Medical Plan Overview BENEFIT GREEN PLAN WITH HSA YELLOW PLAN RED PLAN HSA Employer Contribution IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK Employee Only $1,000 N/A N/A Family $2,000 N/A N/A HSA Seed Funding **One half of the HSA seed money will be deposited in January, and the remainder will be funded through three more deposits in April, July and October. N/A N/A Group Accident Insurance Up to $2,500 per accident N/A N/A Employee Only $2,500 $2,500 $1,000 $2,000 $500 $1,500 Family $5,000 $5,000 $2,000 $3,000 $1,000 $3,000 Coinsurance 90% 70% 70% 50% 80% 60% Out-of-Pocket Maximum Employee Only $5,000 $6,000 $4,000 $8,000 $2,000 $6,000 Family $5,000 $10,000 $8,000 $10,000 $4,000 $10,000 Lifetime Maximum Unlimited Unlimited Unlimited Physician Office Services Preventive Care 100% 100% 100% Primary Care Office Visit $40 Copay $30 Copay Telehealth Visit $40 Copay then $40 Copay $40 Copay Specialist Office Visit $60 Copay $50 Copay Surgery (in a physician's office) Physical, Occupational, Cognitive, and Speech Therapy Chiropractic Care Emergency and Urgent Care Services Urgent Care Clinic $40 Copay $40 Copay $30 Copay $30 Copay Emergency Room $150 After $150 After Ambulance
Hospital Services (continued) Inpatient Hospital Facility Inpatient Professional Services Outpatient Surgery- Facility Charges Outpatient Professional Services Lab and X-ray Services Physician s Office Outpatient Hospital or Independent Facility Ancillary Services Skilled Nursing Home Health Care Hospice Durable Medical Equipment Pharmacy Retail 50% $10 /$35 /$60 $10 /$35 /$60 Home Delivery $15 /$50 /$90 /$90 After Deductibl Not Covered $20 /$70/ $120 Not Covered $20 /$70/ $120 Not Covered Medical Rates (Monthly) COVERAGE GREEN PLAN WITH HSA YELLOW PLAN RED PLAN NON-TOBACCO TOBACCO NON-TOBACCO TOBACCO NON-TOBACCO TOBACCO Employee Only $86 $186 $188 $288 $290 $390 Employee + Spouse $194 $294 $420 $520 $640 $740 Employee + Child(ren) $172 $272 $355 $455 $538 $638 Family $258 $358 $560 $660 $850 $950
Dental Plan Overview BENEFITS IN-NETWORK OUT-OF-NETWORK Individual (Calendar Year) $50 Family $150 Annual Maximum $1,500 Family Limit Up to 3 members of the family must meet the individual deductible Preventive Care Exams and Cleanings X-Rays Fluoride Treatments 100% 100% Sealants (per tooth) Emergency Care to Relieve Pain Basic Care Fillings Root Canals/Endodontics Oral Surgery Surgical Extractions Anesthesia Major Care* Crowns and Bridges Dentures Inlays/Onlays Prosthesis Over Implant Orthodontia 50% Adult and Child Orthodontia Lifetime Maximum $1,500 *Out-of-network charges may be higher as providers are not subject to the insurance company s negotiated rate. **Out-of-Network coinsurance is applied up to the Reasonable and Customary fees. Dental Rates (Monthly) COVERAGE COST PER MONTH Employee Only $26.38 Employee + Spouse $55.16 Employee + Child(ren) $73.21 Family $109.18
Vision Overview BENEFIT IN-NETWORK OUT-OF-NETWORK Exam (1 per year) $10 Copay Not Covered Exam Allowance 100% After Copay Up to $45 Materials Copay $15 Not Covered Eyeglass Lens Allowance (one pair per year) Single Vision 100% After Copay Up to $32 Bifocal 100% After Copay Up to $55 Trifocal 100% After Copay Up to $65 Lenticular 100% After Copay Up to $80 Contact Lens Allowance (one pair or single purchase per frequency period in lieu of frames) Elective Up to $130 Up to $115 Therapeutic Covered at 100% Up to $210 Frame Retail Allowance (1 every 2 years) Up to $150 Up to $83 Vision Rates (Monthly) COVERAGE COST PER MONTH Employee Only $6.50 Employee + Spouse $10.08 Employee + Child(ren) $9.42 Family $16.92 FSA Maximum Contributions Medical Spending Account Dependent Care Spending Account $2,550 per year $5,000 per year
Disability and Life Benefits SHORT-TERM DISABILITY (EMPLOYER PAID) Benefits Eligibility Benefit Start Date Benefit Length of Benefit LONG-TERM DISABILITY (EMPLOYER PAID) Benefit Eligibility Benefit Start Date Length of Benefit At least 1 year of service Begins on the 6th day of total disability or after expiration of all employer-provided PTO 60% of employees bi-weekly earnings 90 days First of the month following 30 days of service 91 st day of continuous disability (or as required by law) Continues until your normal social security retirement age (provided you are continuously disabled) Employees EMPLOYER-PAID LIFE INSURANCE Benefit Eligibility For the majority of employees, the benefit is 60% of your monthly earnings up to a maximum of $10,000. The corporate officers, executives, and management members have a higher monthly maximum of $15,000. First of the month following 30 days of service Employees Corporate Officers and General Managers An amount equal to 5 times your annual base earnings up to a maximum of $2 million (Any amount over $1 million will be subject to Evidence of Insurability.) All Other Employees An amount equal to 3 times your annual base earnings subject to a maximum of $1 million DEPENDENT SUPPLEMENTAL LIFE INSURANCE Spouse Increments of $10,000 to a maximum of $500,000 (Any amounts over $20,000 are subject to Evidence of Insurability.) Child(ren) Amounts of $1K, $2,500, $5K, $7,500, or $10K Increments of $2,500 to a maximum of $10,000 for each child no medical information is required; Child(ren) age 26 or older may be covered if they were disabled prior to attaining age 26; Child(ren) 14 days to 6 months are limited to a reduced benefit of $1,000; Child(ren) ages 6 months to age 26 are eligible for $10,000.
Supplemental Life Spouse Rates EMPLOYEE AGE RATE (PER 10,000) <30 $0.98 30-34 $1.29 35-39 $1.64 40-44 $2.57 45-49 $4.35 50-54 $7.43 55-59 $12.21 60-64 $15.80 65-69 $22.78 70 and over $46.22 Supplemental Dependent Life Child Rates $2,500 $0.42 $5,000 $0.82 $7,500 $1.22 $10,000 $1.62
Group Accident Insurance Group Accident Insurance helps cover expenses for medical services due to an unexpected illness or injury caused by an accident. Covered services include services such as hospital confinement, surgical expenses, lab tests, anesthesia medications, and physicians visit expenses. More details can be provided during your enrollment session. Benefit Eligibility Active employment working at least 30 hours per week. Benefit Rates Green Plan Enrollees provided and paid for in full by Gray Television Yellow Plan Enrollees may purchase the benefit at an additional cost. Red Plan Enrollees may purchase the benefit at an additional cost. COVERAGE MAXIMUM BENEFIT IN DOLLARS (per insured person - per policy GREEN PLAN MONTHLY RATE MONTHLY RATE Employee Only $2,500 $0 included with plan $16.78 Employee + Spouse $2,500 $0 included with plan $23.49 Employee + Child(ren) $2,500 $0 included with plan $29.12 Family $2,500 $0 included with plan $41.55 Voluntary Benefits Group Voluntary Critical Illness (Employee Paid) Benefit Benefit is in addition to medical and disability income coverage. Cash benefit received if Diagnosed with critical illness; Benefit is determined by condition. Benefit Rates Based on age and tobacco use. Specific rates and more information can be provided during your enrollment session. Group Indemnity Medical Plan Benefit Benefit is in addition to medical and disability income coverage. Cash benefit paid to help cover out-of-pocket medical costs (deductibles, copays, premiums) and/or daily living expenses. More details can be provided during your enrollment session. Employee Employee + Spouse Employee + Child Family $9.88 $26.00 $17.03 $28.21