SMCI Benefit Guide 2017 2018

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EMPLOYEE BENEFITS GUIDE

Effective
December 1, 2017 - November 30, 2018

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.

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 benefits described in this guide. Your spouse
and eligible dependents may enroll for medical, dental, vision and supplemental life insurance.
Premiums for all plans are paid thru pre-tax
payroll deductions, resulting in 25 - 30% tax
savings.

What do I have to do?
Medical: You must complete an enrollment form when you are first eligible, electing or waiving
coverage.
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. To increase coverage, an evidence of insurability form must be submitted for consideration.

When can I make changes?
You are able to make changes during the month of November 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 dependent 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 supplemental life benefits.

All Savers Medical Benefits
The Benefits Shown are In-Network Benefits

United HealthCare

Out-of-Network Benefits are paid at a lower

Copay Plan P35003060

rate and members can be balance-billed

Covered Insured Pays:

Individual Deductible:

$3,500

Family Deductible:

$7,000

Aggregate or Embedded Deductible:

Embedded

Coinsurance Amount:

0%

Individual Coinsurance Limit:

N/A

Family Coinsurance Limit:

N/A

Individual Total Out-of-Pocket Maximum:

$6,550

Family Total Out-of-Pocket Maximum:

$13,100

In & Out Patient Hospital Services:

Subject to Deductible

In & Out Patient Testing:

Subject to Deductible

Primary Care Office Visit Copay:

$30

Specialist Office Visit Copay:
Preventive Care Office Visit (In-Network Only):

$60
Covered at 100%

Urgent Care:

$100

Emergency Care:

$300

Prescription Benefits:
Mail Order Prescription Benefits:

$15 / $35 / $60 / $100
$37.50 / $87.50 / $150.00 / $250

Maximum Lifetime Benefit:

Unlimited

Note: The out-of-network deductible is $7,000, coinsurance 50%, maximum out-of-pocket $14,000, based on reasonable &
customary charges.

SMCI Pays 100% of EE
Cost and 50% of Dependent Cost

Coverage Level

UHC AllSavers Semi-Monthly ContribuTotal Monthly tions SMCI pays on your
Cost
behalf

Employee Pays 50% of
the Dependent Cost

Your Semi-Monthly Payroll Deduction

$582.01

$291.01

$0.00

Employee & Spouse

$1,244.40

$456.61

$165.60

Employee & Children

$1,078.80

$415.21

$124.20

Employee & Family

$1,741.21

$580.81

$289.80

Employee Only

This is intended as a brief overview of the benefits. Refer to the full Certificate of Coverage for all binding contractual provisions.

Getting Started
Visit: myallsaversmember.com
Registration is quick and simple.


Click on Register Now. You’ll need your health plan ID card, or
coverage materials.



Follow the step-by-step instructions.



Track Claims and expenses for your family



Plan ahead for tests and treatments



Stay on top of your medical history



Receive tips for improving your health



Find a doctor

Stay Well
Be Well

Trio Motion
F I T

RALLY

Trio Device & FIT Rewards
Use a free wearable to track steps,
reach goals and earn rewards.
Visit: TrioMotionFit.com

Rally Wellness
Health survey, missions, challenges,
and rewards.
Visit: rally-support.com/customer

Get Well
Healthiest You
Doctor Connect & Mobile APP
Connect with doctors 24x7, shop and price prescriptions
and so much more.
Download the app, fill in the fields, start using
or call 866-703-1259
Visit: member.healthiestyou.com

What you need to know about your Health Flexible Savings Account
through TASC: 800-422-4661
What is a Flexible Spending Account? A Medical Flexible Spending Account (FSA) is an account to which you
contribute part of your pay before FICA, State 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 IRS Section 213 (D) expenses 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 would receive an income tax
deduction for qualifying medical, dental and vision expenses that exceed 10% of your adjusted gross family income.
(Few taxpayers ever meet that qualification or receive a tax deduction.)
How can I participate? First determine regular medical, dental and vision expenses you and your dependent(s)
will incur during this plan year (1/1/2018 to 12/31/2018). Enter the amount you want to set aside before 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. However, 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 election 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 incurred
through December 31, 2018. You will have a 60-day timeframe to submit the Reimbursement Request 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 Enrollment
period and prior to the Plan renewal date, you must complete a new Election Form for the upcoming plan year if
you are making a change. The 2018 annual contribution limit for Healthcare Reimbursement is $2,650.

What expenses are not eligible? Over-the-counter medicines cannot be purchased with FSA money without a
prescription. Cosmetic procedures are also not eligible.
What happens if my request for Medical Care Reimbursement is greater than the amount of money in
my account? The annual amount is available to you from the beginning of the 1/1/2018 plan year, and if you request more than the annual elected amount, only the elected amount will be available to you.

On-line access: https://tascparticipant.lh1ondemand.com
Mobile App: MyTASC
MEDICAL FSA
ELIGIBLE EXPENSES
•

Artificial limbs or teeth

•

Hearing devices

•

Birth control pills, contraceptive devices &

•

Hospital bills

sterilization procedures

•

Insulin, diabetic supplies, and test kits

•

Childbirth classes

•

Medical tests and other services

•

Co-pays, co-insurance, & deductibles

•

Orthodontia

•

Durable medical equipment

•

•

Dental exams, cleanings & other qualified services

Some over the counter items when accompanied by a prescription from a medical provider

Welcome to Delta Dental! We are pleased to offer Dental benefits for you and your family.

PREVENTIVE SERVICES

BASIC SERVICES

MAJOR SERVICES

No Waiting Period

No Waiting Period

No Waiting Period

Zero Deductible

$50 Calendar Year Deductible

$50 Calendar Year Deductible

100% Coverage

80% Coverage

50% Coverage

Fillings
Inlays, Onlays, Crowns

Oral Exams / Cleanings
(1 per 6 months)

Full Mouth X-rays
Oral Surgery & General Anesthesia

(1 per 36 months)

Oral Exams / Problem Focused

Endodontics & Periodontics

(Combined w/ Exam Limit)

(root canals)

Bridges and Dentures

Bitewing x-rays
(<14: 1 per 12 months)

Repair & Maintenance of Crowns,
Bridges & Dentures

Simple Extractions

(19+: 1 per 12 months)

Fluoride Treatment

Sealants & Space Maintainers

(<16: 1 per 12 months)

(age & frequency limits apply)

Calendar Year Annual Maximum:

Implants

$1,500 per member

ORTHODONTICS - $1,000 Lifetime Maximum per member (dependents to age 19 only)
Www.deltadental.com

DENTAL INSURANCE COSTS
SMCI Pays

Employee Pays

100% of the EE Cost

Dependent Cost Only!

TOTAL

Semi-Monthly

Semi-Monthly

MONTHLY

Payroll Deductions

COST

Contributions on Your
Behalf

EMPLOYEE

$41.74

$20.87

$0.00

EMPLOYEE & SPOUSE

$85.91

$20.87

$22.09

EMPLOYEE & CHILD(REN)

Customer Service:
$95.35

$20.87

$26.81

$149.13

$20.87

$53.70

COVERAGE LEVEL

EMPLOYEE & FAMILY

Website: www.deltadentalsc.com

Welcome to EyeMed! We are pleased to offer Vision benefits for you and your family.

IN NETWORK
•

o

•

$150

•

After your

e

sive eye exam eve y 12 months with a $10 co
allowance eve y 12 months towards gl

ses and/or contact lens* with a one-time $25 co

allowance has been used, receive a 15

•

**.

•

Discounts of

•

S

on

surgery including

y.

A

y.

discount on glasses contact lens at

at

contact lens fitting fee of no more than $55 or 10% discount off
contact lens***
most ovi
s*.

e usual and

fitting for

•

No claims or
to file.
*Material allowance does not cover non-prescription lenses, non-prescription or cosmetic contact lenses, or non-prescription sunglasses.

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.

VISION INSURANCE COSTS:
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

EMPLOYER PAID SHORT-TERM DISABILITY
•

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 LONG-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).

•

If you remain actively at work beyond your normal retirement age, your benefit will never
be paid for less than 12 months, as long as you remain disabled.

•

Unlimited Return to Work Incentive.

•

3 months survivor benefit.

•

Your benefit will be taxable, as Southern Mutual pays 100% of your monthly premiums.

Group Number G000AY4G

Customer Service: (800) 228-7104

Website: www.mutualofomaha.com

EMPLOYER PAID BASIC LIFE INSURANCE
•

$50,000 Life and Accidental Death & Dismemberment Insurance

•

Southern Mutual pays 100% of the premium

VOLUNTARY LIFE INSURANCE
•

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 for New Hires = $100,000

•

Spouse Max Benefit - 50% of employee amount, up to $20,000
Guarantee Issue for Spouses of New Hires = $20,000.

•

Child Max Benefit - $10,000, in increments of $2,000
Guarantee Issue for Children of New Hires = $10,000

VOLUNTARY LIFE INSURANCE RATES
Employee

Spouse

Age Bracket Monthly Cost Per Monthly Cost Per
$10,000
$10,000

Sample Employee

Sample Employee

Per-Pay-Period

Per-Pay-Period

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

Child Term Life Rate for $10,000: $1.30

Customer Service: (800) 228-7104

Group Number G000AY4G

Website: www.mutualofomaha.com

We at Southern Mutual Church Insurance appreciate our employees,
and we hope you agree that our benefits package reflects this.

CONTACT INFORMATION

Assurance Benefits Group, LLC
1898 Calhoun Street #6
Columbia, SC 29201
Tammie J. King, RHU, REBC
Office (803) 227-8639, x102
Cell (803) 738-6858

Fax (803) 227-8659
Tammie@ABG-LLC.com

Carol Iverson
Office (803) 227-8639, x103
Fax (803) 227-8659
Carol@ABG-LLC.com

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.



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