SMCI Benefit Guide 2017 2018

User Manual:

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December 1, 2017 - November 30, 2018
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-
Premiums for all plans are paid thru pre-tax
payroll deductions, resulting in 25 - 30% tax
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 childs 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
Dental: You must complete an enrollment form when you are first eligible, electing or waiving cov-
Vision (Optional): You must complete an enrollment form to elect coverage.
Long Term & Short Term Disability: You are automatically enrolled in this employer paid bene-
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 enroll-
ment form to elect coverage. To increase coverage, an evidence of insurability form must be sub-
mitted for consideration.
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.
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: $60
Preventive Care Office Visit (In-Network Only): Covered at 100%
Urgent Care: $100
Emergency Care: $300
Prescription Benefits: $15 / $35 / $60 / $100
Mail Order Prescription Benefits: $37.50 / $87.50 / $150.00 / $250
Maximum Lifetime Benefit: Unlimited
This is intended as a brief overview of the benefits. Refer to the full Certificate of Coverage for all binding contractual provisions.
Note: The out-of-network deducble 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 Depend-
ent Cost
Employee Pays 50% of
the Dependent Cost
Coverage Level
UHC AllSavers
Total Monthly
Semi-Monthly Contribu-
tions SMCI pays on your
Your Semi-Monthly Pay-
roll Deduction
Employee Only $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
Getting Started
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
Registration is quick and simple.
Click on Register Now. Youll need your health plan ID card, or
coverage materials.
Follow the step-by-step instructions.
Stay Well
Trio Motion
Trio Device & FIT Rewards
Use a free wearable to track steps,
reach goals and earn rewards.
Be Well
Rally Wellness
Health survey, missions, challenges,
and rewards.
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
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 direct-
ly 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 Itrule? You may submit a request for reimbursement for expenses
through December 31, 2018. You will have a 60-day timeframe to submit the Reimbursement Request Form for ex-
penses incurred during that time. SMCI allows up to $500 of unused funds to be rolled over to the next calendar
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 re-
quest more than the annual elected amount, only the elected amount will be available to you.
On-line access:
Mobile App: MyTASC
What you need to know about your Health Flexible Savings Account
through TASC: 800-422-4661
Arcial limbs or teeth
Birth control pills, contracepve devices &
sterilizaon procedures
Childbirth classes
Co-pays, co-insurance, & deducbles
Durable medical equipment
Dental exams, cleanings & other qualied ser-
Hearing devices
Hospital bills
Insulin, diabec supplies, and test kits
Medical tests and other services
Some over the counter items when accompa-
nied by a prescripon from a medical provider
No Waiting Period
No Waiting Period
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)
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)
Welcome to Delta Dental! We are pleased to oer Dental benets for you and your family.
ORTHODONTICS - $1,000 Lifetime Maximum per member (dependents to age 19 only)
Customer Service:
100% of the EE Cost
Contribuons on Your
Employee Pays
Dependent Cost Only!
Payroll Deducons
EMPLOYEE $20.87 $0.00
EMPLOYEE & SPOUSE $20.87 $22.09
EMPLOYEE & CHILD(REN) $20.87 $26.81
EMPLOYEE & FAMILY $20.87 $53.70
Calendar Year Annual Maximum: $1,500 per member
- You will be mailed a membership card.
- To find an in-network provider near you, go to or call 1.866.939.3633
- Please visit 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.
Employee Pays Total Cost
Semi-Monthly Payroll Deductions
Welcome to EyeMed! We are pleased to offer Vision benefits for you and your family.
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-
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
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.
Benefit is 60% of your monthly pre-disability earnings, to a maximum of $7,500 per
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.
Customer Service: (800) 228-7104 Website:
Group Number G000AY4G
Customer Service: (800) 228-7104 Website:
Sample Employee Sample Employee
Employee Spouse Per-Pay-Period Per-Pay-Period
Age Bracket Monthly Cost Per
Monthly Cost Per
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 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
$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
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.
We at Southern Mutual Church Insurance appreciate our employees,
and we hope you agree that our benefits package reflects this.
Assurance Benefits Group, LLC
1898 Calhoun Street #6
Columbia, SC 29201
Carol Iverson
Office (803) 227-8639, x103
Fax (803) 227-8659
Tammie J. King, RHU, REBC
Office (803) 227-8639, x102
Cell (803) 738-6858
Fax (803) 227-8659

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