SMCI Benefit Guide 2015 2016
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EMPLOYEE BENEFITS GUIDE
Effective
December 1, 2015 - November 30, 2016
Am I eligible?
If you are a Southern Mutual full-time W2
employee, working 30 or more hours per
week, you are eligible to enroll in the bene-
fits described in this guide. Your spouse
and eligible dependents may enroll for medi-
cal, dental, vision and supplemental life in-
surance.
Premiums for all plans are paid thru pre-tax
payroll deductions, resulting in 25 - 30% tax
savings.
When can I make changes?
You are able to make changes during the month of Novem-
ber during our Open Enrollment Period. After November, you
must have a qualified change in status in order to make
changes to the benefits you elect during the plan year.
Qualified changes in status include: marriage, divorce, legal
separation, birth, adoption of a child, change in child’s de-
pendent status, death of spouse or child. Involuntary loss of
other coverage due to a change in spouse employment or
loss of Medicaid eligibility would also apply. Employees have
an open enrollment period during the month of November to
make changes to the medical, dental, vision and supple-
mental life benefits.
What do I have to do?
Medical:
You must complete an enrollment form when you are first eligible, electing or waiving coverage.
Please be sure to provide a beneficiary for the life benefit provided by UHC.
Dental:
You must complete an enrollment form when you are first eligible, electing or waiving coverage.
Vision (Optional):
You must complete an enrollment form to elect coverage.
Long Term & Short Term Disability
You are automatically enrolled in this employer paid benefit.
Group Term Life Insurance:
You are automatically enrolled in this employer paid benefit. You must complete an enrollment form
to select a beneficiary.
Supplemental Life / Dependent Life Insurance (Optional):
You must complete an enrollment form to elect coverage.
Welcome!
Southern Mutual provides a very comprehensive benefits offering to you and your family members.
Most of your insurance benefits become effective on your full time date of hire; however, if you
elect to purchase optional vision benefits, this coverage becomes effective on the first day of the
month following your date of hire.
Your UHC Benefits at a Glance for 12.01.2015 - 11.30.2016
Medical & Life Insurance
United Healthcare
Policy #0489680
Southern Mutual offers a Traditional Copay Plan with Office Visit and Rx Copays In-
cluded.
Southern Mutual pays 100% of the employee only medical plan premium and 45% of
any dependent costs. Employees are responsible for any remaining dependent cost
which will be payroll deducted on a pre-tax basis resulting in approximately 30% sav-
ings.
Southern Mutual offers $15,000 of Life and Accidental Death & Dismemberment Insur-
ance to each employee. Premiums are paid by Southern Mutual.
Care 24 Services offers you access to a w ide range of health and w ell -being
information—seven days a week, 24 hours a day. Call 1-888-887-4114 to speak with a
registered nurse and/or master’s-level counselor who can help with almost any prob-
lem ranging from medical and family matters to personal, legal, financial and emotion-
al needs.
Health Discount Program - even if you already have medical, dental and vision
coveage, as an enrollment health plan member, you can save even more by using the
health discount program for things such as teeth whitening, laser eye surgery, alter-
native medical care (i.e. chiropractics, acupuncture, etc.), infertility, etc. In addition,
you can save on many wellness resources like weight management programs (i.e.
Jenny Craig, NutriSystem, etc.), fitness clubs, smoking cessation programs and more.
To find out more visit www.myuhc.com and select “Extra Programs and Discounts”.
Children are covered to age 26 regardless of student or marital status.
Customer Service: 1-800-357-0978
Website: www.myuhc.com
COVERAGE LEVEL
UHC & AmFirst
TOTAL
MONTHLY
COST
SMCI Pays 100% of EE Cost
and 45% of Dependent Cost
Employee Pays 55% of the
Dependent Cost
Semi Monthly
contributions SMCI pays
on your behalf
Your Semi Monthly Deduction
EMPLOYEE ONLY $575.47 $287.74 $0.00
EMPLOYEE & SPOUSE $1,253.84 $440.38 $186.55
EMPLOYEE & CHILD
(REN) $1,084.82 $402.35 $140.07
EMPLOYEE & FAMILY $1,767.25 $555.89 $327.74
Medical Benefits Copay Plan
Individual Deductible: In-Network:
UHC $10,000
EE Pays - $3,000 per Individual
Use Both Cards
Family Deductible (Limit is 2x the Individual): In-Network:
UHC $20,000
EE Pays - $6,000 per Family
Use Both Cards
Calendar or Benefit Year Deductible? Calendar Year
Coinsurance %: In-Network: EE 20%, AmFirst 80%, then UHC 100%
Co-insurance Out of Pocket: In-Network:
EE Pays $1000
Use Both Cards
Co-insurance Limit Per Family: In-Network:
EE Pays $2000 per Family
Use Both Cards
Maximum Annual Exposure *** UHC $10,000
EE Pays $4,000 & AmFirst Pays $6,000 (Deductible + Coinsurance Out of Pocket) Single (In-Network): **
(Deductible + Coinsurance Out of Pocket) Family (In-Network): **
UHC $20,000
EE Pays $8,000 & AmFirst Pays $12,000
PCP / Specialist: $25 / $50
Office Visit Copay Covers: Consultation
Diagnostic Labs & X-Rays?* Yes
High Tech Radiology? Deductible + Coinsurance
In Office Surgery? Deductible + Coinsurance
Outpatient Preferred Labs (covered @ 100%): Any In-Network Lab
PCP Referral Required? No
Urgent Care (Doctors Care): $75
Emergency Room: $150
Network: UHC
Drug Card (generic/preferred/nonpreferred): $100 Rx Deductible $10 / $35 / $60
Specialty Medication: N/A
Mail Order (up to 90 day supply): $100 Rx Deductible then $25 / $88 / $150
Preventive Care: In Network Benefits
Plan Pays 100%
No Limit & No Copay
Annual Physicals:
Gyn Exams & Prostate Screenings:
Preventive Mammograms:
Vision Benefit Exam covered w/copay every 24 months
Maximum Annual Benefit (in/out of network): Unlimited
Maximum Lifetime Benefit (in/out of network): Unlimited
*Labs & X-Rays must be performed at an in-network physicians office on the same date, billed by the same physician and filed as an office visit.
**Plus Copays.
Customer Service: 1-800-357-0978 Website: www.myuhc.com
Note: This is a brief summary, so please see your actual Insurance Policies for contractual benefits.
***YOU MUST USE YOUR UHC & AMFIRST FOR ALL SERVICES UNTIL THE MEMBER’S MAX ANNUAL EXPOSURE IS MET!!
AmFirst Gap Plan For Southern Mutual
Group Supplemental Coverage
Health Insurance designed exclusively for those covered under a comprehensive major
medical plan.
This plan picks up where your major medical plan leaves off - on Hospital and Medical
Expenses that you incur when you are in the Hospital.
This plan is designed to help fill the gap between what your current plan pays and what you owe on
the covered expenses from:
The hospital and doctor as the result of an in-patient hospital confinement.
Additional benefits for outpatient expenses.
Supplemental Deductible and Co-Insurance
Annual Deductible - $3,000 per Individual
Co-Insurance - 20% to $1,000 per Individual Out of Pocket Maximum
Maximum Annual Exposure - $4,000 per Individual
This plan will then pay the benefits described below for each insured, after the deductible for this plan has
been satisfied, as provided in the policy until the AmFirst Plan payments under all benefits reach the Maxi-
mum Total Benefit Amount.
A. Supplemental Benefits for Covered Hospital Confinement
For medically necessary expenses incurred while you are confined in the hospital this plan pays:
Deductible and Co-insurance
Pays the amount applied to your Deductible and Co-insurance by your major medical health plan
for covered charges incurred during the covered hospital confinement not paid by your major
medical plan.
B. Supplemental Benefits for Covered Outpatient Expenses
For medically necessary expenses incurred on an outpatient basis this plan pays:
Deductible and Co-insurance Pays the amount applied to your Deductible and Co-insurance by
your major medical plan.
Charges for the professional fees of a physician in a doctor’s office or medical clinic and
outpatient prescription drugs are not covered.
Maximum Total Benefit Amount Premium Saver Pays: $6,000 Single and $12,000 Family
AmFirst pays the same benefit regardless of whether Members go in-network or out-of-network.
It is in the best interest of the Member to ALWAYS seek out in-network providers to receive discounted services,
maximize their benefits and minimize their cost!
Policy #14966
Customer Service: 1-888-859-3795 Claims Assistance: 1-888-888-2519
How to register on myuhc.com
By registering on myuhc.com, you can find the answers to your health and benefits questions and the infor-
mation you need in one easy-to-use, convenient location online.
Registration is quick and simple:
1.) Go to myuhc.com
2.) Click the
Register Now
button
3.) Enter ID card information or your Social Security number and date of birth
4.) Enter or confirm your e-mail address or sign up for a free e-mail account
5.) Check to receive informational e-mails and confirm enrollment for electronic documents
6.) Create a username and password—then start using myuhc.com
On myuhc.com you can:
~ Check past and current statements and claims status
~ Review eligibility and look up benefits
~ Find a hospital or doctor
~ Print a temporary ID card or request a replacement card
~ Estimate health care costs - compare hospitals in quality and cost at the procedure level
~ “Chat” with a nurse online in real-time
~ Take a health assessment and participate in online health coaching programs
~ Learn about health conditions, symptoms and the latest treatment options
~ Use the Personal Health Record to organize health data and receive condition-specific information
to organize your overall health
~ Track your medical expenses, manage prescriptions and organize your claims
Online Health Assessment on myuhc.com
Take your first step towards a healthier lifestyle by taking a free, personalized health assessment at
myuhc.com. You can identify your personal health needs, learn healthy habits and compare your “lifestyle
score” to others of the same age and gender. Based upon your score, an interactive Health Coach may recom-
mend up to three health improvement goals to help you achieve your personal health goals such as:
~ Weight Management ~ Exercise
~ Nutrition ~ Tobacco Cessation
~ Stress Management ~ Heart Health Lifestyle
~ Diabetes Lifestyle
To access the Health Assessment, log onto myuhc.com and click on the “Health Assessment” tab on the right
side of the home page.
Personal Health Record on myuhc.com
It’s your health history, a medical library and a customizable organizer rolled into one secure and easy-to-use
tool. With the Personal Health Record you can
~ Review medical and pharmacy claims information, as well as lab results
~ Record allergies, immunizations, your family health history and personal contacts
~ Utilize Health Trackers to track progress such as blood pressure, cholesterol and weight
~ Print or download Personal Health History using historical claims data
What is a Flexible Spending Account? A Medical Flexible Spending Account (FSA) is an account to
which you contribute part of your pay before Social Security, Medicare and Federal Income (withholding) Tax to
pay for qualified medical, dental and certain vision expenses for yourself, your spouse, and/or your dependents.
What are qualified expenses? Any IR S Section 213 (D) ex penses are eligible to be reimbursed
through your Medical FSA. These expenses include most medical, Rx, dental & vision related services.
Why should I participate in a Medical Reiumbursement FSA? Normally, you w ould receive an income
tax deduction for qualifying medical, dental and vision expenses that exceed 10% of your adjusted gross family in-
come. (Few taxpayers ever meet that qualification or receive a tax deduction.) With the medical expenses Flexible
Spending Account, every dollar contributed to your account escapes FICA, State and Federal Withholding taxes.
How can I participate? First determ ine regular medical, dental and vision expenses you and your de-
pendent(s) will incur during this plan year (1/1/2016 to 12/31/2016). Enter the amount you want to set aside be-
fore taxes on the Election Form. Each pay period, SMCI will deduct this amount from your paycheck and deposit the
funds directly into your Flexible Spending Account.
Can I revoke my annual election amount? Generally, no. How ever, if you have a qualified change in
status (marriage, divorce, birth, adoption, unpaid leave of absence, change in employment status of you or your
spouse from full-time to part-time or vice-versa) you can revoke your annual elected amount and make a new elec-
tion for the remainder of the plan year.
Do I have a “Use It Or Lose It” rule? You may submit a request for reimbursement for expenses
in-
curred
through Decem ber 31, 2016. You w ill have a 60-day timeframe to submit the Reimbursement Re-
quest Form for expenses incurred during that time. SMCI allows up to $500 of unused funds to be rolled over to the
next calendar year.
When can I elect to participate, and how much may I contribute? Each year, during the Open Enroll-
ment period and prior to the Plan renewal date, you must complete a new Election Form for the upcoming Plan
Year. The 2015 annual contribution limit for Healthcare Reimbursement is $2,550.
What expenses are not eligible? You must use all the funds for eligible expenses betw een 1/ 1/ 2016
and 12/31/2016. SMCI allows up to $500 of unused funds to be rolled over to the next calendar year.
What happens if my request for Medical Care Reimbursement is greater than the amount of money in
my account? The annual am ount is available to you from the beginning of the 1/ 1/ 2016 plan year,
and if you request more than the annual elected amount, only the elected amount will be available to you.
What you need to know about Health Flexible Savings Accounts
MEDICAL FSA
ELIGIBLE EXPENSES
Artificial limbs or teeth
Birth control pills, contraceptive devices &
sterilization procedures
Childbirth classes
Co-pays, co-insurance, & deductibles
Durable medical equipment
Dental exams, cleanings & other qualified ser-
vices
Eye exams and vision correction surgery
Eyeglasses, contact lenses and solution
Hearing devices
Hospital bills
Insulin, diabetic supplies, and test kits
Medical tests and other services
Orthodontia
Some over the counter items when accompa-
nied by a prescription from a medical provid-
er
Physical exams and medical screenings
X-rays, MRI’s and other screenings
...hundreds more
DENTAL INSURANCE COSTS
PREVENTIVE SERVICES
No Waiting Period
BASIC SERVICES
No Waiting Period
MAJOR SERVICES
No Waiting Period
Zero Deductible
100% Coverage
$50 Calendar Year Deductible
80% Coverage
$50 Calendar Year Deductible
50% Coverage
Oral Exams / Cleanings
(1 per 6 months)
Fillings
Full Mouth X-rays
(1 per 36 months)
Inlays, Onlays, Crowns
Oral Surgery & General Anesthesia
Oral Exams / Problem Focused
(Combined w/ Exam Limit)
Endodontics & Periodontics
(root canals)
Bridges and Dentures
Bitewing x-rays
(<14: 1 per 12 months)
(19+: 1 per 12 months)
Simple Extractions Repair & Maintenance of Crowns,
Bridges & Dentures
Fluoride Treatment
(<16: 1 per 12 months)
Sealants & Space Maintainers
(age & frequency limits apply)
Implants
Welcome to Delta Dental! We are pleased to offer Dental benefits for you and your family.
Calendar Year Annual
Maximum:
$1,500 per member
ORTHODONTICS - $1,000 Lifetime Maximum per member
(dependents to age 19 only)
Customer Service:
Website: www.deltadentalsc.com
COVERAGE LEVEL
SMCI Pays
100% of the EE Cost
Semi-Monthly
Contributions on Your
Behalf
Employee Pays
Dependent Cost Only!
Semi-Monthly
Payroll Deductions
TOTAL
MONTHLY
COST
EMPLOYEE $16.52 $0.00 $33.03
EMPLOYEE & SPOUSE $16.52 $17.47 $67.97
EMPLOYEE & CHILD(REN) $16.52 $21.21 $75.44
EMPLOYEE & FAMILY $16.52 $42.49 $118.00
TYPE OF COVERAGE
Employee Pays Total Cost
Semi-Monthly Payroll Deductions
EMPLOYEE $4.30
EMPLOYEE & SPOUSE $8.17
EMPLOYEE & CHILD(REN) $8.60
EMPLOYEE & FAMILY $12.63
VISION INSURANCE COSTS:
Welcome to EyeMed! We are pleased to offer Vision benefits for you and your family.
IN NETWORK
o e sive eye exam eve y 12 months with a $10 co y.
$150 allowance eve y 12 months towards gl ses and/or contact lens* with a one-time $25 co y.
After your allowance has been used, receive a 15 discount on glasses contact lens at
**.
Discounts of on surgery including A at
Scontact lens fitting fee of no more than $55 or 10% discount off e usual and fitting for
contact lens*** most ovi s*.
No claims or to file.
*Material allowance does not cover non-prescription lenses, non-prescription or cosmetic contact lenses, or non-prescription sun-
glasses.
OUT OF NETWORK
If you choose to use an out-of-network provider, you will be reimbursed the following amounts:
Exam including contact lens fitting: $40 reimbursement
Materials: $105 reimbursement
- You will be mailed a membership card.
- To find an in-network provider near you, go to www.eyemed.com or call 1.866.939.3633
- Please visit www.eyemed.com for participating refractive surgery providers and discounts.
- To make an appointment, call an in-network provider and let them know that you are an EyeMed member
- You are responsible for payment to the in-network provider of any amount exceeding the material allowance, any
copays and any contact lens fitting fees.
- This is a routine vision program. Medical and surgical treatments of the eyes are not covered benefits.
- Dependent children are covered to age 26 regardless of student status.
Benefit is 60% of your weekly pre-disability earnings, to a maximum of $1,500 per week.
Payable on the 31st day of an accident or the 31st day for an illness.
9 Week benefit duration.
Your benefit will be taxable, as Southern Mutual pays 100% of your monthly premiums.
EMPLOYER PAID SHORT-TERM DISABILITY
Benefit is 60% of your monthly pre-disability earnings, to a maximum of $7,500 per
month.
Payable after 90 days of a total or partial disability.
Own Occupation Period is 24 months.
Maximum duration of benefits is to Social Security Normal Retirement Age (SSNRA).
Unlimited Return to Work Incentive.
3 months survivor benefit.
Your benefit will be taxable, as Southern Mutual pays 100% of your monthly premiums.
EMPLOYER PAID LONG-TERM DISABILITY
Customer Service: (800) 228-7104 Website: www.mutualofomaha.com
Group Number G000AY4G
EMPLOYER PAID BASIC LIFE INSURANCE
Customer Service: (800) 228-7104 Website: www.mutualofomaha.com
VOLUNTARY LIFE INSURANCE RATES
Sample Employee Sample Employee
Employee Spouse Per-Pay-Period Per-Pay-Period
Age Bracket Monthly Cost
Per $10,000
Monthly Cost
Per $10,000
Cost for $20,000 Cost for $100,000
0-24 $1.12 $1.12 $1.12 $5.60
25-29 $1.25 $1.25 $1.25 $6.25
30-34 $1.33 $1.33 $1.33 $6.65
35-39 $1.56 $1.56 $1.56 $7.80
40-44 $1.95 $1.95 $1.95 $9.75
45-49 $2.72 $2.72 $2.72 $13.60
50-54 $4.18 $4.18 $4.18 $20.90
55-59 $6.77 $6.77 $6.77 $33.85
60-64 $10.42 $10.42 $10.42 $52.10
65-69 $16.88 $16.88 $16.88 $84.40
70-74 $29.18 $29.18 $29.18 $145.90
75-79 $48.80 $48.80 $48.80 $244.00
Employee Max Benefit - Lesser of 5x annual earnings or $100,000 in increments of
$10,000, rounded to the next higher $1,000
Guarantee Issue = $100,000
Spouse Max Benefit - 50% of employee amount, up to $20,000
Guarantee Issue = $20,000.
Child Max Benefit - $10,000, in increments of $2,000
Guarantee Issue = $10,000
VOLUNTARY LIFE INSURANCE
$50,000 Life and Accidental Death & Dismemberment Insurance
Southern Mutual pays 100% of the premium
Group Number G000AY4G Child Term Life Rate for $10,000: $1.30
CONTACT INFORMATION
This Guide is only intended to offer an outline of benefits. All details and contract obligations of plans
are stated in the group contract/insurance documents. In the event of conflict between this guide and
the group contract/insurance documents, the group contract/insurance documents will prevail. Please
contact your Human Resources Department for further information.
Assurance Benefits Group, LLC
1898 Calhoun Street #6
Columbia, SC 29201
We at Southern Mutual Church Insurance appreciate our employees,
and we hope you agree that our benefits package reflects this.
Charlotte Hamilton
Office 803.227.8639 x103
Cell 803.465.1885
Fax 803.227.8659
Charlotte@ABG-LLC.com
Tammie J. King, RHU, REBC
Office 803.227.8639 x102
Cell 803.738.6858
Fax 803.227.8659
Tammie@ABG-LLC.com
