 $0.00 $0.08 $0.09 $0.10 *Guaranteed Issue The Guaranteed Issue amount is the maximum benefit available with Evidence of Insurability. The Guaranteed Issue amount applies to all eligible employees/spouses who properly enroll for coverage within 31 days after becoming eligible. 13
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Stynchula, Herbert & Associates, Inc. www.stynherb.com (703)273-0222 The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by your employer. The text contained in this Summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies, or errors are always possible. In case of discrepancy between the Benefits Summary and the actual plan documents the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about this summary, contact Human Resources. 15