District Attorneys General Conference Office: New Employee Information Pack and Directions
Employee Appointment Form Complete form. It does require the General’s signature
Employee Record Form (DA0007) Employee completes entire form
I-9 Form Fill out pages 1 and 2 completely and send in all appropriate paperwork. Name on paperwork must completely match name on social security card
Payroll Deduction Authorization for Property (FA-0973) Have employee sign and date, Administrator or AA signs and dates
Revenue Funded Position Acknowledgement Employee signs, General signs and dates, Bottom of form will be completed by Conference. Child Support employees do not need to complete this
Drug Free Workplace Policy Employee signs and dates, fills out their social security number
Leave Beneficiary Form Employee needs to fill out and have notarized. If any employee passes away while still employed and has an annual/sick leave balance and this form is not on file the leave will be paid out to the TCRS beneficiary that is on file. Conference Office needs original of this form.
TennCare Notice If your employee is on TennCare, they need to contact the TennCare office to inform them of employer having insurance available.
Insurance
Insurance booklets and information is included in the packet for employee to review. To enroll in benefits, all employees must do so in Edison Self-Service. The only insurance forms the employee completes is the Insurance Checklist and Optional Term Life Enrollment Form, if enrolling.
Self-Service Enrollment includes coverage for the following: health, dental, vision, Voluntary Accidental Coverage, Flexible Benefits, HSA Accounts and Short and Long Term Disability. Employee will receive an email confirmation when all steps are completed. Email confirmation must be forwarded to the Conference Office.
Insurance Checklist must be completed and signed by the employees and the Administrative Assistant/Administrator.
Basic Life Beneficiary and Voluntary Accidental Coverage Beneficiaries must also be submitted in Edison Self-Service.
Optional Forms
Southeast Financial Credit Union (FA-0722) Employee sets up account with Credit Union to complete this form
*Higher Education Fee Discount or Fee Waiver (optional forms) Follow instructions on form
Additional Forms:
Assistant District Attorney/Criminal Investigators: Completely fill out and send in Notarized any of the following that are applicable: Oath of Office Affidavit of Intent Prior Service Request Affidavit of Prior Service Enclose: Certification from former employer if requesting prior prosecutorial credit; Copy of Law License; DD-214 if requesting Military credit Affidavit of Prior Service- Criminal Investigator- Enclose Certification from former employer if requesting credit for prior law enforcement experience.
ALL NEW EMPLOYEES MUST SET UP PROXIES IN EDISON TO ALLOW CONFERENCE STAFF TO ENTER THEIR TRAVEL REIMBURSEMENTS. INSTRUCTIONS ARE ATTACHED. PLEASE ENTER ONCE IMMEDIATELY AFTER RECEIVING ACCESS TO EDISON SELF SERVICE.
All new employee paperwork can be emailed to the Conference Office. However, we do need the original on the Leave and Last Wages Beneficiary form.
Also, please make sure that all new employees complete the Title VI Training and questionnaire that is located on the internet/intranet and that they forward their benefits enrollment confirmation email to the Conference Office.
TENNESSEE DISTRICT ATTORNEY GENERAL CONFERENCE
EMPLOYEE PERSONNEL FORMS AND REFERENCE AUDIT
Name SSN:
_____ Appointment Form ____ Insurance Checklist
____ Employee Record From ____ Benefits Enrollment Confirmation
____ Drug Free Workplace Policy ____ Leave Beneficiary Designation
____ Copy of Resume ____ Grant Position Funding
____ Copy of Degree/Transcript ____ I9 Form and Documentation
____ Title VI Training Questionnaire ____Sexual Harassment Training
Assistant DA or CI Forms
____ Copy of Law License ____ Oath of Office
____ Prior Service Credit Request ____ Affidavit of Prior Service
____ Affidavit of Intent
OPTIONAL FORMS
____ Credit Union
____ Deferred Compensation (for employees that go into Legacy System with TCRS)
____ Optional Term Life Enrollment Form
ALL NEW EMPLOYEES WILL RECEIVE INFORMATION IN THE MAIL FROM THE TENNESSEE CONSOLIDATED RETIREMENT SYSTEM and Empower.
Comments:
TENNESSEE DISTRICT ATTORNEYS GENERAL CONFERENCE
EMPLOYEE RECORD FORM
JUDICIAL DISTRICT
Employee Name (Last) (First) (Middle)
Home Address County______(Street & Number)
City _ State ______Zip Code ______
ADDRESS TO WHICH MAIL SHOULD BE SENT IF NOT SAME AS ABOVE
Street Address
City Zip Code
WORK ADDRESS
Street______City______Zip Code______
PERSONAL INFORMATION
Social Security Number Date Employed ______
Veteran ______Sex Race Disabled ______Date of Birth______Marital Status ____ Date of Marriage______Home Phone Office Phone
Title of Position Signature
EDUCATIONAL BACKGROUND
Are you a high school graduate? Yes _____ No_____ Date ______if no, do you have a GED certificate? Yes____ No____ Date______.
Schools Attended After High School-- College, Business, Trade or Technical Training
Schools Attended Dates Attended Did you Type of Degree Major Graduate ______
A COPY OF HS DIPLOMA AND DEGREE MUST BE SUBMITTED
THE FOLLOWING MUST BE COMPLETED FOR THE PURPOSE OF COMPUTING LONGEVITY: I have ___have not previously been employed by the State of Tennessee or a District Attorney General DA-0007 (rev. 08/19)
RETIREMENT CHANGES EFFECTIVE FOR EMPLOYEES HIRED ON OR AFTER JULY 1, 2014
There are no changes to current state employees.
New Hybrid Pension Plan (for all employees, except the DA). This plan consists of a Defined Benefit Portion (TCRS) and a Defined Contribution Portion (401K) that are not optional to the employee.
Effective July 1, 2014 all new employees will be entered into the new Hybrid Pension Plan instead of the Old Legacy System, unless the following apply to the newly hired employee.
Has prior state service and was vested (5 years of creditable service) and wasn’t refunded their account balance when employment terminated.
Has prior state service and wasn’t vested but has been gone from state employment less than 7 years.
Contribution and Benefit Changes
Employee pays 5% of salary into their retirement and the state will pay 3.87%. (Old Legacy System for current employees, the employee pays nothing. All contributions are paid by the state. )
Employee pays 2% of salary into a 401K plan and the state will pay 5%. New employees have the option to opt out of the 2% contribution within the first 30 days of employment but the state will still pay 5% into the 401K Plan. New employees can also contribute more than the 2%. If the employee contributes $50 or more into the 401K they get the 5% state contribution plus the $50 match. (401K is optional for current employees with a $50 match for employees contributing at least $50 monthly.)
Vesting is the same for both plans. Employees must have 5 years of state service before vesting.
Employees will receive a package at home from both the TCRS and the 401K Vender explaining their benefits. It also includes instructions on selecting beneficiaries or employees can log onto the following links and set up their log in information.
Tennessee Consolidated Retirement System: https://mytcrs.tn.gov/
Empower (401K Company): https://retirereadytn.empower-retirement.com/participant/#/login
Eligibility to retire: Full Service Retirement – Rule of 90 (example: 55 years old with 35 years of service) or age 65 with 5 years of service.
Early Retirement – Rule of 80 (example: 57 years old with 23 years of service) or age 60 with 5 years of service.
Current employees in the Legacy System are eligible for full retirement at age 60 and vested or 30 years of service. Early retirement is age 55 with 10 years of service.
Service Retirement Formula:
The annual base benefit on the Defined Benefit Portion (TCRS portion) will be calculated at 1.0% instead of the current Legacy System amount of 1.57%. The Defined Contribution Portion will be handled by the 401K Provider.
Service Retirement Formula - The annual service retirement allowance (or annual base benefit) payable to a member is equal to 1.0% of the member’s AFC (average final compensation), multiplied by the number of years of creditable service. The annual service accrual (1.0% formula) may be decreased as part of the cost controls for the Plan.
The following example shows the formula used for computing the TCRS retirement allowance for a member with 10 or more years of service. The example uses a 60-year-old member retiring under the maximum plan with an AFC of $50,000 and 30 years of service. In this example, TCRS service retirement benefits replace 30% of the member’s AFC after 30 years of service.
Accrual Years of Factor AFC Creditable Service .01 x $50,000 x 30 = $15,000 ÷ 12 Monthly Benefit $ 1,250
• The 1.0% annual service accrual formula and the employer/employee contributions may be decreased/increased in the future as part of the cost controls for the plan. Terminations:
If employee leaves employment they can apply for a refund of their accumulated contributions plus interest but the employer contributions to the Defined Benefit Portion are not refundable. If employee obtains a refund they give up their TCRS membership and all rights and benefits in the retirement system.
With the Defined Contribution Benefit Portion (401K), the employee upon termination or retirement may leave his/her account in the plan to withdraw in the future or withdraw immediately or rollover their benefits to another qualified investment program. There are penalties for early withdrawals for the 401K Portion just as there is now.
Department of Human Resources – Agency Resource Center
BENEFICIARY DESIGNATION FOR LEAVE BALANCES AND LAST WAGES
Part I: EMPLOYEE INFORMATION
Name:______Social Security Number:______
Employee Edison I.D. Number:______
Part II: BENEFICIARY DESIGNATION FOR PAYMENT OF ANNUAL, SICK, AND COMPENSATORY LEAVE BALANCES
I, ______, Pursuant to TCA 8-50-808, designate the person or persons listed below to receive, upon my death, a lump sum payment for any annual, sick, or compensatory leave balances.
______(Employee Signature) (Date)
Leave Balance Beneficiary Information (If additional space is needed please attach a second page).
Name (First, Middle, Last) Phone # Address Relationship Sex Birth Date Social Security #
Part III: BENEFICIARY DESIGNATION FOR PAYMENT OF LAST WAGES
I, ______, designate the person or persons listed below to receive, upon my death, a lump sum payment for any last wages. I understand a spouse is a required beneficiary to receive 100% of my last wages. If I do not have a spouse, any living children are required beneficiaries at equal percentages. If I do not have a spouse nor children, my last wages must be left to my estate.
______(Employee Signature) (Date)
Last Wages Beneficiary Information (If additional space is needed please attach a second page).
Name (First, Middle, Last) Phone # Address Relationship Sex Birth Date Social Security #
PR- 0474 (Rev. 8/20) RDA 10158
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**** Marissa Chudzik mari0928002 NEW EMPLOYEE ORIENTATION PACKET
State Employees New Employee Orientation Packet TABLE OF CONTENTS HEALTH BENEFITS • Key Terms • Telehealth • Three Networks • Partners Employee Assistance • Pharmacy Program (EAP) • Know Your Health • Wellness • Premier PPO • The Partners Health & • Standard PPO Wellness Center • Consumer Driven Health Plan with a Health Savings Account (CDHP/HSA) DENTAL BENEFITS • Prepaid Dental Health Maintenance Organization (DHMO) Plan • Dental Preferred Provider Organization (DPPO) Plan VISION BENEFITS • Davis Vision • Basic Plan • Expanded Plan LIFE INSURANCE DISABILITY INSURANCE • What is disability insurance? • Short Term Disability • Long Term Disability FLEXIBLE SPENDING ACCOUNTS • What is a flexible spending account (FSA)? • Medical FSA • Limited Purpose FSA (L-FSA) • Transportation/parking FSA • Dependent Care FSA DEADLINE & ENROLLMENT • Things to Remember LINKS New Employee Orientation Packet HEALTH
Helpful Links BENEFITS • Premiums & Deductibles • Co-Pay Comparison • Network • CDHP/HSA • Plans • Behavioral Health • Pharmacy Cost Comparison • Carrier Information • Employee Assistance Program (EAP) • Know Your Health • Partners for Health
KEY TERMS Coinsurance – A payment amount expressed as a fixed Notes percentage of a cost. This amount varies by plan, so pay close attention to this when we look at the comparison charts.
Copayment (Copay) - A fixed dollar amount you pay for certain services, such as a visit to your primary care doctor for an illness. Copayments apply toward your out-of- pocket maximum but do not apply toward your deductible.
Deductible - The amount you pay each year before insurance will begin paying for services that require coinsurance. This amount goes toward your out of pocket maximum.
Network - A group of doctors, hospitals and other healthcare providers who have an agreement with a carrier to provide services at set fees.
Out-of-Pocket Maximum - The most you will pay during the plan year.
Premium - The amount you pay monthly to have coverage. THREE NETWORKS Choice between the following networks of providers (doctors, hospitals, facilities) when you enroll in a health insurance option: KNOW YOUR HEALTH TOOL 1. Blue Cross Blue Shield Network S 2. Cigna Local Plus The Know your Health Tool provides a variety of 3. Cigna Open Access Plus* resources to help you make more informed, smarter healthcare decisions for you and your family. Find the All three networks have providers available across right hospital and doctor, take steps to prevent illness Tennessee and the country. Doctors and facilities in the and learn how to ask the right questions to get the networks can change during the year. Check the networks answers you need. The more you know, the healthier carefully for your preferred doctor or hospital when you can be. making your selection.
*$40/$80 monthly surcharge applies If you’re using this document on your computer, you can click on any of the logos PHARMACY at the bottom right of your All medical plans include Pharmacy benefits byCVS/ screen to be taken to the Partners for Health website. Caremark. New Employee Orientation Packet HEALTH BENEFITS PREMIER PPO STANDARD PPO • Higher monthly premium • Lower monthly premium • Lower financial risk when you receive care • Higher financial risk when you receive care • Lower deductibles & copays • Higher deductibles & copays • Lower coinsurance percentages • Higher coinsurance percentages
CDHP/HSA TELEHEALTH When you get care or need a prescription, you pay • 24/7, non-emergency Virtual Visits for those expenses until • You can talk to a doctor by phone, computer or tablet from anywhere you meet your deductible, at any time for minor illnesses like colds, flu, allergies, fever, and more. then you pay coinsurance The cost is less than a typical office visit. for your medical and • The PPO plan member pays $15 dollar copay. pharmacy costs. This plan has the lowest monthly PARTNERS EAP premium. • All state employees have access to an Employee Assistance Program • Money saved on (EAP). monthly premiums can be placed into the • Enrolled members have access to Behavioral Health benefits. Health Savings Account • Administered by Optum (HSA) for future • Services are offered at no cost –employees can get five EAP visits, per healthcare expenses. problem, per year at no cost to you. • The CDHP/HSA can also help you save money for retirement. When you leave or WELLNESS retire, you take the money in the account • Active Health is our wellness program vendor. with you. • Health plan members will receive information about the program, and If you enroll in the cash incentives you can earn by participating. • CDHP, the State • Enrolled members also have access to our Diabetes Prevention of Tennessee Programs and there is more information on the website under automatically adds Wellness. $250 for individuals and $500 for families. PARTNERS HEALTH & WELLNESS CENTER • An HSA is a tax-exempt Located in downtown Nashville, on the 3rd floor of the WRS TN Tower. It account that individuals welcomes all state employees enrolled in the State Group Health Insurance can use to save money Plan. or pay for qualified • The center provides non-emergency primary care services at no cost to expenses on a tax-free PPO members and CDHP members pay for services until they meet their basis. The money in the deductible, then they are provided at no cost. account earns interest. Balances over $1,000 can be invested. New Employee Orientation Packet DENTAL BENEFITS Helpful Links • Dental Plan Information • Dental Plan Comparison • Dental Premiums
PREPAID (DHMO) PLAN DENTAL PREFERRED PROVIDER • Managed by Cigna ORGANIZATION (DPPO) PLAN • Low monthly premium and restricted to an • Managed by MetLife established network of general dentists • Higher monthly premium • If you choose this dental plan, you would first call • Provides a larger network of participating dentists Cigna to select a general dentist that you can choose from • This would be your assigned dentist and you • You or your dentist will file claims for covered would be responsible for the pre-set copays services associated with dental services • Some services require a waiting period • There is no waiting period for services New Employee Orientation Packet VISION BENEFITS Helpful Links • Vision Plan Information • Vision Plan Comparison • Davis Vision • Vision Premiums
DAVIS VISION BOTH PLANS OFFER SAME SERVICES Choose from the following plans: • Routine eye exam once every calendar year BASIC PLAN • Frames once every two calendar years • Offers discounted rates and allowances • Choice of eyeglass lenses or contact lenses once EXPANDED PLAN every calendar year • Combination of copays, greater allowances and • Discount on LASIK/refractive surgery discounted rates than the Basic Plan • Discount on Hearing Aids (includes Free Hearing Exam) through Your Hearing Network (YHN) New Employee Orientation Packet LIFE INSURANCE Helpful Links • Life Insurance Information • Securian Life Benefits • Insurance Premiums • Life Insurance Assistance
LIFE INSURANCE POLICY BRIEF Minnesota Life/Securian Financial is our vendor for Life Insurance Policies. • Basic-term Life Insurance and Basic AD&D are mandatory for all benefit-eligible employees. • The monthly premium is employer paid when the medical insurance is waived. • If you choose to enroll in medical insurance, the monthly premium is determined by coverage level and salary and employees pay the monthly premium for this coverage through payroll deduction. • For Voluntary Term Life-you must enroll within the first 30 days of employment for Guaranteed Issue coverage and you enroll on the Securian website. New Employee Orientation Packet DISABILITY INSURANCE Helpful Links • Disability Information • Long Term Rates • MetLife • Short Term Options • Short Term Rates • Long Term Options
WHAT IS DISABILITY INSURANCE? TWO OPTIONS Helps cover living expenses by protecting your pre- 1. Long Term Disability disability income lost due to sickness or accidental injury. It pays a PORTION of your salary. Replaces a portion of your income during a disability that is expected to last longer than 90 to 180 days. You must use all of your accumulated leave (sick, annual, and comp time) before disability payments You have 30 days after your eligibility date begin. N to enroll without being required to answer O health questions. 2. Short Term Disability T To enroll after 30 days, you must wait Replaces a portion of your income during a disability, until AE or until an SQE occurs. If enrolling which could last up to 26 weeks. E during this time, you will answer health ! questions & MetLife will determine if you You must use all of your accumulated leave (sick, qualify. annual, and comp time) before disability payments begin. New Employee Orientation Packet FLEXIBLE SPENDING Helpful Links ACCOUNTS • Flexible Benefits Information • Optum Bank • FSA/HSA Comparison Chart
WHAT IS A FLEXIBLE SPENDING ACCOUNT (FSA)? Allows you to pay for eligible healthcare and dependent care with pre-tax dollars. This lowers the amount of taxes you pay. Please keep in mind that the IRS establishes contribution limits each year.
MEDICAL FSA • Used to cover medical, dental, vision and prescription cost not covered by insurance. • You do not qualify if you are enrolled in a CDHP/HSA. • Annual limit - $ 2,750. Carry over limit - $ 500.
LIMITED PURPOSE FSA (L-FSA) • May only be used to cover certain dental and vision cost that are not covered by insurance. • For employees enrolled in the CDHP/HSA, the L-FSA is a great way to save tax-free on eligible vision and dental expenses while continuing to grow your HSA balance. • Your entire election (up to $2,750) is available for use at the beginning of the year. Carryover limit - $500.
TRANSPORTATION/PARKING FSA • Maximum contribution to transportation FSA and/or the parking FSA is $270 per month. • Used to pay for certain work-related commuting and/or parking expenses.
DEPENDENT CARE FSA • Used to pay for certain dependent-care costs, such as after school care, baby-sitting fees, adult or child daycare and preschool.
DEADLINE & ENROLLMENT Helpful Links • Employee Self-Service
THINGS TO REMEMBER: • You have ONLY 30 days from your hire date to enroll using Employee Self-Service, located within Edison.
• Dependent Verification is due at the time of elections. New Employee Orientation Packet LINKS https://www.tn.gov/partnersforhealth.html https://www.tn.gov/partnersforhealth/health-options/behavioral-health.html https://www.tn.gov/partnersforhealth/health-options/carrier-network.html https://www.tn.gov/partnersforhealth/health-options/cdhp.html https://davisvision.com/stateoftn https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/benefit_grid_2021_dental_final.pdf https://www.tn.gov/partnersforhealth/other-benefits/disability.html https://www.tn.gov/partnersforhealth/other-benefits/eap.html https://hub.edison.tn.gov/psp/paprd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST https://www.tn.gov/partnersforhealth/other-benefits/flexible-benefits.html https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/hsa_fsa_comparison_grid.pdf https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/benefit_grid_2021_st_he_final.pdf https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/premium_std_21.pdf https://www.tn.gov/partnersforhealth/other-benefits/dental.html https://www.tn.gov/partnersforhealth/know-your-health.html https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/life_benefit_scout.pdf https://www.tn.gov/partnersforhealth/other-benefits/life.html https://www.tn.gov/content/tn/partnersforhealth/insurance-premiums.html https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/ltd_options_2020.pdf https://www.metlife.com/stateoftn/disability/state/ https://www.tn.gov/partnersforhealth/health-options/health.html https://www.optumbank.com/tennessee.html https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/premium_st_active_21.pdf https://web1.lifebenefits.com/content/lifebenefits/tennessee/en.html https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/std_options_2020.pdf https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/benefit_grid_2021_vision_final.pdf https://www.tn.gov/partnersforhealth/other-benefits/vision.html https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/premium_vision_21.pdf https://www.tn.gov/wfhtn STATE OF TENNESSEE GROUP INSURANCE PROGRAM EMPLOYEE INSURANCE CHECKLIST — STATE PLAN State of Tennessee • Department of Finance and Administration • Benefits Administration 312 Rosa L. Parks Avenue, 19th Floor • Nashville, Tennessee 37243 • 615.741.3590 or 800.253.9981
DO NOT submit this form to Benefits Administration (BA). This form must be completed during an employee’s initial enrollment period. Place a check mark beside each item discussed. After completing the form, place the original in the employee’s insurance or personnel file and give the employee a copy. EMPLOYEE INFORMATION NAME EDISON ID AGENCY
ELIGIBILITY AND ENROLLMENT q Explain the eligibility criteria for employees and dependents. q Explain enrollment must be completed within 31 days of their eligibility date. If completing a paper form, it must be returned to the human resource office with the applicable dependent verification documents by to allow ABC time to submit a Benefit eForm to BA within the 31-day requirement. If electronic enrollment is available through Edison Employee Self Service (ESS), the enrollment with dependent verification must be submitted by . Paper application is not necessary if using ESS. Explain enrollment in voluntary term life insurance is through the vendor’s website. q Explain if not enrolled when first eligible, the employee will only be allowed insurance coverage during the year by approval through a special enrollment provision. If a completed application is not returned by the 15th of the month prior to coverage beginning, the employee may have double deductions on the first paycheck from which health premiums are collected. Explain guaranteed issue for disability and voluntary term life insurance. q Explain changes which can be made during the fall annual enrollment period, effective the following January 1. • Employees/dependents may request to enroll in, cancel or transfer between health options and carriers • Employees/dependents may request to enroll in, cancel or transfer between dental and vision options • Employees may request to apply for short term and/or long term disability • Employees/dependents may request to enroll in voluntary accidental death insurance and apply for voluntary term life • Employees may request to start a flexible spending account (FSA) INSURANCE PRODUCTS Health Options Other q Premier PPO q Dental — Prepaid and Preferred Provider q Standard PPO q Vision — Basic and Expanded Plans q CDHP/HSA q Flexible Benefits Life Options q Short Term Disability (State and Higher Education) q Basic Term Life and Accidental Death and Dismemberment q Long Term Disability (State Only) q Voluntary Term Life q Voluntary Accidental Death and Dismemberment
INFORMATION TO BE PROVIDED q Provide Edison login, password and ESS instructions. q If the Edison password is not set up timely to complete ESS, provide an enrollment application to process insurance elections through a Benefit eForm. Also provide Basic Life Beneficiary Designation Application and Voluntary AD&D Insurance Application. The beneficiary designations, life insurance forms and enrollment application must be signed and placed in the employee’s insurance/personnel file even if refusing coverage. Or provide this navigational path to enter beneficiary information in Edison: HCM>Benefits>Employee/Dependent Information>Life Insurance Beneficiaries. q Provide the ParTNers for Health web address, tn.gov/partnersforhealth, and describe the information located on the website, including vendor materials, publications and the customer service page (emphasize search feature for network providers) with contact information for BA and vendor partners. q Explain where to find online forms for health, dental, disability, vision, life, retirement, leave of absence, flexible benefits enrollment and reimbursement and miscellaneous forms, provide printed copies if requested. Provide the url to the voluntary term life insurance website. q Provide access to the eligibility and enrollment guide and HIPAA privacy notice or printed copies if requested. q Explain the benefits available through the Employee Assistance Program (EAP) and the wellness program. q Explain flexible, medical, limited purpose, dependent care, transportation and parking reimbursement accounts. q Explain the benefits available in the health, dental, disability, life and vision insurance programs. q Explain monthly premiums, including employee deduction and employer contribution. q Explain the deferred compensation choices and provide enrollment form or the web address to enroll. q Provide the web address to the TennCare notice so employee is aware of responsibilities if they or their dependents are enrolled in TennCare. q Explain the Summary of Benefits and Coverage and the marketplace letter and provide the web address or printed copies if requested.
EMPLOYEE SIGNATURE AGENCY BENEFITS COORDINATOR SIGNATURE
DATE DATE FA-0980 (rev 11/20) RDA SW20 New Health Insurance Marketplace Coverage Form Approved Options and Your Health Coverage OMB No. 1210-0149
PART A: General Information There is a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by your employer.
What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace is held annually in the fall. Check the www.healthcare.gov website for more information and deadlines.
Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.1
Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution — as well as your employee contribution to employer-offered coverage — is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.
How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact Benefits Administration.
The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.
1 An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs. PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. 3. Employer name 4. Employer Identification Number (EIN)
State of Tennessee 62-6001445 5. Employer address 6. Employer phone number
19th Floor Wm Snodgrass Tower 312 Rosa L Parks Avenue 7. City 8. State 9. ZIP code
Nashville TN 37243 10. Who can we contact about employee health coverage at this job?
Benefits Administration 11. Phone number (if different from above) 12. Email address
615.532.6045 [email protected]
Here is some basic information about health coverage offered by this employer: • As your employer, we offer a health plan to: All employees. Some employees. Eligible employees are: • Full-time employees regularly scheduled to work at least 30 hours per week • Seasonal or part-time employees with 24 months of service and certified by their appointing authority to work at least 1,450 hours per fiscal year, (July–June) [per state law, will not apply to employees hired on or after July 1, 2015] • All other individuals cited in state statute, approved as an exception by the State Insurance Committee, or defined as full time employees for health insurance purposes by federal law • With respect to dependents: We do offer coverage. Eligible dependents are: • Your spouse (legally married) • Natural or adopted children • Stepchildren • Children for whom you are the legal guardian • Children for whom the plan has qualified medical child support orders We do not offer coverage.
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.
** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.
If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.
The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coverage choices.
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? ______(mm/dd/yyyy) (Continue) No (STOP and return this form to employee)
14. Does the employer offer a health plan that meets the minimum value standard*? Yes (Go to question 15) No (STOP and return form to employee)
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $62 b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly
• An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) NOTICE TO TENNCARE ENROLLEES
Are You or Your Dependents Insured by TennCare?
Employees and their dependents are eligible for health insurance through a state-sponsored medical plan. These employees include:
• Regular full-time employees of participating agencies of state government • Local education agencies • Local government agencies
If you and/or your dependents are currently enrolled in TennCare, you are required to contact the Tennessee Health Connection (TNHC). This must be done within 10 days of your date of employ- ment. You will need to report:
• your new job, • salary, and • that you now have access to medical insurance with your employer.
If you have chosen to sign up for state-sponsored medical insurance you will need to provide TNHC with the date your coverage will begin and the name of the insurance provider.
TennCare could decide that you may still be eligible to keep TennCare. If TennCare cancels your coverage or the coverage of your dependents at a future date, you will have 60 days from the termination date to apply to your employer for coverage on the state-sponsored plan.
For questions or instructions on how to apply after TennCare has cancelled your coverage please contact Finance and Administration, Benefits Administration at800.253.9981 .
Tennessee Code Annotated 71-5-118
It is now a felony offense to obtain TennCare coverage under fraudulent means. Violators, if con- victed, can be sent to prison.
It is now a felony offense for a person to knowingly obtain, attempt to obtain or aid and abet any other person to obtain, by fraudulent, means any coverage provided to TennCare enrollees.
In addition to any penalties for a felony offense, any person committing the offense and violating the law may be di disdisqualified from participating in the TennCare Program as an enrollee. YOUR RIGHTS healthcare operations and certain other disclosures (such as any you asked us to YOUR RIGHTS When it comes to your health information, you make). We’ll provide one accounting a year You have the right to: have certain rights. This brochure explains for free but will charge a reasonable, cost- • Request assistance with getting a copy of your rights and some of our responsibilities. based fee if you ask for another one within your health and claims records STATE GROUP 12 months. Get a copy of health and claims records • Request assistance with correcting your INSURANCE PROGRAM health and claims records • You can ask to see or get a copy of your Get a copy of this privacy notice protected health information we have • You can ask for a paper copy of this notice • Request confidential communication about you. Ask us how to do this. at any time, even if you have agreed to • Ask us to limit the information we share • We will assist you with obtaining a copy or a receive the notice electronically. We will • Get a list of those with whom we’ve shared summary of your health and claims records, provide you with a paper copy promptly. your information Notice of Privacy usually within 30 days of your request. We Choose someone to act for you • Get a copy of this privacy notice Practices may charge a reasonable, cost-based fee. • Choose someone to act for you • If you have given someone medical power of attorney or if someone is your legal • File a complaint if you believe your privacy Ask us to correct health and claims records guardian, that person can exercise your rights have been violated • You can ask us to correct your health and claims records if you think they are incorrect rights and make choices about your health or incomplete. Ask us how to do this. information. YOUR CHOICES • We may say “no” to your request, but we’ll • We will make sure the person has this You have some choices in the way that we use Your Information. tell you why in writing within 60 days. authority and can act for you before we and share information as we: take any action. • Answer coverage questions from your Your Rights. Request confidential communications family and friends • You can ask us to contact you in a specific File a complaint if you feel your rights are • Provide disaster relief Our Responsibilities. way (for example, home or office phone) or violated to send mail to a different address. • You can complain if you feel we have violated your rights by contacting us using • We will consider all reasonable requests and OUR USES AND DISCLOSURES the information in this brochure. must say “yes” if you tell us you would be in We may use and share your information as we: danger if we do not. • You can file a complaint with the U.S. • Help manage the healthcare treatment you Department of Health and Human receive This notice describes how medical information Ask us to limit what we use or share Services Office for Civil Rights by sending • Run our organization about you may be used and disclosed and how • You can ask us not to use or share certain a letter to 200 Independence Avenue, • Pay for your health services you can get access to this information. health information for treatment, payment S.W., Washington, D.C. 20201, calling • Administer your health plan or our operations. 877.696.6775, or visiting hhs.gov/ocr/ • Help with public health and safety issues Please review it carefully. • We are not required to agree to your privacy/hipaa/complaints/. • Do research request and we may say “no” if it would • We will not retaliate against you for filing a affect your care. complaint. • Comply with the law • Respond to organ and tissue donation Get a list of those with whom we’ve shared requests and work with a medical examiner information YOUR CHOICES or funeral director • You can ask for a list (accounting) of the For certain health information, you can tell • Address workers’ compensation, law times we’ve shared your health information us your choices about what we share. If you enforcement, and other government for six years prior to the date you ask, who have a clear preference for how we share your requests we shared it with and why. information in the situations described below, • Respond to lawsuits and legal actions • We will include all the disclosures except talk to us. Tell us what you want us to do, and for those about treatment, payment, we will follow your instructions. In these cases, you have both the right and Pay for your health services Do research • We will let you know promptly if a breach choice to tell us to: • We can use and disclose your health • We can use or share your information for occurs that may have compromised the • Share information with your family, close information as we pay for your health health research. privacy or security of your information. friends or others involved in payment for services. • We must follow the duties and privacy Comply with the law your care. Example: We share information about practices described in this notice and give • We will share information about you if state • Share information in a disaster relief you with your dental plan to coordinate you a copy of it. or federal laws require it, including with the situation. payment for your dental work. Department of Health and Human Services • We will not use or share your information If you are not able to tell us your if it wants to see that we’re complying with other than as described here unless you tell Administer your plan preference, for example if you are federal privacy law. us we can in writing. If you tell us we can, unconscious, we may go ahead and • We may disclose your health information you may change your mind at any time. Let share your information if we believe to your health plan sponsor for plan Respond to organ and tissue donation requests us know in writing if you change your mind. administration. it is in your best interest. We may also and work with a medical examiner or funeral For more information see: hhs.gov/ocr/ share your information when needed to Example: Your company contracts director privacy/hipaa/understanding/consumers/ lessen a serious and imminent threat to with us to provide a health plan, and • We can share health information about you noticepp.html. health or safety. we provide your company with certain with organ procurement organizations. statistics to explain the premiums we • We can share health information with charge. a coroner, medical examiner or funeral CHANGES TO THE OUR USES AND DISCLOSURES director when an individual dies. TERMS OF THIS NOTICE We typically use or share your health The State Group Insurance Program must information in the following ways. HOW ELSE WE CAN USE OR SHARE Address workers’ compensation, law enforcement and other government requests follow the privacy practices contained in this YOUR HEALTH INFORMATION notice from its effective date of April 14, 2003, Help manage the healthcare treatment you We can use or share health information about We are allowed or required to share your as amended on November 1, 2016, until this receive you: information in other ways — usually in ways notice is changed or replaced. • We can use your health information and that contribute to the public good, such as • For workers’ compensation claims. share it with professionals who are treating We can change the terms of this notice, and public health and research. We have to meet • For law enforcement purposes or with a law you. the changes will apply to all information many conditions in the law before we can share enforcement official. we have about you. The new notice will be Run our organization your information for these purposes. For more • With health oversight agencies for activities information see: hhs.gov/ocr/privacy/hipaa/ available upon request, on our website at • We can use and disclose your information authorized by law. understanding/consumers/index.html. tn.gov/finance and we will mail a copy to you. to run our organization and contact you • For special government functions such as when necessary. Help with public health and safety issues military, national security, and presidential protective services. • We are not allowed to use genetic We can share health information about you for MORE INFORMATION information to decide whether we will certain situations such as: If you want more information concerning give you coverage and the price of that Respond to lawsuits and legal actions the state group insurance programs’ privacy • Preventing disease. We can share health information about you in coverage. This does not apply to long-term practices or have questions or concerns, please response to a court or administrative order, or care plans. • Helping with product recalls (for example, contact the privacy office at 866.252.1523 or pacemaker). in response to a subpoena. Example: We use health information email [email protected] about you to develop better services for • Reporting adverse reactions to medications. you. • Reporting suspected abuse, neglect or OUR RESPONSIBILITIES domestic violence. We are required by law to maintain the • Preventing or reducing a serious threat to privacy and security of your protected health anyone’s health or safety. information. Department of Finance and Administration. Authorization Number 317308. November 2016. 20,000 copies. This public document was promulgated at a cost of $0.11 per copy. DEPENDENT ELIGIBILITY Definitions and Required Documents
TYPE OF DEFINITION REQUIRED DOCUMENT(S) FOR VERIFICATION DEPENDENT Spouse A person to whom the participant is legally married You will need to provide a document proving marital relationship AND one document from the additional documents list below: Proof of Marital Relationship • Government issued marriage certificate or license • Naturalization papers indicating marital status Additional Documents • Bank Statement issued within the last six months with both names; or • Mortgage Statement issued within the last six months with both names; or • Residential Lease Agreement within the current terms with both names; or • Credit Card Statement issued within the last six months with both names; or • Property Tax Statement issued within the last 12 months with both names; or • The first page of most recent Federal Tax Return filed showing “married filing jointly” or “married filing separately” with the name of the spouse provided thereon, submit page 1 of the return with the income figures blacked out If just married in the previous 12 months, only a marriage certificate is needed for proof of eligibility Natural (biological) A natural (biological) child The child’s birth certificate; or child under age 26 Certificate of Report of Birth (DS-1350); or Consular Report of Birth Abroad of a Citizen of the United States of America (FS-240); or Certification of Birth Abroad (FS-545) Adopted child under A child the participant has adopted or is in the Final court order granting adoption; or age 26 process of legally adopting International adoption papers from country of adoption; or Court order placing child in custody of member for purpose of adoption Child for whom the A child for whom the participant is the legal Court order making member a guardian of another and stating the length of the participant is legal guardian guardianship guardian Stepchild under A stepchild Verification of marriage between employee and spouse (as outlined above) and birth age 26 certificate of the child showing the relationship to the spouse , or documents determined by BA to be the legal equivalent Child for whom the A child who is named as an alternate recipient with Court documents signed by a judge; or plan has received a respect to the participant under a qualified medical Medical support orders issued by a state agency qualified medical child support order (QMCSO) child support order Disabled dependent A dependent of any age (who falls under one of the Certificate of Incapacitation for Dependent Child form must be submitted prior to the categories previously listed) and due to a mental dependent’s 26th birthday. or physical disability, is unable to earn a living. The dependent’s disability must have begun before age The insurance carrier will review the form, make a determination, and provide BA with 26 and while covered under a state-sponsored plan. documentation once a determination has been made. If approved for incapacity, the child will continue the same coverage. Never send original documents. Please mark out or black out any social security numbers and any personal financial information on the copies of your documents BEFORE you return them.
Revised 07/20 Your 2021 Eligibility & Enrollment Guide State and Higher Education Employees
Tennessee State Group Insurance Program If you need help… Contact your agency benefits coordinator.He/she has received special training in our insurance programs. For additional information about a specific benefit or program, refer to the chart below.
BENEFITS CONTACT PHONE WEBSITE Plan Administrator Benefits Administration 800.253.9981 or 615.741.3590 — tn.gov/partnersforhealth M-F, 8-4:30 Health Insurance BlueCross BlueShield of Tennessee 800.558.6213 — M-F, 7-5 bcbst.com/members/tn_state Cigna 800.997.1617 — 24/7 cigna.com/stateoftn Health Savings Account Optum Bank 866.600.4984 — 24/7 optumbank.com/Tennessee Pharmacy Benefits CVS Caremark 877.522.8679 — 24/7 info.caremark.com/stateoftn Behavioral Health, Substance Use and Optum Health 855.HERE4TN — 24/7 here4TN.com Employee Assistance Program (855.437.3486) Wellness Program ActiveHealth Management 888.741.3390 — M-F, 8-8 http://go.activehealth.com/ wellnesstn Disability Insurance MetLife 855.700.8001 — M-F, 7-10 metlife.com/StateOfTN Dental Insurance Cigna 800.997.1617 — 24/7 cigna.com/stateoftn MetLife 855.700.8001 — M-F, 7-10 metlife.com/StateOfTN Vision Insurance Davis Vision 800.208.6404 — M-F, 7-10, Sat, davisvision.com/stateofTN 8-3 Sun, 11-3 Basic Client Code: 8155 Expanded Client Code: 8156 Life Insurance Securian Financial (Minnesota Life) 866.881.0631 — M-F, 7-6 lifebenefits.com/stateoftn
OTHER PROGRAMS Edison Tennessee Department of Finance password reset for higher education www.edison.tn.gov & Administration 800.253.9981 — M-F, 8-4:30; state call Edison help desk at 866.376.0104 — M-F, 7-4:30 Flexible Benefits medical & dependent care Optum Bank 866.600.4984 — 24/7 optumbank.com/Tennessee transportation & parking (state employees only) Benefits Administration 800.253.9981 — M-F, 8-4:30 tn.gov/partnersforhealth
Online resources... Visit the ParTNers for Health website at https://www.tn.gov/PartnersForHealth. It has information about all the benefits described in this guide. Enrollment forms and handbooks referenced in this guide are located on our website or you can get copies from your agency benefits coordinator.
The ParTNers for Health website also includes a green “Help” button, or live-chat feature, that is operational during normal business hours.
In Zendesk at https://benefitssupport.tn.gov/hc/en-us, you can search the help center, find articles or submit questions. To access Zendesk, you can also click the blue “Questions?” button on the website. Follow us on social media... TABLE OF CONTENTS
If viewing online, you can hover over linked topics and click to go to that page.
INTRODUCTION 1 Authority 1 ELIGIBILITY AND ENROLLMENT 3 Employee Eligibility 3 Dependent Eligibility 3 Enrollment and Effective Date of Coverage 5 Choosing a Premium Level (Tier) 5 Premium Payment 6 Adding New Dependents 6 Updating Personal Information 7 Annual Enrollment Period 7 Cancelling Coverage 8 Transferring Between Plans 9 If You Don’t Apply When First Eligible 9 CONTINUING COVERAGE DURING LEAVE OR AFTER TERMINATION 11 Extended Periods of Leave 11 Leave Due to a Work-related Injury 12 Termination of Employment 12 Continuing Coverage Through COBRA 12 Continuing Coverage at Retirement 12 Coverage for Dependents in the Event of Your Death 13 AVAILABLE BENEFITS 15 Health Insurance 15 Disability Insurance 22 Dental Insurance 25 Vision Insurance 27 Employee Assistance Program 30 Here4TN Behavioral Health and Substance Use Services 30 ParTNers for Health Wellness Program 30 Life Insurance 32 Flexible Spending Accounts 34 OTHER INFORMATION 35 Coordination of Benefits 35 Subrogation 35 On-the-job Illness or Injury 35 Fraud, Waste and Abuse 36 To File an Appeal 36 LEGAL NOTICES 39 TN Department of Finance and Administration, Authorization No. 317374, October 2020. This public document was promulgated at a cost of $0.01 per copy. INTRODUCTION
Benefits Administration, within the Department of Finance and Administration (F&A), manages the State Group Insurance Program. ParTNers For Health is the official logo and website name for Benefits Administration.
The State Group Insurance Program’s State Plan includes employees of state government and higher education. This guide explains insurance options and coverage rules for state and higher education employees participating in the State Plan. There is a separate guide for continuing insurance at retirement.
If you are eligible for the State Plan, you may enroll in health, dental, vision, life and disability insurance. Flexible spending accounts (FSA) are also available. Authority
The State Insurance Committee is authorized to determine the premiums, benefits package, funding method, administrative procedures, eligibility provisions and rules relating to the State Plan. You will be given written notice of changes.
State Insurance Committee • Commissioner of Finance and Administration (Chairman) • State Treasurer • Comptroller of the Treasury • Commissioner of Commerce and Insurance • Commissioner of Human Resources • Two members elected by popular vote of general state employees • One higher education member selected under procedure established by the Tennessee Higher Education Commission • One member from the Tennessee State Employees Association selected by its Board of Directors • Chairs of the House and Senate Finance, Ways and Means Committees
Certain state and federal laws and regulations, which may be amended or the subject of court rulings, apply to the group insurance program. These laws, regulations and court rulings shall control over any inconsistent language in this guide.
-1- -2- ELIGIBILITY AND ENROLLMENT Employees
Eligible • Full-time employees regularly scheduled to work at least 30 hours per week • All other individuals cited in state statute, approved as an exception by the State Insurance Committee or defined as full-time employees for health insurance purposes by federal law
NOT Eligible Individuals who do not meet the employee eligibility rules outlined above are ineligible UNLESS they otherwise meet the definition of an eligible employee under applicable state or federal laws or by approval of the State Insurance Committee. As an example, the following individuals are normally ineligible but might qualify for coverage if they meet the federal definition of a STATE OF TENNESSEE GROUP INSURANCE PROGRAM full-time employee under the Patient Protection and Affordable Care Act (PPACA). ENROLLMENT CHANGE APPLICATION • IndividualsState performing of Tennessee services • Department on a contract of Finance basis and Administration • Benefits Administration • Individuals312 in Rosa positions L. Parks that Avenue, are temporary 19th Floor •appointments Nashville, TN 37243 • 800.253.9981 • fax 615.741.8196
PART 1: ACTION REQUESTED — PLEASE SEE PAGE 4 FOR INSTRUCTIONS TYPE OF ACTION COVERAGE PARTICIPANTS REASON FOR THIS ACTION Life Event Special Enrollment Dependents q Health AFFECTED (also complete pg 3) q Add coverage q New Hire/Newly Eligible q Marriage q Dental q Employee q Death Ifq you Change enroll coverage in health, vision or dental coverage, you may alsoq Courtenroll Order your eligible dependents.q Newborn You or your spouse must be q Vision q Spouse q Divorce enrolledForm not forin voluntarycancellation term life in order to add a child term riderq Other to the coverage. q Legal Guardianship q Disability q Child(ren) q Loss of Eligibility q Adoption EligiblePART 2: EMPLOYEE INFORMATION FIRST• Spouse NAME (legally married) MI LAST NAME DATE OF BIRTH GENDER MARITAL STATUS • Natural or adopted children q M q F q S q M q D q W SOCIAL SECURITY NUMBER EMPLOYING AGENCY YOUR CURRENT STATUS • Stepchildren EMPLOYER GROUP: q HED q State q Local Ed q Local Gov q Active q COBRA • Children for whom you are the legal guardian HOME ADDRESS q UPDATE MY ADDRESS CITY ST ZIP CODE COUNTY • Children for whom the plan has qualified medical child support orders PART 3: HEALTH COVERAGE SELECTION — CHOOSE CAREFULLY. EXCEPT FOR QUALIFYING EVENTS, CHANGES ARE NOT ALLOWED OUTSIDE THIS PLAN’S ANNUAL ENROLLMENT. SELECT AN OPTION EMPLOYEE HSA SELECT A CARRIER REGION WHERE SELECT A HEALTH PREMIUM LEVEL Not Eligible CONTRIBUTION YOU LIVE OR WORK q Premier PPO LOCAL ED & GOV ONLY q BlueCross BlueShield q employee only • Ex-spouse (even if courtMAY ordered) ALSO CHOOSE (STATE ONLY) Network S q East • Parents of the employee or spouse Annual contribution q employee + child(ren) q Limited PPO q Cigna LocalPlus q Middle q CDHP/HSA (state) q employee + spouse • Foster children q Local CDHP/HSA $ q Cigna Open Access q West q employee + spouse + child(ren) q• StandardChildren PPO over age 26 (unless they meet qualifications for incapacitation/disability) (surcharge applies) PART• Live-in 4: DENTAL companions COVERAGE SELECTION who are not legally marriedPART 5: VISIONto the COVERAGE employee SELECTION PART 6: DISABILITY SELECTION (ST/UT/TBR) SELECT A PLAN SELECT A DENTAL PREMIUM LEVEL SELECT A PLAN SELECT A VISION PREMIUM LEVEL SHORT TERM DISABILITY LONG TERM DISABILITY (ST ONLY) Allq eligible MetLife DPPO dependentsq employee must only be listed by nameq on Basic the Plan enrollmentq employee change only application in partq 60%/14 7. You day are alsoq required 60%/90 day to Elim provide Period aq valid Cigna Social Prepaid Security q employee number + child(ren) for a dependentq (if Expanded they have one).q employee Other + required child(ren) informationElimination includes Period dateq of 60%/180 birth, relationship,day Elim Period DHMO Plan q 60%/30 day gender and acquireq employeedate. See + spouse below. q employee + spouse q 63%/90 day Elim Period Elimination Period q employee + spouse + child(ren) q employee + spouse + child(ren) q 63%/180 day Elim Period PART 7: DEPENDENT INFORMATION — ATTACH A SEPARATE SHEET IF NECESSARY NAME (FIRST, MI, LAST) DATE OF BIRTH RELATIONSHIP GENDER ACQUIRE DATE * SOCIAL SECURITY NUMBER HEALTH DENTAL VISION
q M q F q q q
q M q F q q q
q M q F q q q * The acquire date is the date of marriage, birth, adoption or guardianship. Proof of a dependent’s eligibility must be submitted with this application for all new dependents (see page 2). q A separate sheet with more dependents is attached PART 8: EMPLOYEE AUTHORIZATION q Accept I confirm that the information above is true. I understand my health,-3- dental and vision selections are effective until the end of the plan year (December 31) subject to plan eligibility criteria, and that I cannot change insurance plans or carriers during the plan year. If I experience a qualifying event mid- year, I may be eligible for changes in enrollment of plan members and dependents as a special enrollment. I understand that submission of fraudulent information may lead to consequences including cancellation of insurance, disciplinary action from my employer, or possible criminal penalties. I understand that if my dependent loses eligibility, it is my responsibility to notify my benefits coordinator, and coverage will terminate at the end of the month in which the loss of eligibility occurs. I understand that I will be held responsible for any claims paid in error. q Refuse I have been given the opportunity by my employer to apply for the group insurance program and have decided not to take advantage of this offer. I understand that if I later wish to apply, I or my dependents will have to provide proof of a special qualifying event or wait until annual enrollment. EMPLOYEE SIGNATURE DATE HOME PHONE (REQUIRED) EMAIL ADDRESS (REQUIRED)
AGENCY SECTION — RETURN THIS FORM TO YOUR AGENCY BENEFITS COORDINATOR ORIGINAL HIRE DATE COVERAGE BEGIN DATE POSITION NUMBER EDISON ID NOTES TO BENEFITS ADMINISTRATION
AGENCY BENEFITS COORDINATOR SIGNATURE DATE q PPACA Eligible q 1450 Eligible Active employees should return this completed form to your agency benefits coordinator. COBRA participants should send to Benefits Administration.
FA-1043 (rev 07/20) RDA 11367 Proof of the dependent’s eligibility is also required. Refer to the dependent definitions and required documents chart below and also at tn.gov/content/dam/tn/finance/fa-benefits/documents/deva_eligible_docs.pdf for the types of proof you must provide.
A dependent can only be covered once within the State Plan but can be covered under two separate plans (state, local education or local government). Dependent children are eligible for coverage through the last day of the month of their 26th birthday.
DEPENDENT ELIGIBILITY Definitions and Required Documents
TYPE OF DEFINITION REQUIRED DOCUMENT(S) FOR VERIFICATION DEPENDENT Spouse A person to whom the participant is legally married You will need to provide a document proving marital relationship AND one document from the additional documents list below: Proof of Marital Relationship • Government issued marriage certificate or license • Naturalization papers indicating marital status Additional Documents • Bank Statement issued within the last six months with both names; or • Mortgage Statement issued within the last six months with both names; or • Residential Lease Agreement within the current terms with both names; or • Credit Card Statement issued within the last six months with both names; or • Property Tax Statement issued within the last 12 months with both names; or • The first page of most recent Federal Tax Return filed showing “married filing jointly” or “married filing separately” with the name of the spouse provided thereon, submit page 1 of the return with the income figures blacked out If just married in the previous 12 months, only a marriage certificate is needed for proof of eligibility Natural (biological) A natural (biological) child The child’s birth certificate; or child under age 26 Certificate of Report of Birth (DS-1350); or Consular Report of Birth Abroad of a Citizen of the United States of America (FS-240); or Certification of Birth Abroad (FS-545) Adopted child under A child the participant has adopted or is in the Final court order granting adoption; or age 26 process of legally adopting International adoption papers from country of adoption; or Court order placing child in custody of member for purpose of adoption Child for whom the A child for whom the participant is the legal Court order making member a guardian of another and stating the length of the participant is legal guardian guardianship guardian Stepchild under A stepchild Verification of marriage between employee and spouse (as outlined above) and birth age 26 certificate of the child showing the relationship to the spouse, or documents determined by BA to be the legal equivalent Child for whom the A child who is named as an alternate recipient with Court documents signed by a judge; or plan has received a respect to the participant under a qualified medical Medical support orders issued by a state agency qualified medical child support order (QMCSO) child support order Disabled dependent A dependent of any age (who falls under one of the Certificate of Incapacitation for Dependent Child form must be submitted prior to the categories previously listed) and due to a mental dependent’s 26th birthday. or physical disability, is unable to earn a living. The dependent’s disability must have begun before age The insurance carrier will review the form, make a determination, and provide BA with 26 and while covered under a state-sponsored plan. documentation once a determination has been made. If approved for incapacity, the child will continue the same coverage. Never send original documents. Please mark out or black out any social security numbers and any personal financial information on the copies of your documents BEFORE you return them.
Revised 07/20
-4- Children who are mentally or physically disabled and not able to earn a living may continue coverage beyond age 26 if they were disabled before their 26th birthday and they were already insured under the State Group Insurance Program. The child must meet the requirements for dependent eligibility. A request for extended coverage must be provided to Benefits Administration before the dependent’s 26th birthday. The insurance carrier will decide if a dependent is eligible based on disability. Coverage will end and will not be restored once the child is no longer disabled.
An employee may not be enrolled as both head of contract and dependent within the State Plan. A newly hired employee can choose coverage for his/her spouse as a dependent when that spouse is an eligible employee who declined coverage when first eligible. The employee’s spouse will have dependent status unless he/she requests to change during the annual enrollment period or later qualifies under the special enrollment provisions. The spouse who is also an employee, however, may only apply as an employee for the voluntary term life insurance program. Enrollment and Effective Date of Coverage
As a new employee, your eligibility date is your hire date. You must complete enrollment within 31 days after your hire date. Coverage starts on the first day of the month after you complete one full calendar month of employment, except for voluntary term life insurance. Voluntary term life insurance will become effective after you have completed three full calendar months of employment.
If you are a part-time employee who has completed one full calendar month of employment and then gain full-time status, your coverage will start the first day of the month after gaining full-time status. Newly eligible employees must submit an Enrollment Change Application within 31 calendar days of the date of the status change, but you should make the request as soon as possible to avoid the possibility of double premium payroll deductions.
You must be in a positive pay status (i.e., any type of approved leave with pay) on the day your Positive Pay Status — Being coverage begins. If you do not enroll in health coverage by the end of your enrollment period, paid even if you are not actually you must wait for the annual enrollment period, unless you have a qualifying event during the performing your normal work year. Refer to the special enrollment provisions on pages 7-8 of this guide for more information. duties. This is related to any type of approved leave with pay. A dependent’s coverage starts on the same date as yours unless newly acquired. The application to add a newly acquired dependent (tn.gov/content/dam/tn/finance/fa-benefits/ documents/1043_2020.pdf) must be submitted within 60 days of the acquire date.
Family coverage based on enrolling newly acquired dependent children due to birth, adoption or legal custody must begin on the first day of the month in which the event occurred and the children shall be eligible for coverage on the date they were acquired. Coverage for an adopted child begins when the child has been adopted or has been placed for adoption.
If enrolled in single coverage and adding a newly acquired spouse, you may choose to begin family coverage on the first day of the month in which your spouse was acquired or the first day of the following month. Depending on the date you choose, your newly acquired spouse will be covered beginning with the acquire date (date of marriage) or the first day of the following month.
Insurance cards will be mailed to you three to four weeks after your application is processed. You may call the insurance carrier to ask for extra cards or print a temporary card from the carrier’s website.
Choosing a Premium Level (Tier) There are four premium levels for health, dental and vision coverage. You may choose the same or different levels for health, dental and vision. • Employee Only Family Coverage — Is any coverage • Employee + Child(ren) level other than “Employee Only.” • Employee + Spouse • Employee + Spouse + Child(ren)
-5- If you enroll as a family, which is any coverage level other than Employee Only, all of you must enroll in the same health, dental and vision options. However, if you are married to an employee who is also a member of the state, local education or local government plan, you can each enroll in Employee Only coverage if you are not covering dependent children. If you have children, one of you can choose Employee Only and the other can choose Employee + Child(ren). Then you can each choose your own benefit option and carrier.
If you are in the State Plan and your spouse is also in the State Plan, you both may want to think about choosing coverage as the head of contract. State Plan employees can get a higher level of basic term life insurance coverage as the head of contract. Refer to the available benefits section of this guide beginning on page 13 for more information.
Edison Employee Self Service (ESS) Instructions You will need to log in to Edison at https://hub.edison.tn.gov/psp/paprd/EMPLOYEE/EMPL/h/?tab=PAPP_GUEST to enroll. Instructions for enrolling are available at tn.gov/partnersforhealth. Click on the For New Employees tile and then look under Resources for State Employee Self Service (ESS) Instructions.
If you have trouble logging in to Edison, go to the Edison home page and instead of clicking on the red Portal Login button, click on the First Time Login/New Hire blue button. It will take you to a page where you can verify your identity and receive your access ID. Active State of Tennessee employees can call the Edison Help Desk for password assistance at 866.376.0104.
Premium Payment For state and higher education employees, the state pays about 80% of the cost of your Pre-tax Premiums — State employee health insurance premium if you are in a positive pay status or on approved family medical premiums for health, dental and vision leave. If you are approved for worker’s compensation and receiving pay for lost time, the are paid before income or Social Security state pays the entire health insurance premium. tax is deducted. Insurance premiums are taken from the paycheck you get at the end of each month to pay Pre-tax premiums reduce an employee’s for the next month’s coverage. taxable income because they are taken out before taxes are withheld. Voluntary coverages, such as dental, disability and vision, get no state support, and you must pay the total premium.
The plan permits a 30-day deferral of premium for premiums being billed directly instead of through payroll deduction. If the premium is not paid at the end of that deferral period, coverage will be cancelled back to the date you last paid a premium. There is a provision for restoring your coverage through a one-time opportunity for coverage reinstatement.
Premiums are not prorated. You must pay the premium for the entire month in which the effective date occurs and for each covered month thereafter.
Adding New Dependents Enrollment must be completed within 60 days of the date a dependent is acquired (tn.gov/ content/dam/tn/finance/fa-benefits/documents/1043_2020.pdf). The “acquire date” is the Add Dependents — Within 60 days date of birth, marriage, or, in case of adoption, when a child is adopted or placed for adoption. of the acquire date/Within 40 days Premium changes start on the first day of the month in which the dependent was acquired or for qualified medical support order the first day of the following month, depending on the coverage start date.
An employee’s child named under a qualified medical support order must be added within 40 days of the court order.
If adding dependents while on Employee Only coverage, you must request the correct family coverage level for the month the dependent was acquired so claims are paid for that month. This change is retroactive, and you must pay the premium for the entire month each month the dependent is insured.
-6- To add a dependent more than 60 days after the acquire date, the following rules apply based on the type of coverage you currently have:
If you have Employee Only coverage
• The new dependent can enroll if they have a qualifying event under the special enrollment provisions or during the annual enrollment period.
If you have family coverage
• The new dependent can enroll if they have a qualifying event under the special enrollment provisions or during the annual enrollment period. • The new dependent can also enroll if the level of family coverage you had on the date the dependent was acquired was sufficient to include that dependent without requiring a premium increase. You must have maintained that same level of family coverage without a break. The dependent’s coverage start date may go back to the acquire date in this case.
More information is provided under the special enrollment provisions section of this guide, starting on page 9.
Updating Personal Information State employees can update personal information in Edison, or by contacting their agency benefits coordinator or human resources offices. Higher education employees can update information in Edison, contact their agency benefits coordinators or call the Benefits Administration service center (800.253.9981 or 615.741.3590) to request an address or email address change.
All employees who contact Benefits Administration will be required to provide their Social Security number or Edison ID, date of birth, previous address and confirm authorization of the change before Benefits Administration (BA) can update the information.
It is your responsibility to keep your address, phone number and email address current with your employer.
Annual Enrollment Period During the fall of each year, benefit information is mailed to you and provided in detail on our Partners for Health website at tn.gov/partnersforhealth. Review this information carefully to make the best decisions for you and your family members. The annual enrollment period gives you a chance to enroll in health, dental, vision, voluntary accidental death coverage, voluntary term life and disability insurance coverage. You can also make changes to your existing coverage, like increasing or decreasing voluntary term life insurance, transferring between health, dental, disability and vision options and cancelling insurance.
During the annual enrollment period, state employees (does not include higher education employees) MUST choose health savings account (HSA) amounts and all employees MUST choose flexible spending account (FSA) election amounts if you want to put money in them for the next year.
Most changes you request start the following January 1. However, voluntary term life and disability insurance may start January 1, February 1 or March 1. This is because the insurance carriers may need to review your medical history to determine if you qualify for coverage.
Benefit enrollments remain in effect for a full year (January 1 through December 31). However, you may cancel disability and voluntary term life coverage at any time. You may not cancel other coverage outside of the enrollment period unless eligibility is lost or there is a qualifying event. For more information, see the section on cancelling coverage below.
-7- Cancelling Coverage Outside of the annual enrollment period, you can only cancel coverage (other than disability and voluntary term life insurance) for yourself and/or your covered dependents, IF: 60-day Deadline — • You lose eligibility for the State Group Insurance Program (e.g., changing from full-time to part-time) Read details at left • You experience a special qualifying event, family status change or other qualifying event as approved by Benefits Administration
You must notify your agency benefits coordinator of any event that causes you or your dependents to become ineligible for coverage. You must repay any claims paid in error. Refunds for any premium overpayments are limited to three months from the date notice is received.
When cancelled for loss of eligibility, coverage ends the last day of the month eligibility is lost. For example, coverage for adopted children ends when the legal obligation ends. Insurance continued for a disabled dependent child ends when he/she is no longer disabled or at the end of the 31-day period after any requested proof is not given.
Divorce — If you request to terminate coverage of a dependent spouse while a divorce case is pending, such termination will be subject to laws and court orders related to the divorce or legal separation. This includes the requirements of Tennessee Code Annotated Section 34-4-106 and the requirement that you provide notice of termination of health insurance to your covered dependent spouse under Tennessee Code Annotated Section 56-7-2366. As the employee, it is your responsibility to make sure that any request to terminate your dependent spouse is consistent with those legal requirements.
Cancelling coverage in the middle of the plan year —You may only cancel coverage for yourself and/or your dependents in the middle of the plan year if you lose eligibility or you experience an event that results in you/your dependents becoming newly eligible for coverage under another plan. There are no exceptions. You have 60 days from the date that you and/or your dependents become newly eligible for other coverage to turn in an application and proof to your agency benefits coordinator (https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/1047_2020.pdf). The required proof is shown on the application. Events that might result in becoming newly eligible for coverage elsewhere are: • Marriage, divorce, legal separation, annulment • Birth, adoption/placement for adoption • Death of spouse, dependent • New employment, return from unpaid leave, change from part-time to full-time employment (spouse or dependents) • Entitlement to Medicare, Medicaid or TRICARE • Court decree or order • Annual enrollment • Change in place of residence or workplace out of the national service area (i.e., move out of the U.S.) • Marketplace enrollment (Marketplace enrollments are those offered under the Patient Protection and Affordable Care Act (PPACA)
Once your application and required proof are received, the coverage end date will be either: • The last day of the month before the eligibility date of other coverage • The last day of the month that the event occurred
You may request to cancel the Prepaid Dental Plan if there is no participating general dentist within a 25-mile radius of your home address. If you request to cancel disability coverage, 30 days advance written notice is required.
-8- Transferring Between Plans Members eligible for coverage under more than one state-sponsored plan may transfer between the state, local education and local government plans. You may apply for a transfer during the plan’s designated enrollment period with an effective date of January 1 of the following year. In no case may you transfer to another state-sponsored plan and remain on your current plan as the head of contract.
If You Don’t Apply When First Eligible If you do not enroll in health coverage when you are first eligible, you must wait for the annual enrollment period. You can also apply during the year through special enrollment due to certain life events.
Special Enrollment Provisions The Health Insurance Portability and Accountability Act (HIPAA) is a federal law. It allows you to enroll in a group health plan due to certain life events or loss of eligibility under another plan. The State Group Insurance Program will consider special enrollment requests for health, dental, disability, voluntary term life and vision insurance coverage.
An employee experiencing one of the events below may enroll in employee only or family coverage. Previously eligible dependents (those who were not enrolled when initially eligible and are otherwise still eligible) may also be enrolled. Submission of medical history will be required by the disability and voluntary term life insurance carriers to determine your qualification for coverage.
• A new dependent spouse is acquired through marriage • A new dependent is acquired through birth • A new dependent is acquired through adoption or legal custody
You must make the request within 60 days of acquiring the new dependent (https://www.tn.gov/content/dam/tn/finance/fa- benefits/documents/1043_2020.pdf). You must also submit proof, as listed on the enrollment application, to show: • The date of the birth • The date of placement for adoption 60-day Deadline — Read details at left • The date of marriage
The above events are subject to special enrollment ONLY IF you want to use the event to enroll yourself or you already have coverage and want to add other previously eligible dependents at the same time as the new dependent. If you already have coverage and only want to add a newly acquired dependent, this is treated as a regular enrollment change.
Options for coverage start dates due to the events above are: • Day on which the event occurred if enrollment is due to birth, adoption or placement for adoption • Day on which the event occurred or the first day of the next month if enrollment is due to marriage
-9- Other events allow enrollment based on a loss of coverage under another plan: • Death of a spouse or ex-spouse • Divorce • Legal separation • Loss of eligibility (does not include loss due to failure to pay premiums or termination of coverage for cause) • Termination of spouse’s or ex-spouse’s employment • Employer ends total premium support to the spouse’s, ex-spouse’s or dependent’s insurance coverage (not partial) • Spouse’s or ex-spouse’s work hours reduced • Loss of coverage due to exhausting lifetime benefit maximum • Loss of TennCare (does not include loss due to non-payment of premiums)
Applications for the above events must be made within 60 days of the loss of the insurance coverage.
You must submit proof as required to show ALL of the following: • A qualifying event has occurred • You and/or your dependents were covered under another group health plan at the time of the event • You and/or your dependents may not continue coverage under the other plan
If enrolling due to loss of coverage under another plan, options for coverage start dates are: • The day after the loss of other coverage, or • The first day of the month following loss of other coverage Important Reminders • If you are enrolling dependents who qualify under the special enrollment provisions, you may choose to change to another carrier or health option, if eligible • If you or your dependents had COBRA continuation coverage under another plan and coverage has been exhausted, enrollment requirements will be waived if application is received within 60 days of the loss of coverage • Loss of eligibility does not include a loss due to failure of the employee or dependent to pay premiums on a timely basis or termination of coverage for cause
-10- CONTINUING COVERAGE DURING LEAVE OR AFTER TERMINATION
Extended Periods of Leave Family and Medical Leave Act (FMLA) FMLA allows you to take up to 12 weeks of leave during a 12-month period for things like a serious illness, the birth or adoption of a child or caring for a sick spouse, child or parent. If you are on approved family and medical leave, you will continue to get state support of your health insurance premium. Initial approval for family and medical leave is up to each agency head. You must have completed a minimum of 12 months of employment and worked 1,250 hours in the 12 months immediately before the onset of leave. Cancelation due to failure to pay premiums does not apply to FMLA.
Leave Without Pay — Health Insurance Continued If continuing coverage while on an approved leave of absence, you must pay the total monthly health insurance premium once you have been without pay for one full calendar month. You will be billed at home each month for your share and the employer’s share. The maximum period for a leave of absence is two continuous years. At the end of the two years, you must immediately report back to work for no less than one full calendar month before you can continue coverage during another leave of absence. If you do not immediately return to work at the end of two years of leave, coverage is cancelled, and COBRA eligibility will not apply.
Leave Without Pay — Insurance Suspended You may suspend coverage while on leave if your premiums are paid current. All insurance programs are suspended, including any voluntary coverage. The $20,000 basic term life and the $40,000 basic accidental death coverages provided at no cost to all eligible employees will remain in effect. You may reinstate coverage when you return to work. If cancelled for nonpayment, you must wait for the next annual enrollment period to re-enroll unless you have a qualifying event under the special enrollment provisions during the year.
To Reinstate Coverage After You Return You must submit an application to your agency benefits coordinator within 31 days of your return to work. You must enroll in the same health option you had before. If you do not enroll within 31 days of your return to work, you must wait for the next annual enrollment period to re-enroll unless you have a qualifying event under the special enrollment provisions during the year. Coverage goes into effect the first day of the next month after you return to work. There are additional requirements for the disability insurance that may be found in the sample certificate of coverage.
If you and your spouse are both insured with the State Group Insurance Program, you can be covered by your spouse as a dependent during your leave of absence. Any deductibles or out-of-pocket expenses will be transferred to the new contract. To transfer coverage, submit an enrollment application to suspend your coverage. Your spouse should submit an enrollment application to add you as a dependent. Benefits Administration must be contacted to assist with this change and to transfer deductibles and out-of-pocket expenses.
Reinstatement for Military Personnel Returning from Active Service An employee who returns to work after active military duty may reinstate coverage on the earliest of the following: • The first day of the month, which includes the date discharged from active duty • The first of the month following the date of discharge from active duty • The date returning to active payroll • The first of the month following return to the employer’s active payroll
If restored before returning to the employer’s active payroll, you must pay 100 percent of the total premium. In all instances, you must pay the entire premium for the month.
Reinstatement of coverage is not automatic. Military personnel must re-apply within 90 days from the end of leave.
-11- Leave Due to a Work-related Injury If you have a work-related injury or illness, contact your agency benefits coordinator about how this will affect your insurance. You must keep insurance premiums current until you receive a notice of lost-time pay from the Division of Claims Administration. You will receive a refund for any health insurance payments you make once you receive notice.
If approved for lost-time pay, only the premium for health insurance is paid by your agency. You must pay the premium for any voluntary coverage on a monthly basis. You are responsible for 100% of the premium when lost-time pay ends if you do not have any paid leave. Lost-time Pay — Payments received due to lost time (without All benefits paid by the plan for work-related injury or illness claims will be recovered. This pay) caused by an approved work- means that you are required to repay all claims paid related to a work-related injury. related injury. Approved by the Department of Treasury, Division of Termination of Employment Claims Administration. Your insurance coverages end when your agency terminates your employment and the information is sent to Benefits Administration. • State employees: If your last day worked is the last day of the month, your coverage will end on the last day of the following month. If your last day worked is any date other than the last day of the month, your coverage will end on the last day of the current month. Disability insurance will end after your last day worked. • Higher education employees: Coverage will end on the last day of the month following the month you terminate employment. Disability insurance will end after your last day worked.
A COBRA notice to continue health, dental and/or vision coverage (depending upon your enrollment as an active employee) will be mailed to you. Disability and life insurance conversion notices will also be mailed, if applicable.
If your spouse is also insured as a head of contract under either the state, local education or local government plan, you have the option to transfer to your spouse’s contract as a dependent. Application must be made within one full calendar month of your termination of employment.
Continuing Coverage through COBRA You may be able to continue health, dental and/or vision insurance coverage under the Consolidated Omnibus Budget Reconciliation Act. This is a federal law known as COBRA. This law allows employees and dependents whose insurance would end to continue the same benefits for specific periods of time. Persons may continue health, dental and/or vision insurance if: • Coverage is lost due to a qualifying event (refer to the COBRA brochure at tn.gov/content/dam/tn/finance/fa-benefits/ documents/cobra.pdf on our website for a list of events) • You are not insured under another group health plan as an employee or dependent
BA will send you a COBRA packet to the address on file within 7-10 days after receiving notification of your coverage ending. Make sure your correct home address is on file with your agency benefits coordinator. You have 60 days from the date coverage ends or the date of the COBRA notice, whichever is later, to return your application to Benefits Administration. Coverage will be restored immediately if premiums are sent with the application. If you do not receive a letter within 30 days after your insurance ends, you should contact Benefits Administration.
Continuing Coverage at Retirement Please note that under TCA 8-27-205, your initial employment with the state or participating local education agency must have commenced prior to July 1, 2015 in addition to other eligibility criteria. There are separate eligibility guides for retirement insurance. The Guide to Continuing Insurance at Retirement for State and Higher Education is available on the Partners for Health website under “Publications” at tn.gov/partnersforhealth.
-12- Coverage for Dependents in the Event of Your Death If you die while actively employed, your covered dependents will be offered continuation of whatever State health, dental and vision insurance they have on the date of your death. Your dependents may also be able to convert life insurance.
Health — Your covered dependents get six months of health coverage at no cost. After that, your dependents may continue health coverage under COBRA for a maximum of 36 months, as long as they remain eligible. Instead of COBRA, your eligible dependents may continue coverage through retiree group health if you meet the eligibility criteria for continuation of coverage as a retiree at the time of your death.
If you are a member of the Tennessee Consolidated Retirement System (TCRS), election of a monthly pension benefit is one of the required criteria to continue insurance for your covered dependents on the retiree plan if you die. Your covered dependents do not have to be the pension beneficiaries, but if either you or your designated pension beneficiary elected to take a lump sum pension payout, this will result in your surviving dependents losing the right to continue retiree health insurance coverage even if the other eligibility criteria are met.
If eligible, premiums for continued coverage of your eligible surviving dependents will be deducted from your monthly TCRS pension check if a covered dependent is your designated pension beneficiary. Covered surviving dependents must submit insurance premiums directly to Benefits Administration if your TCRS pension check is insufficient to cover the premiums or if your designated pension beneficiary is someone other than a dependent covered on your insurance at the time of your death.
Dental and Vision — Your dependents may be eligible for continuation of dental and vision coverage through COBRA or the retirement program as outlined below.
Your surviving dependents covered under your dental and/or vision plan on the date of your death may continue their enrollment in the plan with one of the two options listed below. (Note: Your dependents must continue enrollment in the retiree health plan to be able to continue retiree vision insurance.)
• If you are eligible for continuation of coverage as a retiree at the time of your death, your dependents may elect COBRA or retiree continuation of dental and/or vision elections in effect for them on the date of your death • If you are not eligible for continuation of coverage as a retiree at the time of your death, your dependents may elect COBRA continuation for dental and/or vision elections in effect for them on the date of your death.
All eligibility questions to continue coverage for surviving dependents on the state plans should be directed to Benefits Administration.
If You Die in the Line of Duty Your covered dependents will get six months of health coverage at no cost. After that, they Line of Duty — An employee on may only continue health coverage at an active employee rate until they become eligible the job in a positive pay status; as for other insurance coverage or they no longer meet the dependent eligibility rules. determined by the State Division of Claims Administration in the If You Are Covered Under COBRA Department of Treasury. Your covered dependents will have up to a total of 36 months of COBRA, provided they continue to meet the eligibility requirements.
-13- -14- AVAILABLE BENEFITS
Health Insurance You have a choice of three health insurance options: • Premier Preferred Provider Organization (PPO) • Standard PPO • Consumer-driven Health Plan (CDHP)/Health Savings Account (HSA)
You also have a choice of three insurance carrier networks. There are two narrow networks, BlueCross BlueShield Network S and Cigna LocalPlus, which exclude some providers to keep premiums and rate increases low. There is also one broad network, Cigna Open Access Plus (OAP), for maximum choice. • BlueCross BlueShield (BCBST) Network S • Cigna LocalPlus Network • Cigna Open Access Plus Network – is a broad network with the most providers in Tennessee. OAP gives you access to more providers than the other networks but this broad choice costs more. You pay a monthly surcharge: $40 for employee only and employee+child(ren)/$80 for employee+spouse and employee+spouse+child(ren)
With each health insurance option, you can see any doctor you want. However, each carrier network has a list of doctors, hospitals and other healthcare providers that you are encouraged to use. The in-network providers have agreed to take lower fees for their services. Your cost is higher if you use out-of-network providers.
Network providers and facilities can and do change. Benefits Administration cannot guarantee that all providers and hospitals that are in a network when you enroll will stay in that network. A provider or hospital leaving a network is not a qualifying event and does not allow you to make changes.
Each health insurance option: • Provides the same comprehensive health insurance coverage (although medical policies for specific services may vary between carriers) • Includes in-person and Telehealth medical services through PhysicanNow or MDLive programs sponsored by BCBST and Cigna • Covers in-network preventive care (like annual well visits and routine screenings) at no cost to you • Covers maintenance prescription drugs without having to first meet a deductible • Has a deductible • Has out-of-pocket maximums to limit your costs
There are some differences between the PPOs and the CDHP: With the PPOs • You pay a higher monthly premium but have a lower deductible • You pay fixed copays for doctor office visits and prescription drugs without first having to meet your deductible
With the CDHP/HSA • You pay a lower monthly premium but have a higher deductible • You pay the full discounted network cost for ALL healthcare expenses, except for in-network preventive care and certain maintenance drugs, until you meet your deductible • You have a tax-free HSA which can be used to cover your qualified medical expenses, including your deductible
-15- CDHP/HSA If you enroll in this option, the state will deposit $250 for employee only coverage or $500 for family coverage into your HSA. If your coverage effective date is September 2 through the end of the year, you will not receive the state contribution towards your HSA.
Health Savings Account If you enroll in the CDHP, a HSA will be set up for you. You can contribute pre-tax money to your HSA through payroll deduction to cover your qualified medical expenses, including your deductible, or save it. For example, you could take the money you save in premiums for this plan versus a PPO and put it in your HSA. The HSA is managed by Optum Bank, a company selected and contracted by the state.
Benefits of a HSA • The money you save in the HSA (both yours and any employer contributions) rolls over each year and collects interest. You don’t lose it at the end of the year. • You can use money in your account to pay your deductible and qualified medical, behavioral health, vision and dental expenses. • The money is yours. You take your HSA with you if you leave or retire. • The HSA offers a triple tax advantage on money in your account: 1. Both employer and employee contributions are tax free
2. Withdrawals for qualified medical expenses are tax free
3. Interest accrued on HSA balance is tax free
• The HSA can be used to pay for qualified medical expenses that may not be covered by your health insurance plan (like vision and dental expenses, hearing aids, contact lens supplies and more) with a great tax advantage. • It serves as another retirement savings account option. Money in your account can be used tax free for health expenses even after you retire. And, when you turn 65, it can be used for non-medical expenses. But non-medical expenses will be taxed.
Contribution Limits • IRS guidelines allow total tax-free annual contributions up to $3,600 for individuals and $7,200 for families in 2021. • At age 55 and older, you can make an additional $1,000/year contribution.
These limits include the $250 individual and $500 family state contributions.
Your full HSA contribution is not available upfront at the beginning of the year or after you enroll. Your pledged amount is taken out of each paycheck each pay period. You may only spend the money that is available in your HSA at the time of service or care.
Enrolling in Social Security at age 65 automatically triggers Medicare Part A enrollment. If enrolled in a CDHP, this may have tax consequences and affect your HSA contribution.
Consult with your tax advisor for advice.
CDHP/HSA Restrictions You cannot enroll if you are enrolled in another plan, including a PPO, your spouse’s plan or any government plan (e.g., Medicare A and/or B, Medicaid, TRICARE, Social Security benefits), or if you have received care from any Veterans Affairs (VA) facility or the Indian Health Services (IHS) within the past three months. Generally, members receiving free care at any VA facility cannot enroll in the CDHP because a HSA is automatically opened for them. Individuals are not eligible to make HSA contributions for any month if they receive medical benefits from the VA at any time during the previous three months. However, members may be eligible if they did not receive any care from a VA facility for three months, or member only receives care from a VA facility for a service- connected disability (it must be a disability). Go to https://www.irs.gov/irb/2004-33_IRB/ar08.html for HSA eligibility information.
-16- HSA and FSA Restrictions You cannot enroll in the CDHP/HSA if either you or your spouse have a medical flexible spending account (FSA) or health reimbursement account (HRA) at either employer. But if your employer offers one, you can have a limited purpose FSA (L-FSA) for vision or dental expenses along with your HSA.
Pharmacy Pharmacy benefits are included when you and your dependents enroll in a health plan. The plan you choose determines the out- of-pocket prescription costs. Specialty drugs must be filled through a Specialty Network Pharmacy and can only be filled every 30 days.
There are lower out-of-pocket costs on a large group of maintenance drugs. To pay the lower price for these certain medications, you must use the special, less costly Retail-90 network (pharmacy or mail order) and fill a 90-day supply of your medication. The maintenance tier list includes certain medications for high blood pressure, high cholesterol, coronary artery disease, congestive heart failure, depression, asthma/chronic obstructive pulmonary disease (COPD), diabetes (oral medications, insulins, needles, test strips and lancets) and some osteoporosis medications.
Eligible members will be able to receive certain low-dose statins in-network at zero cost share. These medications are primarily used to treat high cholesterol. No high dose or brand statins are included.
Any and all compound medications (as determined by the pharmacy benefits manager) must be processed electronically. Paper claims will not be reimbursed and will be denied. In addition, many compound medications require prior authorization by the pharmacy benefits manager before claims processing and determination on payment will occur.
Members won’t have to pay for some specific medications used to treat opioid dependency.
Basic Features of the Health Options
In-network PPOs (Premier & Standard) CDHP/HSA Covered Services Each option covers the same set of services Preventive Care — routine screenings and preventive Covered at 100% (no deductible) care Employee Contribution — premium Higher than the CDHP Lower than the PPOs Deductible — the dollar amount of covered services Lower than the CDHP Higher than the PPOs you must pay each calendar year before the plan begins reimbursement Physician Office Visits — includes specialists and You pay fixed copays without having to first You pay the discounted network cost until the behavioral health and substance use services meet your deductible deductible is met, then you pay coinsurance Non Office Visit Medical Services— hospital, You pay the discounted network cost until the deductible is met, then you pay coinsurance surgical, therapy, ambulance, advanced x-rays Prescription Drugs You pay fixed copays without having to first You pay for the medication at the discounted meet your deductible network cost until your deductible is met — then you pay coinsurance until you meet the out-of-pocket maximum Out-of-Pocket Maximum — The most you pay for Higher than the CDHP Lower than the PPOs covered services; once you reach the out-of-pocket maximum, the plan pays 100% Health Savings Account None The state will contribute $250 for single coverage and $500 for family coverage to help offset the deductible — your contributions are pre-tax
-17- 2021 Benefit Comparison PPO services in this table ARE NOT subject to a deductible. CDHP/HSA services in this table ARE subject to a deductible with the exception of in-network preventive care and 90-day supply maintenance medications. In the table, $ = your copayment amount; % = your coinsurance; and 100% covered or No charge = you pay $0 in-network. See footnote on page 19.
Note: This grid is available in a one-page, easy-to-use format at this link on the Benefits Administration website: https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/benefit_grid_2021_st_he_final.pdf
HEALTHCARE OPTION PREMIER PPO STANDARD PPO Member Costs Member Costs COVERED SERVICES IN-NETWORK [1] OUT-OF-NETWORK [1] IN-NETWORK [1] OUT-OF-NETWORK [1] PREVENTIVE CARE — OFFICE VISITS Well-baby, well-child visits as recommended No charge $45 No charge $50 Adult annual physical exam Annual well-woman exam Immunizations as recommended Annual hearing and non-refractive vision screening Screenings including Pap smears, labs, nutritional guidance, tobacco cessation counseling and other services as recommended OUTPATIENT SERVICES — SERVICES SUBJECT TO A COINSURANCE MAY BE EXTRA Primary Care Office Visit $25 $45 $30 $50 Family practice, general practice, internal medicine, OB/ GYN and pediatrics Nurse practitioners, physician assistants and nurse midwives (licensed healthcare facility only) working under the supervision of a primary care provider Including surgery in office setting and initial maternity visit Specialist Office Visit $45 $70 $50 $75 Including surgery in office setting Nurse practitioners, physician assistants and nurse midwives (licensed healthcare facility only) working under the supervision of a specialist Behavioral Health and Substance Use [2] $25 $45 $30 $50 Including virtual visits Telehealth (approved carrier programs only) $15 N/A $15 N/A Allergy Injection Without an Office Visit 100% covered 100% covered up to MAC 100% covered 100% covered up to MAC Chiropractic and Acupuncture Visits 1-20: $25 Visits 1-20: $45 Visits 1-20: $30 Visits 1-20: $50 Limit of 50 visits of each per year Visits 21-50: $45 Visits 21-50: $70 Visits 21-50: $50 Visits 21-50: $75 Convenience Clinic $25 $45 $30 $50 Urgent Care Facility $45 $70 $50 $75 Emergency Room Visit $150 $175 PHARMACY 30-Day Supply $7 generic; copay plus amount $14 generic; copay plus amount $40 preferred brand; exceeding MAC $50 preferred brand; exceeding MAC $90 non-preferred $100 non-preferred 90-Day Supply (90-day network pharmacy or mail $14 generic; N/A - no network $28 generic; N/A - no network order) $80 preferred brand; $100 preferred brand; $180 non-preferred $200 non-preferred 90-Day Supply (certain maintenance medications from $7 generic; N/A - no network $14 generic; N/A - no network 90-day network pharmacy or mail order) [3] $40 preferred brand; $50 preferred brand; $160 non-preferred $180 non-preferred Specialty Medications (30-day supply from a specialty 10%; N/A - no network 10%; N/A - no network network pharmacy) min $50; max $150 min $50; max $150
-18- 2021 Monthly Premiums for Health
ALL REGIONS
CDHP/HSA BCBST CIGNA CIGNA EMPLOYER Member Costs LOCALPLUS OPEN ACCESS SHARE IN-NETWORK [1] OUT-OF-NETWORK [1] PREMIER PPO Employee Only $140 $140 $180 $558 No charge 40% Employee + Child(ren) $210 $210 $250 $837 Employee + Spouse $292 $292 $372 $1,172 Employee + Spouse + Child(ren) $362 $362 $442 $1,451 STANDARD PPO Employee Only $95 $95 $135 $558 Employee + Child(ren) $143 $143 $183 $837 Employee + Spouse $200 $200 $280 $1,172 Employee + Spouse + Child(ren) $248 $248 $328 $1,451 20% 40% CDHP/HSA Employee Only $62 $62 $102 $558 Employee + Child(ren) $91 $91 $131 $837 Employee + Spouse $129 $129 $209 $1,172 Employee + Spouse + Child(ren) $158 $158 $238 $1,451
20% 40%
20% 40%
20% N/A 20% 40% 20% 40%
20% 40% 20% 40% 20%
20% 40% plus amount exceeding MAC
20% N/A - no network
10% without first having N/A - no network to meet deductible
20% N/A - no network
-19- 2021 Benefit Comparison, continued PPO services in this table ARE subject to a deductible unless noted with a [5]. CDHP/HSA services in this table ARE subject to a deductible with the exception of in-network preventive care. In the table, % = your coinsurance. See footnote on page 19.
Note: This grid is available in a one-page, easy-to-use format at this link on the Benefits Administration website: https://www.tn.gov/content/dam/tn/finance/fa-benefits/documents/benefit_grid_2021_st_he_final.pdf
HEALTHCARE OPTION PREMIER PPO STANDARD PPO Member Costs Member Costs COVERED SERVICES IN-NETWORK [1] OUT-OF-NETWORK [1] IN-NETWORK [1] OUT-OF-NETWORK [1] PREVENTIVE CARE — OUTPATIENT FACILITIES Screenings including colonoscopy, mammogram, No charge [5] 40% No charge [5] 40% colorectal, bone density scans and other services as recommended OTHER SERVICES Hospital/Facility Services [4] 10% 40% 20% 40% Inpatient care; outpatient surgery Inpatient behavioral health and substance use [2] [6] Maternity 10% 40% 20% 40% Global billing for labor and delivery and routine services beyond the initial office visit Home Care [4] 10% 40% 20% 40% Home health; home infusion therapy Rehabilitation and Therapy Services 10% 40% 20% 40% Inpatient and skilled nursing facility [4]; outpatient Outpatient IN-NETWORK physical, occupational and speech therapy [5] X-Ray, Lab and Diagnostics (not including advanced 10% 20% x-rays, scans and imaging) [5] Advanced X-Ray, Scans and Imaging 10% 40% 20% 40% Including MRI, MRA, MRS, CT, CTA, PET and nuclear cardiac imaging studies [4] All Reading, Interpretation and Results [5] 10% 20% Ambulance (Air and ground) 10% 20% Equipment and Supplies [4] 10% 40% 20% 40% Durable medical equipment and external prosthetics Other supplies (i.e., ostomy, bandages, dressings) Also Covered Certain limited Dental benefits, Hospice Care and Out-of-Country Charges are also covered subject to applicable deductible and coinsurance. DEDUCTIBLE Employee Only $500 $1,000 $1,000 $2,000 Employee + Child(ren) $750 $1,500 $1,500 $3,000 Employee + Spouse $1,000 $2,000 $2,000 $4,000 Employee + Spouse + Child(ren) $1,250 $2,500 $2,500 $5,000 OUT-OF-POCKET MAXIMUM – MEDICAL AND PHARMACY COMBINED – ELIGIBLE EXPENSES, INCLUDING DEDUCTIBLE, COUNT TOWARD THE OUT-OF-POCKET MAXIMUM Employee Only $3,600 $4,000 $4,000 $4,500 Employee + Child(ren) $5,400 $6,000 $6,000 $6,750 Employee + Spouse $7,200 $8,000 $8,000 $9,000 Employee + Spouse + Child(ren) $9,000 $10,000 $10,000 $11,250 CDHP STATE HEALTH SAVINGS ACCOUNT (HSA) CONTRIBUTION For individuals who enroll in the CDHP/HSA N/A N/A
-20- CDHP/HSA Using Edison ESS Member Costs Edison is the State of Tennessee’s Enterprise Resource Planning (ERP) system. When IN-NETWORK [1] OUT-OF-NETWORK [1] using Employee Self Service (ESS) in Edison on your computer to add/make changes to benefits, Internet Explorer 11 is the preferred browser. You may also enroll on your No charge 40% smart phone or mobile device.
Passwords If you have trouble logging in to Edison, go to the Edison home page and click on 20% 40% the Retrieve Access ID button if you have logged in before and don’t remember your Access ID, or click the First Time Login / New Hire link if you have never logged in before. If you know your Access ID but need to reset your password, click the red 20% 40% Employee Portal Login button, enter your Access ID, and click Continue. Then click the link that says Forgot your Password? You can also view helpful troubleshooting videos 20% 40% on the Partners for Health website at https://www.tn.gov/partnersforhealth/videos. html. 20% 40% • Active State of Tennessee employees can call the Edison Help Desk for password assistance at 866.376.0104. • Higher Education employees can call the Benefits Administration Service Center at 20% 40% 800.253.9981 or 615.741.3590.
20% 40%
20% 20% Only eligible expenses will apply toward the deductible and out-of-pocket maximum. Charges for non- 20% 40% covered services and amounts exceeding the maximum allowable charge (MAC) will not be counted. For PPO Plans, no single family member will be subject to a deductible or out-of-pocket maximum greater than the “employee only” amount. Once two or more family members (depending on premium level) have met the total deductible and/or out-of-pocket maximum, it will be met by all covered family members. For CDHP Plan, the deductible and out-of-pocket maximum amount can be met by one or See separate sections in the Member Handbook for details. more persons but must be met in full before it is considered satisfied. See the “Out of Pocket Maximums” section in the Member Handbook for more details. For CDHP Plan, coinsurance is after deductible is met unless otherwise noted. $1,500 $3,000 [1] Subject to maximum allowable charge (MAC). The MAC is the most a plan will pay for a covered service. For non-emergent care from an out-of-network provider who charges more than the MAC, $3,000 $6,000 you will pay the copay or coinsurance PLUS the difference between MAC and actual charge. $3,000 $6,000 [2] The following behavioral health services are treated as “inpatient” for the purpose of determining member cost-sharing: residential treatment, partial hospitalization/day treatment programs and $3,000 $6,000 intensive outpatient therapy. In addition to services treated as “inpatient,” prior authorization (PA) is required for certain outpatient behavioral health services including, but not limited to, applied behavioral analysis, transcranial magnetic stimulation, electroconvulsive therapy, psychological $2,500 $4,500 testing, and other behavioral health services as determined by the Contractor’s clinical staff. [3] Applies to certain antihypertensives for coronary artery disease (CAD) and congestive heart failure $5,000 $9,000 (CHF); oral diabetic medications, insulin and diabetic supplies; statins; medications for asthma, COPD $5,000 $9,000 (emphysema and chronic bronchitis), depression and osteoporosis medications. [4] Prior authorization (PA) required. When using out-of-network providers, benefits for medically $5,000 $9,000 necessary services will be reduced by half if PA is required but not obtained, subject to the maximum allowable charge. If services are not medically necessary, no benefits will be provided. [5] For PPO Plans, the deductible DOES NOT apply. State contribution to HSA: [6] Select Substance Use Treatment Facilities are preferred with an enhanced benefit - PPO members $250 for employee only; $500 for employee+child(ren), won’t have to pay a deductible or coinsurance for facility-based substance use treatment; CDHP employee+spouse and employee+spouse+child(ren) members must meet their deductible first, then coinsurance is waived. Copays for PPO and deductible/coinsurance for CDHP will apply for standard outpatient treatment services. Call coverage 855-Here4TN for assistance.
-21- Disability Insurance The state offers voluntary disability benefits to full-time state and higher education employees.
• Full-time state employees may enroll in short term disability (STD) insurance and/or long term disability (LTD) insurance. • Full-time higher education employees may enroll in short term disability insurance. Higher education employees should contact their agency benefits coordinators for more information on long term disability insurance available to them. • Those who enroll will pay 100% of the premium with after-tax dollars. By paying with after-tax dollars, any benefits paid to you will result in a tax free benefit. • State employees only: If you intend to enroll in both short term and long term disability insurance, you should consider enrolling in one of the long term disability options with a 180-day elimination period. The 26-week short term disability insurance will best cover the 180-day elimination period for your long term disability, at a lower monthly cost. • Enroll in either or both of the state group insurance disability programs within the first 31 days of your eligibility date and you will not be required to answer any medical history questions. If you wait to apply for coverage during the next annual enrollment period or due to a special qualifying event, you will be required to answer questions about your full medical history. MetLife will review your completed medical questionnaire and determine whether to approve or deny your coverage. • You must use all of your accumulated leave (sick, annual and compensatory or comp time) before your disability payments begin. • Benefits payable during the payable benefit period may be reduced by other sources of income, e.g., worker’s compensation, unemployment insurance, and sick leave bank. See the certificate of coverage for a comprehensive list of other sources of income which may reduce the STD and/or LTD benefit.
Why is having disability insurance important? Disability Insurance is insurance for your paycheck. If you are unable to work due to sickness, pregnancy or as a direct result of accidental injury, disability insurance can help pay your most important expenses. These include:
• Mortgage or rent • Car payments • Food • Child care/tuition • Utilities
Short term disability insurance (available to state and higher education employees) Short term disability insurance replaces a percentage of your income during a disability, which could last up to 26 weeks. It may be good for those who:
• Have little annual or sick leave • Take part in high-risk activities • Don’t have six-month emergency funds
To calculate your monthly premium, go to metlife.com/StateOfTN, click on state employees or higher education employees and then click on Rates at the top.
Long term disability insurance (available to state employees only) Long term disability insurance replaces a percentage of your income during a disability that is expected to last for an extended period of time. This period of time is typically longer than 90 or 180 days. It may be good for those who:
• Need their income to pay for housing, food and other bills • Would have trouble supporting themselves if out of work more than 90 days
For more information and to calculate your rates, go to metlife.com/StateOfTN.
-22- The State Group Insurance Program long term disability and short term disability insurance plans are both managed by MetLife. Please call the MetLife State of Tennessee Dedicated Customer Service Line with questions: 855.700.8001, Mon.-Fri., 7 a.m.-10 p.m., Central time.
Note: A complete description of the benefits, provisions, conditions, limitations and exclusions for both the MetLife STD and LTD plans will be included in their respective Certificate of Insurance. If any discrepancies exist between the information listed above and the legal plan documents, the legal plan documents will govern. We recommend you review these documents. These documents may be reviewed at https://www.tn.gov/partnersforhealth/publications/publications.html.
Short Term Disability Options
Option A Option B All employees working not less than 30 hours/week or seasonal employees hired prior to July 1, 2015, with 24 months of service and certified by their appointing Eligibility authority to work at least 1,450 hours per fiscal year (July- June), or deemed eligible by applicable federal law, state law or action of the State Insurance Committee. % of Gross Annual Base Salary1 Paid Weekly 60% of salary paid weekly
Maximum Weekly Benefit Up to $2,500
Minimum Weekly Benefit2 $25
Elimination (Waiting) Period 14 calendar days 30 calendar days
Duration of Benefit 26 weeks Guaranteed Issue (no health questions asked) for New Hires who enroll within 31 days of eligibility date. A full Evidence of Insurability (EOI)3 Statement of Health is required for all new applicants and for current participants electing a higher plan of benefit during the 2021 Annual Enrollment period. Pre-existing Condition4 None 1 Annual salary will be based on your date-of-hire salary for new hires; thereafter, the gross base annual salary you make on September 1 of each calendar year determines the benefit you are eligible for beginning October 1 of each calendar year.
2 The Minimum Monthly Benefit will not apply if you are receiving 100% of Your Predisability Salary under your employer’s paid leave policy, which includes annual, sick and comp time.
3 MetLife will review your information and evaluate your request for coverage based upon your answers to the health questions, MetLife’s underwriting rules and other information you authorize us to review. In certain cases, MetLife may request additional information to evaluate your request for coverage.
4 Pre-existing Condition means a Sickness or accidental injury for which you: 1) received medical treatment, consultation, care or services; or took prescribed medication or had medications prescribed; in the 3 months before Your insurance under the certificate takes effect.
2021 Monthly Premiums for Short Term Disability (STD) STD COST: PER $100 OF MEMBER’S COVERED MONTHLY SALARY Option A: 60%, 14-day elimination period $1.34
Option B: 60%, 30-day elimination period $1.08
-23- Long Term Disability Options
Option 1 Option 2 Option 3 Option 4
All employees working not less than 30 hours/week; seasonal employees hired prior to July 1, 2015 with 24 months of service and certified by their appointing authority to work at Eligibility least 1,450 hours per fiscal year (July-June); or deemed eligible by applicable federal law, state law, or action of the State Insurance Committee
% of Gross Annual Base 60% of salary paid monthly 63% of salary paid monthly Salary1 Paid Monthly
Maximum Monthly Up to $7,500 per month (covers annual salary of Up to $10,000 per month (covers annual salary of Benefit $150,000) $190,476.24)
Minimum Monthly Greater of 10% of benefit or $100 per month Benefit2 Elimination (Waiting) 90 calendar days 180 calendar days 90 calendar days 180 calendar days Period
Own Occupation 24 months 24 months 36 months 36 months
Disabled prior to age 65, then to Social Security Normal Retirement Age (SSNRA); Age 65, 24 months; Maximum Benefit Period Age 66, 21 months; Age 67, 18 months, Age 68, 15 months; age 69+, 12 months
Guaranteed Issue (no health questions asked) for New Hires who enroll within 31 days of eligibility date. Evidence of Insurability 3 A full Statement of Health is required for all new applicants and for current participants electing a higher (EOI) plan of benefit during the Annual Enrollment period.
Pre-existing Condition4 3 months prior to effective date and 12 months from effective date
1 Annual salary will be based on your date-of-hire salary for new hires: thereafter, the gross base annual salary you make on September 1 of each calendar year determines the benefit you are eligible for beginning October 1 of each calendar year.
2 The Minimum Monthly Benefit will not apply if you are receiving 100% of Your Predisability Salary under your employer’s paid leave policy, which includes annual, sick and comp time.
3 MetLife will review your information and evaluate your request for coverage based upon your answers to the health questions, MetLife’s underwriting rules and other information you authorize us to review. In certain cases, MetLife may request additional information to evaluate your request for coverage.
2 Pre-existing Condition means Sickness or accidental injury for which you: 1) received medical treatment, consultation, care or services; or took prescribed medication or had medications prescribed; in the 3 months before Your insurance under the certificate takes effect.
2021 Monthly Premiums for Long Term Disability (LTD)
LTD: EMPLOYEE’S AGE (PER $100 OF COVERED MONTHLY SALARY) Benefit %/ Under Elimination Period 30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ Option 1 60%/90 days $.20 $.20 $.40 $.59 $.75 $.92 $1.10 $1.46 $.97 $.97 Option 2 60%/180 days $.16 $.16 $.31 $.46 $.59 $.72 $.86 $1.14 $.76 $.76 Option 3 63%/90 days $.24 $.24 $.49 $.72 $.91 $1.12 $1.34 $1.78 $1.18 $1.18 Option 4 63%/180 days $.19 $.19 $.39 $.57 $.72 $.89 $1.06 $1.41 $.94 $.94
-24- Dental Insurance 2021 Monthly Premiums for Dental Two different dental plans are offered. You pay the full monthly premium. CIGNA METLIFE Both dental options have specific rules for benefits such as exams and major PREPAID DPPO PLAN PLAN procedures and have a four-tier premium structure just like health insurance. You can enroll in dental coverage as a new employee or during the annual ACTIVE MEMBERS enrollment period. You may also enroll if you have a special qualifying event. Employee Only $13.84 $23.64 You do not have to be enrolled in health coverage to be eligible for dental Employee + Child(ren) $28.75 $54.36 insurance. Employee + Spouse $24.54 $44.72 Employee + Spouse + Child(ren) $33.74 $87.50 Prepaid Plan (Cigna) • Must select and use a network general dentist (NGD) from the prepaid dental plan list for each covered family member — the network is a select number of dentists in Cigna Dental HMO (DHMO). You may select a network pediatric dentist as the NGD for your dependent child under age 13. At age 13, you must switch the child to a NGD or pay the full charge from the pediatric dentist. The list of providers for the state may be found by visiting the website, https://www.cigna.com/sites/stateoftn/. • Copays for dental treatments, including adult and child orthodontia for up to 24 months • An office visit fee copay applies per patient, per office visit, and is in addition to any other applicable patient charges • No claim forms • Preexisting conditions are covered if they are listed in the patient charge schedule, unless treatment starts before coverage begins • Certain limitations and exclusions apply. Please refer to the patient charge schedule and the Cigna dental certificate https://( www.tn.gov/partnersforhealth/publications/publications.html) for additional details • Referrals to specialists are required • No maximum benefit levels • No deductibles • No charge for oral exams, routine semiannual cleanings, most x-rays and fluoride treatments; however, an office visit copay applies • Orthodontic treatment is not covered if the treatment plan began prior to the member’s effective date of coverage with Cigna. The completion of crowns, bridges, dentures or root canal treatment already in progress on the member’s effective date of coverage is also not covered.
DPPO Plan (MetLife) • Use any dentist, but you receive maximum benefits when visiting an in-network MetLife DPPO provider. The list of network providers in the MetLife DPPO network for the state may be found by visiting the website, https://www.metlife.com/stateoftn/. • $1,500 calendar year benefit maximum per person • Deductible applies for basic and major dental care. Coinsurance for basic, major, orthodontic and out-of-network covered services • You or your dentist will file claims for covered services • Referrals to specialists are not required • Pre-treatment estimates are recommended for more expensive services • Benefits for covered services are paid at the lesser of dentist charge, maximum allowable charge or alternate benefit amount • Some services require waiting periods of six months and up to one year, and certain limitations and exclusions apply • Lifetime benefit maximum of $1,250 for orthodontia
NOTE: A complete description of the benefits, provisions, conditions, limitations and exclusions for both the MetLife and Cigna dental plans will be included in their respective Certificate of Insurance. If any discrepancies exist between the information listed above and the legal plan documents, the legal plan documents will govern. We recommend you review these documents. These documents may be reviewed at https://www.tn.gov/partnersforhealth/publications/publications.html.
-25- Dental Insurance Benefits at a Glance The benefits listed below are a sample of the most frequently utilized dental treatments. For a complete list of copays for the Cigna Prepaid option, please refer to the patient charge schedule. Review the Cigna certificate of coverage for complete details on benefits, limitations and exclusions. Both documents are at cigna.com/stateoftn.
MAC or maximum allowable charge is the highest dollar amount of reimbursement for specific dental procedures provided by DPPO network providers. The in-network dentists have agreed to not charge members or the plan more than the MAC. When a member receives dental services from an out-of-network provider, the out-of-network dentist will be paid by the plan for covered procedures according to the in-network MAC and respective plan coinsurance. The member then is responsible for all other charges by the out-of- network dentist. Review additional information on the ParTNers for Health website tn.gov/partnersforhealth.html under Other Benefits and Dental.
CIGNA PREPAID OPTION METLIFE DPPO OPTION COVERED SERVICES GENERAL DENTIST SPECIALIST DENTIST IN-NETWORK OUT-OF-NETWORK Annual Deductible none $25 single; $75 family, $100 single; $300 family, per policy year [1] per policy year [1] Annual Maximum Benefit none $1,500 per person, per policy year Pre-existing Conditions covered some exclusions Office Visit $10 copay [2] no charge 20% of MAC Periodic Oral Evaluation no charge no charge 20% of MAC Routine Cleaning – Adult no charge no charge 20% of MAC Routine Cleaning – Child no charge $15 copay no charge 20% of MAC X-ray — Intraoral, Complete Series no charge $5 copay no charge 20% of MAC Amalgam (silver) Filling Two Surfaces $8 copay $10 copay 20% of MAC 40% of MAC Permanent teeth Endodontics — Root Canal Therapy Molar $125 copay[7] $600 copay [7] 20% of MAC 40 % of MAC (excluding final restoration) Major Restorations — Crowns $190 copay, plus lab fees [3] [7] 50% of MAC [4] Extraction of Erupted Tooth (minor oral surgery) $15 copay $70 copay 20% of MAC 40% of MAC Implant (endosteal) $1,025 copay [7] $1,025 copay [7] 50% of MAC [4][8] Removal of Impacted Tooth — Complete Bony $100 copay $120 copay 50% of MAC (complex oral surgery) Dentures — Complete Upper $310 copay, plus lab fees [3][7] 50% of MAC [4] [8] Orthodontics $140 monthly copay for treatment equal or less than 50% of MAC 24 months. Then, full charge.[6] • Annual Deductible none none • Lifetime Maximum $3,360 copay ($140 x 24 months) for treatment fee $1,250 [5] only. Then, member pays full charge after initial 24 months. [6] • Waiting Period none 12 months • Age Limit none up to age 19
[1] Does not apply to diagnostic and preventive benefits such as periodic oral evaluation, cleaning and x-ray. [2] A charge may apply for a missed appointment when the member does not cancel at least 24 hours prior to the scheduled appointment. [3] Members are responsible for additional lab fees for these services. [4] A 6-month waiting period applies. (See #8 for additional information for dentures and implants.) [5] The orthodontics lifetime maximum is for a dependent member enrolled in the state group dental insurance program even if the member has been covered under different employing agencies. [6] Additional copays apply for specific orthodontic procedures. Cigna will not cover orthodontic procedures after a member’s effective date with Cigna Prepaid if orthodontic treatment began prior to the member’s effective date. Orthodontic treatment started under the prior Cigna Prepaid contract with the state will continue to be covered under the new Cigna Prepaid contract effective January 1, 2021. [7] Completion of crowns, bridges, dentures, implants, or root canal already in progress on member’s effective date of coverage with Cigna Prepaid will not be covered. [8] A 12-month waiting period applies to dentures and implants to replace one or more natural teeth missing before member’s effective date of coverage.
-26- Vision Insurance Voluntary vision coverage is available to state and higher education employees and dependents. You must pay 100% of the premium for coverage. Two options are available: a basic and an expanded plan. Both offer: • Routine eye exam once every calendar year • Frames once every two calendar years • Choice of eyeglasses or contact lenses once every calendar year • Discount on LASIK/Refractive surgery • Discount on hearing aids (includes Free Hearing Exam) through Your Hearing Network (YHN)
What you pay for services depends on the plan you choose. The Basic Plan pays for your eye exam and various “allowances” (dollar amounts) for materials such as eyeglass frames, lenses, contact lenses, etc. The Expanded Plan includes greater “allowances” (dollar amounts) and additional materials versus the Basic Plan. See the benefit chart on the following page to compare benefits in both plans.
The basic and expanded plans are both administered by Davis Vision. You will receive the maximum benefit when visiting a provider in their network. However, out-of-network benefits are also available.
General Limitations and Exclusions The following services are not covered under the vision plan: • Treatment of injury or illness covered by workers’ compensation or employer’s liability laws • Cosmetic surgery and procedures • Services received without cost from any federal, state or local agency • Charges by any hospital or other surgical or treatment facility and any additional fees charged for treatment in any such facility • Services by a vision provider beyond the scope of his/her license • Vision services for which the patient incurs no charge • Vision services where charges exceed the amount that would be collected if no vision coverage existed
Note: If you receive vision services and materials that exceed the covered benefit, you will be responsible for paying the difference for the actual services and materials you receive.
Davis Vision offers some value-added services which include: • Zero copay for single vision, bifocal, trifocal or lenticular lenses purchased at an in-network location • Free pair of “Fashion Selection” eyeglass frames from Davis Vision’s “The Exclusive Collection” under the in-network Basic Plan. “Designer” and “Premier” Selections have $15 and $40 copays respectively • Free pair of eyeglass frames from any Davis Vision’s “The Exclusive Collection”, which includes “Fashion, Designer and Premier” Selections under the in-network Expanded Plan • Free pair of frames at Visionworks retail locations • 40% discount off retail under the in-network Expanded plan and 30% discount off retail under the in-network Basic plan for an additional pair of eyeglasses, except at Walmart, Sam’s Club or Costco locations • 20% discount off retail cost of additional pair of conventional or disposable contact lenses under in-network Expanded plan • One year warranty for breakage of most eyeglasses
-27- Covered Vision Services Here is a comparison of discounts, copays and allowed amounts for 2021 under the vision options. Copays represent what the member pays. Allowances and percentage discounts represent the cost the carrier will cover. Actual costs and benefits may vary based upon the plan design selected. Exclusions and limitations may apply. Out-of-network member costs can be found in the Davis Vision Handbook at https://www.tn.gov/partnersforhealth/publications/publications.html.
SERVICE BASIC PLAN IN-NETWORK COSTS [1] EXPANDED PLAN IN-NETWORK COSTS [1] Eye Exam With Dilation as Necessary $0 copay $10 copay Retinal Imaging $39 copay $39 copay Contact Lens fit and Follow up (standard/specialty) 80% of charge $50/$60 copay Eyeglass Benefit—Frame Retail Frame 80% of balance over $55[2] 80% of balance over $150[2] Visionworks Frame Covered in full Covered in full The Exclusive Collection[3] In lieu of retail frame In lieu of retail and Visionworks frame (Fashion/Designer/Premier) $0/$15/$40 copay $0/$0/$0 copay Eyeglass Benefit—Spectacle Lenses Single Vision, Bifocal, Trifocal & Lenticular Lenses $0 copay $0 copay Progressive Lenses 80% of balance over $55; (Standard/Premium/Ultra/Ultimate) not to exceed $65/$105/$140/$175 out of pocket $50/$90/$140/$175 copay High-index (1.67/1.74) 80% of charge not to exceed $60/$120 $60 copay/$120 copay UV Treatment 80% of charge up to $15 $10 copay Tint (solid and gradient) 80% of charge up to $15 $15 copay Standard Polycarbonate (adults/children[4]) 80% of charge up to $35/$0 copay $30 copay/$0 copay Anti-reflective Coating 80% of charge up to $40/$55/$69/$85 $40/$55/$69/$85 copay (Standard/Premium/Ultra/Ultimate) Polarized 80% of charge up to $75 80% of charge up to $75 Plastic Photochromic Lenses 80% of charge up to $70 80% of charge up to $70 Scratch coating (standard plastic/premium scratch-resistant) $0 copay/80% of charge up to $30 $0 copay/$30 copay Scratch Protection Plan (single vision/multifocal $20 copay/$40 copay $20 copay/$40 copay lenses) Trivex Lenses 80% of charge up to $50 $50 copay Digital Single Vision (intermediate) lenses 80% of charge up to $30 $30 copay Blue Light Filtering 80% of charge up to $15 $15 copay Other Add-ons and Services 80% of charge 80% of charge Contact Lenses Conventional and Disposable 80% of balance over $55 80% of balance over $140 Visually Required[5] 80% of balance over $155 $0 copay Frequency of Vision Benefits Eye Exam Once every calendar year Once every calendar year Eyeglass Lenses Once every calendar year Once every calendar year Frames Once every two calendar years Once every two calendar years Contact Lenses Once every calendar year in lieu of eyeglasses Once every calendar year in lieu of eyeglasses Contact Lens Evaluation, Fitting and Follow-up Once every calendar year in lieu of eyeglasses Once every calendar year in lieu of eyeglasses
[1] Member pay will not be greater than the copay, but could be less based upon the actual charge. [2] $0 copay for eyeglass frames at Visionworks. [3] Collection is available at most participating eye care professional offices. Collection is subject to change. [4] Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions 6.00 diopters or greater. [5] If visually required as first contact lenses following cataract surgery, or multiple pairs of rigid contact lenses for treatment of keratoconus.
-28- Additional Benefits • High Index Lenses — 1.74 • Progressive Lenses — Ultimate Tier • Anti-reflective Coating — Ultimate Tier • Premium Scratch-resistant Coating • Digital Single Vision Lenses • Trivex Lenses • Blue Light Filtering (Coatings & Lens Options) • Scratch Protection Plan
NOTE: A complete description of the benefits, provisions, conditions, limitations and exclusions for the Davis Vision Basic and Expanded plans will be included in their respective Certificate of Insurance. If any discrepancies exist between the information listed above and the legal plan documents, the legal plan documents will govern. We recommend you review these documents. The documents are available at https://www.tn.gov/partnersforhealth/publications/publications.html.
2021 Monthly Premiums for Vision
BASIC PLAN EXPANDED PLAN ACTIVE MEMBERS Employee Only $3.07 $5.56 Employee + Child(ren) $6.13 $11.12 Employee + Spouse $5.82 $10.57 Employee + Spouse + $9.01 $16.35 Child(ren)
-29- Employee Assistance Program Your Employee Assistance Program (EAP) is administered by Optum. EAP services are available to all benefits-eligible state/higher education employees and their eligible dependents, even if they are not enrolled in a health plan.
Master’s level specialists are available 24/7 to assist with stress, legal, financial, mediation and work/life services.
• Get five EAP counseling visits, per problem, per year, per individual at no cost to you. Available in person or by virtual visit . Get the care you need in the privacy and comfort of your own home. • Use Sanvello, an on-demand mobile app to help with stress, anxiety and depression. Available anytime at no extra cost at HERE4TN.com. • Participate in a telephonic coaching program called Take Charge at Work. It helps people (EAP-eligible and working) dealing with stress or depression improve performance at work. Available at no additional cost if you qualify. Participants can earn a wellness program cash incentive, if eligible.
Here4TN Behavioral Health and Substance Use Services You and your dependents enrolled in health coverage are eligible for behavioral health and substance use benefits, which are administered by Optum Health. All enrolled members will get an ID card from Optum to use for your behavioral health services.
Whether you are dealing with a mental health or substance use condition, support is available through your behavioral health coverage. Optum can help you find a provider (in person or virtual visits), explain benefits, identify best treatment options, schedule appointments and answer your questions.
Costs are waived for members who use certain preferred substance use treatment facilities. PPO members who use these facilities won’t pay a deductible or coinsurance for facility-based substance use treatment. CDHP/HSA members’ coinsurance is waived after meeting their deductible. However, copays for PPO members and the deductible/coinsurance for CDHP/HSA members will still apply for standard outpatient treatment services.
To receive maximum benefit coverage, participants must use an in-network provider. For assistance finding a network provider, call 855.Here4TN (855.437.3486).
For virtual visits, you can meet with a provider through private, secure video conferencing. Virtual visits allow you to get the care you need sooner and in the privacy of your home. Virtual visit costs are the same as an office visit.
Talkspace online therapy is also available for all members with behavioral health benefits. Download the application (app) through Here4TN.com. You can communicate safely and securely 24/7 with a therapist from your smartphone or desktop. Talkspace sessions are subject to the same cost share or coinsurance rate (after deductible) as an outpatient office visit.
ParTNers for Health Wellness Program State and higher education members and enrolled spouses have access to a wellness program administered through our vendor ActiveHealth Management. They can help you achieve your health goals through special programs and resources, and you can also get rewarded for taking action by earning cash incentives that will be deposited through payroll*.
Here’s how it works:
You and your enrolled spouse can each earn up to $250 a year by completing certain wellness activities (if eligible). Each participant will be able to earn the maximum $250 per person ($500 annual maximum per family). You must first complete ActiveHealth’s health assessment before you can earn the cash incentives. Note: New hires/new plan members, your earnings may be limited depending on your hire date.
-30- There are a variety of programs to choose from. They include:
• Biometric screenings • Weight management program** • Tobacco cessation program • Wellness counseling (diet, stress, exercise, etc.) • Digital coaching • Disease management program • Group coaching for lifestyle and disease management programs • Online resources (challenges, health education library with videos and articles)
A printable Incentive Table and information about programs and activities are at www.tn.gov/partnersforhealth, under Other Benefits and Wellness.
*Members must be in a positive pay status to receive an incentive. The cash incentive for both the employee and eligible spouse will be deposited directly into the member’s paycheck and will be taxed.
** To be eligible to enroll, your BMI must be equal or greater than 30.
Diabetes Prevention Program Health plan members also have access to a free Diabetes Prevention Program if you meet eligibility criteria. The program can help you prevent or delay type 2 diabetes. It’s offered as part of your health insurance at no cost if you use an in-network provider. There are two online programs offered; one for Cigna members through Omada, and another for BlueCross BlueShield members through Livongo. We also have an in-person program available through the ParTNers Health and Wellness Center.
For details, go to tn.gov/partnersforhealth under Other Benefits and Wellness and scroll down to the Diabetes Prevention Program (DPP) webpage.
Notice Regarding Wellness Program The ParTNers for Health Wellness Program is a voluntary wellness program available to all state and higher education employees and spouses enrolled in health coverage. Local education, local government and retirees enrolled in health coverage have access to certain programs like disease management and the web portal. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program, you will be asked to complete a voluntary health questionnaire (assessment) that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes or heart disease). You are not required to complete the assessment or other medical examinations.
Although you are not required to complete the health questionnaire, only active state and higher education employees and spouses who do so are eligible to receive cash incentives.
If you are unable to participate in any of the health-related activities required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting the ParTNers for Health Wellness Program at 888.741.3390.
The information from your health questionnaire and the results from your biometric screening (active state and higher education employees and spouses only) will be used to provide you with information to help you understand your current health and potential risks. It may also be used to offer you services through the wellness program such as weight management, Diabetes Prevention Program and other programs. You also are encouraged to share your results or concerns with your own doctor.
-31- Protections from Disclosure of Medical Information We are required by law to maintain the privacy and security of your personally identifiable health information (PHI). Although the wellness program and the State of Tennessee may use aggregate information it collects to design a program based on identified health risks in the workplace, the ParTNers for Health Wellness Program will never disclose any of your personal information either publicly or to your employer, except as necessary to respond to a request from you for a reasonable accommodation needed for you to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and will never be used to make decisions regarding your employment.
Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information are the wellness vendor (nutritionists, nurses, nurse practitioners, registered dietitians, health coaches and other healthcare professionals) and their vendor partners (case managers with the medical and behavioral health vendors, weight management vendor and the biometric screening vendor) in order to provide you with services under the wellness program.
In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted and no information you provide as part of the wellness program will be used in making any employment decisions. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, you will be notified promptly.
You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate.
If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact ParTNers for Health at [email protected].
Life Insurance Securian Financial has an online tool, Benefit Scout, to help you estimate the amount of life insurance you need at lifebenefits. com/stateoftn.
Basic Group Term Life and Accidental Death & Dismemberment Insurance The state provides, at no cost to you, $20,000 of basic term life insurance and $40,000 of basic accidental death & dismemberment (AD&D) coverage. If you enroll in health insurance as the head of contract, the amount of coverage increases as your salary increases, with premiums for coverage above $20,000/$40,000 deducted from your paycheck. The maximum amount of coverage is $50,000 for basic term life and $100,000 for accidental death & dismemberment. The face amount of coverage declines at ages above 65. If you do not enroll in health coverage, the amount of coverage does not increase regardless of salary.
Changes in coverage based on age or salary take effect the first day of October based on your age and salary as of September 1.
Eligible dependents (spouse and children) enrolled in health insurance are covered for $3,000 of basic dependent term life coverage and for basic AD&D. The amount of AD&D coverage is based on salary and family composition. If you do not enroll in health coverage, your dependents are not eligible for basic term life or basic AD&D coverage.
Voluntary Accidental Death & Dismemberment You and your dependents (spouse and children) may enroll in this coverage at low group rates, no questions asked. It is in addition to the basic AD&D coverage and you must pay a premium. Benefits are paid for dismemberment if the loss occurs within 180 days of the accident, as long as you or your dependent is covered on the date of the accident and meet the criteria. Coverage amounts are based on your salary. The maximum benefit for you is $60,000.
-32- Voluntary Term Life Insurance You and your dependents may enroll in this coverage whether or not you enroll in health coverage. A premium is required. For employee guaranteed issue coverage, you must enroll during the first 31 calendar days of employment with the state. The effective date of coverage is the first of the month after you have completed three full calendar months of employment. If you do not enroll when first eligible, you can apply for coverage during the annual enrollment period by answering health questions.
You may select up to five times your annual base salary (subject to a maximum of $500,000) if you apply when first eligible, without answering health questions. You may apply for up to seven times your annual base salary (subject to a maximum of $500,000), but evidence of good health is required. The minimum coverage level is $5,000.
Your spouse may apply for $5,000, $10,000 or $15,000 of term life insurance at any age. Spouses below age 55 may apply for increments of $5,000, subject to an overall maximum of $30,000. Spouses must be performing normal duties of a healthy person of similar age and gender and not have been hospitalized, advised to seek medical treatment or received disability benefits within six months prior to the application to enroll date for coverage to be issued without answering any additional health questions. A spouse who does not meet the criteria may apply for coverage by answering specific health questions which the insurance company will use to decide if coverage will be allowed. You do not have to enroll in this coverage for your spouse to participate.
Children may be covered under either a $5,000 or a $10,000 term rider. The rider is added to either your certificate or your spouse’s certificate, but not both. These amounts will cover all eligible children who meet the dependent definition. Coverage for children is guaranteed issue.
The voluntary term life insurance provides a death benefit and the premiums increase with age each January 1st if you move into a higher age bracket. It also offers an advance benefit rider, which allows payment of the life insurance proceeds if an insured encounters a terminal illness with a life expectancy of no more than 12 months.
Enroll Computer enrollment for Voluntary Term Life — It’s easy to enroll (and to designate your beneficiary) online.
1. Log on to lifebenefits.com/stateoftn with the ID and password provided below. You will be prompted to change your password the first time you log on.
• Your ID: The letters TN followed by your Edison ID number • Your password: Your password is your eight-digit date of birth (MMDDYYYY) followed by the last four digits of your Social Security number If you do not have access to a computer or the internet, forms are available by calling Securian Financial at 1.866.881.0631 or from your agency benefits coordinator.
2. Enter your information. Follow the instructions on the site to enroll for insurance coverage for you and your spouse and children if desired, and to designate your beneficiary. After submitting your information, please print a copy of your application for your records.
3. Clean up. Clear your personal information before leaving the computer.
To enroll for Voluntary AD&D — Please log into Edison and complete your enrollment and designate your beneficiary or utilize a paper form. Consult with your agency benefits coordinator in your human resources office on the appropriate method to use for enrollment.
Your enrollment in Basic Term Life and Basic AD&D — Will be automatically processed based upon your enrollment choice for medical insurance in Edison. You should sign-on to Edison to enter your beneficiary information.
For more details, refer to the member handbook, available on the Publications page at https://www.tn.gov/partnersforhealth/ publications/publications.html. Your agency benefits coordinator can provide premium information. For Securian Financial (Minnesota Life) go to lifebenefits.com/stateoftn or call 866.881.0631.
-33- Note: A complete description of the benefits, provisions, conditions, limitations and exclusions for the Securian Financial Basic Life/AD&D, Voluntary AD&D, and Voluntary Life plans will be included in their respective Certificates of Insurance. If any discrepancies exist between the information listed above and the legal plan documents, the legal plan documents will govern. We recommend you review these documents. The documents are available at https://www.tn.gov/partnersforhealth/publications/ publications.html.
Flexible Spending Accounts Flexible spending accounts (FSAs) help you decrease your taxable income and increase your take-home pay. They allow you to pay certain expenses (such as healthcare and dependent care) from your pre-tax income rather than after-tax income. The maximum amount you can contribute to a FSA is set by the Internal Revenue Service (IRS). The limits are subject to change yearly. Unless you have an approved family status change, you cannot enroll in or cancel a medical, limited purpose or dependent care FSA in the middle of a calendar year.
Full-time, Insurance-eligible employees (excludes offline agencies) can enroll in the following FSAs:
• Medical FSA: For medical, dental and vision expenses (Annual limit: $2,750/Carryover limit: $500). If you enroll in the CDHP/ HSA, you do not qualify for a medical FSA. • Limited Purpose FSA: For dental and vision expenses only (Annual limit: $2,750/Carryover limit $500). If you have the CDHP/ HSA, the Limited Purpose FSA is a great way to save on vision and dental expenses. • Dependent Care FSA: For certain dependent-care costs, such as after school care and baby-sitting fees (Annual limit $5,000, up to $2,500 per spouse for married couples filing jointly/No carryover amount). • Transportation and Parking FSA: Available to state employees only for certain work-related commuting and/or parking expenses (Monthly limit is $270). A debit card is not provided. Claims are filed with Benefits Administration.
Optum Bank administers all of the FSAs except Transportation and Parking.
Important:
• You cannot enroll in both a medical FSA and a Limited Purpose FSA in the same year. • For Medical and Limited Purpose FSAs, all contributions are available up front.
Note: Medical FSA and Limited Purpose FSA members get debit cards to use their funds at the pharmacy or provider’s office. Per IRS rules, Optum Bank may need you to verify some debit card purchases by providing your explanation of benefits or claims document. Make sure to respond or your debit card may be suspended.
There is an FSA/HSA chart showing contribution amounts, tax benefits and how to use your funds at tn.gov/partnersforhealth under Publications.
Enrollment • State employees enroll in Edison for Medical, Limited and Dependent Care FSAs. For Transportation and Parking, state employees submit a paper form (https://www.tn.gov/partnersforhealth/publications/forms.html). • Higher education employees enroll on the Optum Bank website at optumbank.com/Tennessee.
-34- OTHER INFORMATION
Coordination of Benefits If you are covered under more than one insurance plan, the plans will coordinate benefits together to determine which plan will pay first, how much each plan will pay, and how much you will pay. When this plan pays secondary you will pay your member cost share as noted in this guide on the Benefit Comparison. At no time should payments exceed 100% of the eligible charges.
As an active employee, your health insurance coverage is generally considered primary for you. However, if you have other health coverage as the head of contract, the oldest plan is your primary coverage. If covered under a retiree plan and an active plan, the active plan will always be primary. If your spouse has coverage through his/her employer, that coverage would be primary for your spouse and secondary for you. Generally, Medicare will pay secondary unless the covered individual is enrolled in Medicare due to End Stage Renal Disease or disability, as other coordination of benefits rules may apply.
Primary coverage on children is determined by which parent’s birthday comes earliest in the calendar year. The insurance of the parent whose birthday falls last will be considered the secondary plan. This coordination of benefits can be superseded if a court orders a divorced parent to provide primary health insurance coverage. If none of the above rules determines the order of benefits, the benefits of the plan which has covered an employee, member or subscriber longer are determined before those of the plan which has covered that person for the shorter time.
From time to time, carriers will send letters to members asking for other coverage information. This is necessary because it is not uncommon for other coverage information to change. This helps ensure accurate claims payment. In addition to sending a letter, the carriers may also attempt to gather this information when members call in. You must respond to the carrier’s request for information, even if you just need to report that you have no other coverage.
If you do not respond to requests for other coverage information, your claims may be pended or held for payment. When claims are pended, it does not mean that coverage has been terminated or that the claims have been denied. However, claims will be denied if the requested information is not received by the deadline. Once the carrier gets the requested information, they will update the information regarding other coverage, and claims that were pended or denied will be released or adjusted for payment.
Subrogation The medical plan has the right to subrogate claims. This means that the medical plan can recover the following: • Any payments made as a result of injury or illness caused by the action or fault of another person • A lawsuit settlement that results in payments from a third party or insurer of a third party • Any payments made due to a workplace injury or illness
These payments would include payments made by worker’s compensation insurance, automobile insurance or homeowners insurance whether you or another party secured the coverage.
You must assist in this process and should not settle any claim without written consent from the Benefits Administration subrogation section. If you do not respond to requests for information or do not agree to pay the plan back for any money received for medical expenses the plan has already paid for, you may be subject to collections activity.
On-the-job Illness or Injury Work-related illnesses or injuries are not covered under the plan. The plan will not cover claims related to a work-related accident or illness regardless of the status of a worker’s compensation claim or other circumstances.
-35- Fraud, Waste and Abuse Making a false statement on an enrollment or claim form is a serious matter. Only those persons defined by the group insurance program as eligible may be covered. Eligibility requirements for employees and dependents are covered in detail in this guide.
If your covered dependent becomes ineligible, you must inform your agency benefits coordinator and submit an application within one full calendar month of the loss of eligibility. Once a dependent becomes ineligible for coverage, he/she cannot be covered even if you are under court order to continue to provide coverage.
If there is any kind of error in your coverage or an error affecting the amount of your premium, you must notify your agency benefits coordinator. Any refunds of premiums are limited to three months from the date a notice is received by Benefits Administration. Claims paid in error for any reason will be recovered from you.
Financial losses due to fraud, waste or abuse have a direct effect on you as a plan member. When claims are paid or benefits are provided to a person who is not eligible for coverage, this reflects in the premiums you and your employer pay for the cost of your healthcare. It is estimated that between 3–14 percent of all paid claims each year are the result of provider or member fraud. You can help prevent fraud and abuse by working with your employer and plan administrator to fight those individuals who engage in fraudulent activities.
How You Can Help • Pay close attention to the explanation of benefits (EOB) forms sent to you when a claim is filed under your contract and always call the carrier to question any charge that you do not understand • Report anyone who permits a relative or friend to “borrow” his/her insurance identification card • Report anyone who makes false statements on their insurance enrollment applications • Report anyone who makes false claims or alters amounts charged on claim forms
Please contact Benefits Administration to report fraud, waste or abuse of the plan. All calls are strictly confidential.
To File an Appeal If you have a problem with coverage or payment of medical, behavioral health and substance use or pharmacy services, there are internal and external procedures to help you. These procedures do not apply to any complaint or grievance alleging possible professional liability, commonly known as malpractice, or for any complaint or grievance concerning benefits provided by any other plan.
You should direct any specific questions regarding initial levels of appeal (the internal appeal process) to the insurance carrier member service numbers provided at the front of this guide. You can also find those numbers on your insurance cards. Benefits Administration is not involved in the appeal process. The appeals process follows federal rules and regulations and assigns appeal responsibilities to the carriers and independent review organizations.
Benefit Appeals Before starting an appeal related to benefits (e.g., a prior-authorization denial or an unpaid claim), you or your authorized representative should first contact the insurance carrier to discuss the issue. You or your authorized representative may ask for an appeal if the issue is not resolved as you would like.
Different insurance carriers manage approvals and payments related to your medical, behavioral health, substance use and pharmacy benefits. To avoid delays in the processing of your appeal, make sure that you submit your request on time and direct it to the correct insurance carrier. For example, you or your authorized representative will have 180 days to start an internal appeal with the medical insurance carrier following notice of an adverse determination with regard to your medical benefits.
-36- Appealing to the Insurance Company To start an appeal (sometimes called a grievance), you or your authorized representative should call the toll-free member service number on your insurance card. You or your authorized representative may file an appeal/member grievance by completing the correct form or as otherwise instructed.
The insurance company will process internal levels of appeal — Level I and Level II appeals. Decision letters will be mailed to you at each level. These letters will tell you if you have further appeal options (including independent external review) and if so, how to pursue those options and how long you have to do so.
-37- -38- LEGAL NOTICES
Anti-Discrimination and Civil Rights Compliance Benefits Administration does not support any practice that excludes participation in programs or denies the benefits of such programs on the basis of race, color, national origin, sex, age or disability in its health programs and activities. If you have a complaint regarding discrimination, please call 615-532-9617.
If you think you have been treated in a different way for these reasons, please mail this information to the Civil Rights Coordinator for the Department of Finance and Administration:
• Your name, address and phone number. You must sign your name. (If you write for someone else, include your name, address, phone number and how you are related to that person, for instance wife, lawyer or friend.) • The name and address of the program you think treated you in a different way. • How, why and when you think you were treated in a different way. • Any other key details.
Mail to: State of Tennessee, Civil Rights Coordinator, Department of Finance and Administration, Office of General Counsel, 20th Floor, 312 Rosa L. Parks Avenue, William R. Snodgrass Tennessee Tower, Nashville, TN 37243.
Need free language help? Have a disability and need free help or an auxiliary aid or service, for instance Braille or large print? Please call 1-866-576-0029.
You may also contact the: U.S. Department of Health & Human Services – Region IV Office for Civil Rights, Sam Nunn Atlanta Federal Center, Suite 16T70, 61 Forsyth Street, SW, Atlanta, Georgia 30303-8909 or 1-800-368-1019 or TTY/TDD at 1-800-537-7697 OR U. S. Office for Civil Rights, Office of Justice Programs, U. S. Department of Justice, 810 7th Street, NW, Washington, DC 20531 OR Tennessee Human Rights Commission, 312 Rosa Parks Avenue, 23rd Floor, William R. Snodgrass Tennessee Tower, Nashville, TN 37243.
If you speak a language other than English, help in your language is available for free.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-576-0029 (TTY: 1-800-848-0298).
-848-800).1 مقرب لصتا .ناجملاب كل رفاوتت ةیوغللا ةدعاسملا تامدخ نإف ،ةغللا ركذا ثدحتت تنك اذإ :ةظوحلم -0029-576- مقر) 866 1 :مكبلاو مصلا فتاھ 0298- 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-866-576-0029 (TTY:1-800-848-0298)。
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành chobạn. Gọi số 1-866-576-0029 (TTY:1-800-848- 0298).
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-866-576-0029 (TTY: 1-800-848- 0298) 번으로 전화해 주십시오.
ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-866-576-0029 (ATS : 1-800-848-0298).
Ni songen mwohmw ohte, komw pahn sohte anahne kawehwe mesen nting me koatoantoal kan ahpw wasa me ntingie [Lokaiahn Pohnpei] komw kalangan oh ntingidieng ni lokaiahn Pohnpei. Call 1-866-576-0029 (TTY: 1-800-848-0298).
ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው
ቁጥር ይደውሉ 1-866-576-0029 (መስማት ለተሳናቸው: 1-800-848-0298).
-39- ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-866-576-0029 (TTY: 1-800-848-0298).
સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-866-576-0029 (TTY:1-800- 848-0298)
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-866-576-0029（TTY:1-800-848-0298）ま で、お電話にてご連絡ください。
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-866-576-0029 (TTY: 1-800-848-0298).
ध्यान दें: यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-866-576-0029 (TTY: 1-800-848-0298) पर कॉल करें।
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-866-576-0029 (телетайп: 1-800-848-0298).
مھارف (TTY: 1-800-848-0298) 0029-576-866 امش یارب ناگیار تروصب ینابز تالیھست ،دینک یم وگتفگ یسراف نابز ھب رگا :ھجوت .دیریگب سامت اب .دشاب یم
The Notice of Privacy Practice Your health record contains personal information about you and your health. This information that may identify you and relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (PHI). The Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (HIPAA), including Privacy and Security Rules. The notice also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of the Notice of Privacy Practices. The Notice of Privacy Practice is located on the Benefits Administration website athttps://www.tn.gov/partnersforhealth.html . You may also request the notice in writing by emailing [email protected].
Prescription Drug Coverage and Medicare Medicare prescription drug coverage became available in 2006 to everyone with Medicare. By law, we are required to inform plan members of this coverage yearly. You can find a copy of the required notice regarding your options on the Benefits Administration website, https://www.tn.gov/partnersforhealth.html.
If you are actively employed or a pre-65 retiree enrolled in health coverage, you have pharmacy benefits. You do not need to enroll in Medicare prescription drug coverage regardless of your age. Once your retiree group health coverage terminates due to becoming Medicare eligible you may want to enroll in Medicare prescription drug coverage if you need pharmacy benefits.
Summary of Benefits and Coverage As required by law, the State of Tennessee Group Health Plan has created a Summary of Benefits and Coverage (SBC) for the state- sponsored health plans. The summary describes your 2021 health coverage options. You can view it online at https://www.tn.gov/ partnersforhealth/summary-of-benefits-and-coverage.html or request that we send you a paper copy free of charge. To ask for a paper copy, call Benefits Administration at 855.809.0071.
Plan Document The information contained in this guide provides a detailed overview of the benefits available to you through the State of Tennessee. More information is contained within the formal plan documents. If there is any discrepancy between the information in this guide and the formal plan documents, the plan documents will govern in all cases. You can find a copy on the Benefits Administration website at https://www.tn.gov/partnersforhealth/publications.html.
-40- Other Publications In addition to the documents mentioned above, the Benefits Administration website contains many other important publications at https://www.tn.gov/partnersforhealth/publications.html, including, but not limited to, a sample basic term life/basic AD&D certificate, sample voluntary AD&D certificate, brochures and handbooks for medical, pharmacy, dental, vision, life insurance and the plan document, brochure and handbook for The Tennessee Plan (Supplemental Medical Insurance for Retirees with Medicare). STATE OF TENNESSEE BENEFITS ADMINISTRATION DEPARTMENT OF FINANCE AND ADMINISTRATION 19TH FLOOR, 312 ROSA L. PARKS AVENUE • WILLIAM R. SNODGRASS TENNESSEE TOWER NASHVILLE, TENNESSEE 37243-1102 State of Tennessee Group term life and AD&D insurance
Insurance products issued by: Minnesota Life Insurance Company
Protect your family’s financial future Enroll in your group life insurance plan Take advantage of guaranteed coverage options You have several opportunities to elect or increase coverage without providing proof of good health:
Within 31 days of your initial eligibility • Voluntary employee term life: Elect up to 5 times annual salary • Voluntary child term life rider: Elect $5,000 or $10,000 • Voluntary accidental death and dismemberment (AD&D) : Elect single or family
Annual enrollment • Voluntary employee term life insurance: Employees currently participating may increase coverage by $5,000 as long as the resulting total does not exceed 5x base annual salary (as of September 1) or $500,000, whichever is less • Voluntary child term life rider: Elect $5,000 or $10,000 • Voluntary AD&D: Elect single or family
Voluntary coverages Voluntary • Maximum coverage is the lesser of 7x base annual salary or employee term $5,000 Increments $500,000 life insurance • Maximum if under age 55: $30,000 Voluntary • Maximum if age 55 or older: $15,000 spouse term life $5,000 Increments • Spouse is not eligible if he/she is also eligible for employee insurance coverage • Proof of good health is required • Children are eligible from live birth to 26 years of age Voluntary child • A child may only be covered by one parent $5,000 or $10,000 term life rider • Employee or spouse must have voluntary term life coverage for the voluntary child term life rider to be elected If your base Employee Family coverage annual salary is: Spouse only Spouse and child (No children) Spouse Child Less than $3,000 $6,000 $4,000 $2,000 $1,000 $3,000-$3,999 9,000 5,000 3,000 1,000 $4,000-$4,999 12,000 7,000 4,000 2,000 $5,000-$5,999 15,000 9,000 5,000 2,000 Voluntary $6,000-$6,999 18,000 11,000 7,000 2,000 AD&D single or family $7,000-$7,999 21,000 13,000 8,000 3,000 $8,000-$8,999 24,000 15,000 10,000 3,000 $9,000-$9,999 27,000 17,000 11,000 3,000 $10,000-$12,499 32,000 19,000 13,000 3,000 $12,500-$14,999 38,000 23,000 15,000 4,000 $15,000-$17,499 44,000 26,000 18,000 4,000 $17,500-$19,999 50,000 30,000 20,000 5,000 $20,000 and over 60,000 36,000 25,000 5,000
3 Basic term life and basic AD&D insurance To enroll The State of Tennessee automatically enrolls you in the basic term life and Visit LifeBenefits.com/stateoftn to basic AD&D insurance programs. The State pays for $20,000 basic term enroll and manage your voluntary life and $40,000 basic AD&D (reduced amounts if age 65 or greater). term life insurance coverage. If you enroll in the State’s medical insurance program, you pay It’s convenient, easy, mobile-friendly 100 percent of the premium for basic term life insurance in excess and available 24/7. You may only of $20,000, basic AD&D insurance in excess of $40,000, and basic elect coverage (employee, spouse dependent term life/AD&D. Dependents must be enrolled in your and child) during initial eligibility, at family medical coverage to have basic term life/basic ad&d. annual enrollment and following a Basic term life and AD&D insurance employee monthly cost by family status change. employee base annual salary bands To log in for the first time, use the Employee basic term life Family basic term life and following information: and AD&D AD&D Your User ID: Your user ID is the Less than $15,000 $0.00 $1.20 letters TN followed by your Edison $15,000-$17,499 0.40 1.62 ID number. $17,500-$19,999 0.99 2.27 Your initial password: Your eight- $20,000-$22,499 1.98 3.32 digit date of birth (MMDDYYYY) $22,500-$24,999 2.67 4.07 followed by the last four digits of $25,000-$27,499 3.37 4.83 your Social Security number. $27,500-$29,999 4.06 5.57 To enroll for voluntary AD&D please $30,000-$32,499 4.75 6.33 log into Edison and complete your $32,500-$34,999 5.45 7.06 enrollment or utilize a paper form. $35,000 and over 5.94 7.61 Consult with your agency benefits “Family” includes both employee and dependent coverage. coordinator in your human resources If your Basic AD&D office on the appropriate method to base Basic Spouse use for enrollment. annual employee Employee only Spouse and child salary is: term life Spouse Child Need some guidance? Less than $20,000 $40,000 $24,000 $16,000 $4,000 Benefit Scout™ provides $15,000 information and tools to help you $15,000- 22,000 44,000 26,000 18,000 4,000 understand and make decisions $17,499 about your life insurance benefits. $17,500- 25,000 50,000 30,000 20,000 5,000 This tool is available once you log $19,999 into LifeBenefits.com/stateoftn $20,000- 30,000 60,000 36,000 25,000 5,000 $22,499 Questions $22,500- 33,500 67,000 40,000 27,000 6,000 $24,999 For assistance, go to $25,000- LifeBenefits.com/stateoftn or 37,000 74,000 44,000 30,000 7,000 $27,499 call 1-866-881-0631 $27,500- 40,500 81,000 49,000 32,000 8,000 $29,999 $30,000- 44,000 88,000 53,000 35,000 9,000 $32,499 $32,500- 47,500 95,000 57,000 38,000 9,000 $34,999 $35,000 50,000 100,000 60,000 40,000 10,000 and over Beginning at age 65, employee term/AD&D and spouse AD&D coverages reduces to a percentage of the amount in effect prior to age 65: to 65 percent at age 65, to 45 percent at age 70 and to 30 percent at age 75. All rates subject to change.
3 4 Monthly cost of coverage Monthly cost of coverage
Voluntary AD&D insurance employee monthly cost by employee Voluntary term life base annual salary bands (Rates/$1,000/month) Rates increase with age Employee voluntary AD&D Family voluntary AD&D Age Voluntary employee Less than $3,000 $ 0.11 $0.29 and spouse $3,000-$3,999 0.16 0.34 Under 30 $0.049 $4,000-$4,999 0.22 0.40 30-34 0.053 $5,000-$5,999 0.27 0.45 35-39 0.065 $6,000-$6,999 0.32 0.50 40-44 0.099 $7,000-$7,999 0.38 0.56 45-49 0.167 $8,000-$8,999 0.43 0.61 50-54 0.282 $9,000-$9,999 0.49 0.67 55-59 0.440 $10,000-$12,499 0.58 0.76 60-64 0.685 $12,500-$14,999 0.68 0.86 65-69 1.136 $15,000-$17,499 0.79 0.97 70-74 1.585 $17,500-$19,999 0.90 1.08 75-79 2.435 $20,000 and over 1.08 1.26 80 and over 4.399 “Family” includes both employee and dependent coverage. Age as of January 1 of each year. All rates subject to change.
Calculate your costs for voluntary term life Voluntary child term life rider One premium provides coverage Use this example as your guide to calculating the life insurance costs for all eligible children for voluntary term life. $5,000 $0.40 per month $10,000 $0.80 per month Example: All rates are subject to change. Employee age 38, chooses $150,000 in coverage $150,000 ÷ $1,000 = 150 x $.065 + $0.24 = $9.99 Take your coverage Coverage Coverage Monthly Administrative Monthly with you amount units rate cost cost If you are no longer eligible for coverage as an active employee, you may be eligible to port up to 50 percent of your voluntary group term life insurance under the group This is a summary of plan provisions related to the insurance policy issued by Minnesota Life Insurance Company to the State of Tennessee. In the event of a conflict between this plan with a minimum of $5,000. summary and the policy and/or certificate, the policy and/or certificate shall dictate the Insurance will be on a direct insurance provisions, exclusions, all limitations and terms of coverage. All elections or bill basis. Continued (ported) increases are subject to the actively at work requirement of the policy for employees and the hospitalization confinement provision for dependents. coverage ends at the end of the Insurance products are underwritten by Minnesota Life Insurance Company, an affiliate year you reach age 70. Rates of Securian Financial Group, Inc. Products are offered under policy form series 13-31526 are the same as those paid by (Basic life), 12-31463 (Voluntary life) and 13-31554 (Voluntary AD&D). active employees. Or you may Securian Financial is the marketing name for Securian Financial Group, Inc., and its convert your life coverage to an affiliates. Minnesota Life Insurance Company is an affiliate of Securian Financial Group, Inc. individual life insurance policy. Premiums may be higher than those paid by active employees for converted coverage. INSURANCE INVESTMENTS RETIREMENT lifebenefits.com
400 Robert Street North, St. Paul, MN 55101-2098 ©2019 Securian Financial Group, Inc. All rights reserved.
F77989-22 Rev 6-2019 DOFU 7-2019 854273 Voluntary Group Term Life Insurance Enrollment
Minnesota Life Insurance Company - A Securian Company AA Group Customer Service 400 Robert Street North St. Paul, Minnesota 55101-2098
EMPLOYER NAME: State of Tennessee POLICY NUMBER: 34175
Reason for Enrollment: New Hire Family Status Change Date of Family Status Change Annual Enrollment 1. Complete sections A, B, and F. 2. If you are electing coverage on your dependents, complete sections C, D, and/or E. If you have questions, please contact Minnesota Life at 1-866-881-0631. A. EMPLOYEE INFORMATION First name Middle initial Last name
Email address
Street address City State Zip code
Date of birth Social Security number Date of employment Gender Male Female Total amount of insurance requested ($5,000 increments to a maximum of 7 times base annual salary or $500,000, whichever is less. Up to 5 times base annual salary is guaranteed if elected within 30 days of hire. Electing 6x or 7x base salary will require you to complete the separate Evidence of Insurability form.) $ Check this box for the $5,000 Annual Enrollment increase ONLY B. EMPLOYEE BENEFICIARY INFORMATION Primary beneficiary(ies) designation (include full name and address) Relationship Share % (Primary The person or persons named will receive the benefits. beneficiaries must total 100%)
Contingent beneficiary(ies) designation (include full name and address) Relationship Share % (Contingent If the primary beneficiary(ies) is no longer living, the benefit is paid to this person(s). beneficiaries must total 100%)
PLEASE NOTE: If you do not designate a beneficiary, any death proceeds would be paid out at State of TN's plan default: 1. Spouse 2. Child(ren) 3. Parent(s) 4. Estate of Insured C. SPOUSE INFORMATION First name Middle initial Last name
Email address
Has your spouse been hospitalized, advised to seek medical treatment, or received disability benefits in the past six months? Yes No Date of birth Social Security number Gender Male Female Total amount of Spouse Voluntary Term Life insurance requested $5,000 $10,000 $15,000 $20,000 (Spouse under age 55 only) $25,000 (Spouse under age 55 only) $30,000 (Spouse under age 55 only) D. SPOUSE BENEFICIARY DESIGNATION (if no beneficiary is designated, employee will be the default beneficiary for spouse coverage) Primary beneficiary(ies) designation (include full name and address) Relationship Share % (Primary The person or persons named will receive the benefits. beneficiaries must total 100%)
Contingent beneficiary(ies) designation (include full name and address) Relationship Share % (Contingent If the primary beneficiary(ies) is no longer living, the benefit is paid to this person(s). beneficiaries must total 100%)
03-30566.41 EdF77977 Rev 12-2016 E. CHILDREN INFORMATION (Employee is the beneficiary of child coverage) List of names and dates of birth for your eligible children:
Total amount of insurance requested $5,000 $10,000 F. AUTHORIZATION I authorize my employer to withdraw premiums from my salary to pay for voluntary insurance coverage.
I authorize the State Group Insurance Plan to release to Minnesota Life on behalf of myself and all family members information (name, address, Social Security number, age, gender, salary, enrollment effective/termination dates) required to establish eligibility and coverage levels for the purpose of obtaining life insurance coverage. This authorization shall be in force for the time period I have a pending application or am enrolled with this life insurance company. The State Group Insurance Plan will not condition treatment, payment, or enrollment eligibility on the signature of this authorization and may not have the right to control further disclosures of this information. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Employee signature Daytime phone number Evening phone number Date signed X
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1.855.Here4TN (1.855.437.3486) www.Here4TN.com Alcohol or drug concerns and loss Grief Family and relationships Stress a referral or for additional information. you. Call or log on to talk with someone, to receive counseling sessions per problem at no cost to Remember, ParTNers EAP provides up to five Life is Unpredictable and Ever Changing. Your ParTNer’s Employee Assistance Program is a Valuable, Confidential and No Cost Resource. Legal and financial issues Depression and anxiety Health and wellness Work-life balance
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B-C1101 (3/14) State and Higher Education
2021 Active Employees Monthly Health Premiums
ALL REGIONS CIGNA CIGNA EMPLOYER BCBST LOCALPLUS OPEN ACCESS SHARE PREMIER PPO Employee Only $140 $140 $180 $558 Employee + Child(ren) $210 $210 $250 $837 Employee + Spouse $292 $292 $372 $1,172 Employee + Spouse + Child(ren) $362 $362 $442 $1,451 STANDARD PPO Employee Only $95 $95 $135 $558 Employee + Child(ren) $143 $143 $183 $837 Employee + Spouse $200 $200 $280 $1,172 Employee + Spouse + Child(ren) $248 $248 $328 $1,451 CDHP/HSA Employee Only $62 $62 $102 $558 Employee + Child(ren) $91 $91 $131 $837 Employee + Spouse $129 $129 $209 $1,172 Employee + Spouse + Child(ren) $158 $158 $238 $1,451 2021 Monthly Dental Premiums
CIGNA METLIFE PREPAID PLAN DPPO PLAN ACTIVE MEMBERS Employee Only $13.84 $23.64 Employee + Child(ren) $28.75 $54.36 Employee + Spouse $24.54 $44.72 Employee + Spouse + Child(ren) $33.74 $87.50
COBRA PARTICIPANTS Employee Only/Single $14.12 $24.11 Employee + Child(ren) $29.33 $55.45 Employee + Spouse $25.03 $45.61 Employee + Spouse + Child(ren) $34.41 $89.25
COBRA DISABILITY PARTICIPANTS Employee Only/Single $20.76 $35.46 Employee + Child(ren) $43.13 $81.54 Employee + Spouse $36.81 $67.08 Employee + Spouse + Child(ren) $50.61 $131.25
RETIREE PARTICIPANTS Retiree Only $15.23 $30.52 Retiree + Child(ren) $31.63 $70.18 Retiree + Spouse $27.01 $57.74 Retiree + Spouse + Child(ren) $37.10 $112.98 2021 Monthly Vision Premiums
BASIC PLAN EXPANDED PLAN ACTIVE MEMBERS Employee Only $3.07 $5.56 Employee + Child(ren) $6.13 $11.12 Employee + Spouse $5.82 $10.57 Employee + Spouse + Child(ren) $9.01 $16.35
COBRA PARTICIPANTS Employee Only/Single $3.13 $5.67 Employee + Child(ren) $6.25 $11.34 Employee + Spouse $5.94 $10.78 Employee + Spouse + Child(ren) $9.19 $16.68
COBRA DISABILITY PARTICIPANTS Employee Only/Single $4.61 $8.34 Employee + Child(ren) $9.20 $16.68 Employee + Spouse $8.73 $15.86 Employee + Spouse + Child(ren) $13.52 $24.53
RETIREE PARTICIPANTS Retiree Only $3.07 $5.56 Retiree + Child(ren) $6.13 $11.12 Retiree + Spouse $5.82 $10.57 Retiree + Spouse + Child(ren) $9.01 $16.35 Spouse Only $3.07 $5.56 One Child Only $3.07 $5.56 Two or More Children Only $6.13 $11.12 Spouse + Children Only $6.13 $11.12 2021 Health Plan Comparison — State and Higher Education PPO services in this table ARE NOT subject to a deductible. CDHP/HSA services in this table ARE subject to a deductible with the exception of in-network preventive care and 90-day supply maintenance medications. In the table, $ = your copayment amount; % = your coinsurance; and 100% covered or No charge = you pay $0 in-network. HEALTHCARE OPTION PREMIER PPO STANDARD PPO CDHP/HSA Member Costs Member Costs Member Costs COVERED SERVICES IN-NETWORK [1] OUT-OF-NETWORK [1] IN-NETWORK [1] OUT-OF-NETWORK [1] IN-NETWORK [1] OUT-OF-NETWORK [1] PREVENTIVE CARE — OFFICE VISITS • Well-baby, well-child visits as recommended No charge $45 No charge $50 No charge 40% • Adult annual physical exam • Annual well-woman exam • Immunizations as recommended • Annual hearing and non-refractive vision screening • Screenings including Pap smears, labs, nutritional guidance, tobacco cessation counseling and other services as recommended OUTPATIENT SERVICES — SERVICES SUBJECT TO A COINSURANCE MAY BE EXTRA Primary Care Office Visit $25 $45 $30 $50 20% 40% • Family practice, general practice, internal medicine, OB/GYN and pediatrics • Nurse practitioners, physician assistants and nurse midwives (licensed healthcare facility only) working under the supervision of a primary care provider • Including surgery in office setting and initial maternity visit Specialist Office Visit $45 $70 $50 $75 20% 40% • Including surgery in office setting • Nurse practitioners, physician assistants and nurse midwives (licensed healthcare facility only) working under the supervision of a specialist Behavioral Health and Substance Use [2] $25 $45 $30 $50 20% 40% • Including virtual visits Telehealth (approved carrier programs only) $15 N/A $15 N/A 20% N/A Allergy Injection Without an Office Visit 100% covered 100% covered up to MAC 100% covered 100% covered up to MAC 20% 40% Chiropractic and Acupuncture Visits 1-20: $25 Visits 1-20: $45 Visits 1-20: $30 Visits 1-20: $50 20% 40% • Limit of 50 visits of each per year Visits 21-50: $45 Visits 21-50: $70 Visits 21-50: $50 Visits 21-50: $75 Convenience Clinic $25 $45 $30 $50 20% 40% Urgent Care Facility $45 $70 $50 $75 20% 40% Emergency Room Visit $150 $175 20% PHARMACY 30-Day Supply $7 generic; copay plus $14 generic; copay plus 20% 40% plus $40 preferred brand; amount exceeding MAC $50 preferred brand; amount exceeding MAC amount exceeding MAC $90 non-preferred $100 non-preferred 90-Day Supply (90-day network pharmacy or mail $14 generic; N/A - no network $28 generic; N/A - no network 20% N/A - no network order) $80 preferred brand; $100 preferred brand; $180 non-preferred $200 non-preferred 90-Day Supply (certain maintenance medications from $7 generic; N/A - no network $14 generic; N/A - no network 10% without first having N/A - no network 90-day network pharmacy or mail order) [3] $40 preferred brand; $50 preferred brand; to meet deductible $160 non-preferred $180 non-preferred Specialty Medications (30-day supply from a specialty 10%; N/A - no network 10%; N/A - no network 20% N/A - no network network pharmacy) min $50; max $150 min $50; max $150
August 2020 Learn more at tn.gov/partnersforhealth 2021 Health Plan Comparison — State and Higher Education PPO services in this table ARE subject to a deductible unless noted with a [5]. CDHP/HSA services in this table ARE subject to a deductible with the exception of in-network preventive care. In the table, % = your coinsurance. HEALTHCARE OPTION PREMIER PPO STANDARD PPO CDHP/HSA Member Costs Member Costs Member Costs COVERED SERVICES IN-NETWORK [1] OUT-OF-NETWORK [1] IN-NETWORK [1] OUT-OF-NETWORK [1] IN-NETWORK [1] OUT-OF-NETWORK [1] PREVENTIVE CARE – OUTPATIENT FACILITIES • Screenings including colonoscopy, mammogram, No charge [5] 40% No charge [5] 40% No charge 40% colorectal, bone density scans and other services as recommended OTHER SERVICES Hospital/Facility Services [4] 10% 40% 20% 40% 20% 40% • Inpatient care; outpatient surgery • Inpatient behavioral health and substance use [2] [6] Maternity 10% 40% 20% 40% 20% 40% • Global billing for labor and delivery and routine services beyond the initial office visit Home Care [4] 10% 40% 20% 40% 20% 40% • Home health; home infusion therapy Rehabilitation and Therapy Services 10% 40% 20% 40% 20% 40% • Inpatient and skilled nursing facility [4]; outpatient • Outpatient IN-NETWORK physical, occupational and speech therapy [5] X-Ray, Lab and Diagnostics (not including advanced 10% 20% 20% 40% x-rays, scans and imaging) [5] Advanced X-Ray, Scans and Imaging 10% 40% 20% 40% 20% 40% • Including MRI, MRA, MRS, CT, CTA, PET and nuclear cardiac imaging studies [4] All Reading, Interpretation and Results [5] 10% 20% 20% Ambulance (air and ground) 10% 20% 20% Equipment and Supplies [4] 10% 40% 20% 40% 20% 40% • Durable medical equipment and external prosthetics • Other supplies (i.e., ostomy, bandages, dressings) Also Covered Certain limited Dental benefits, Hospice Care and Out-of-Country Charges are also covered subject to applicable deductible and coinsurance. See separate sections in the Member Handbook for details. DEDUCTIBLE Employee Only $500 $1,000 $1,000 $2,000 $1,500 $3,000 Employee + Child(ren) $750 $1,500 $1,500 $3,000 $3,000 $6,000 Employee + Spouse $1,000 $2,000 $2,000 $4,000 $3,000 $6,000 Employee + Spouse + Child(ren) $1,250 $2,500 $2,500 $5,000 $3,000 $6,000 OUT-OF-POCKET MAXIMUM – MEDICAL AND PHARMACY COMBINED – ELIGIBLE EXPENSES, INCLUDING DEDUCTIBLE, COUNT TOWARD THE OUT-OF-POCKET MAXIMUM Employee Only $3,600 $4,000 $4,000 $4,500 $2,500 $4,500 Employee + Child(ren) $5,400 $6,000 $6,000 $6,750 $5,000 $9,000 Employee + Spouse $7,200 $8,000 $8,000 $9,000 $5,000 $9,000 Employee + Spouse + Child(ren) $9,000 $10,000 $10,000 $11,250 $5,000 $9,000 CDHP STATE HEALTH SAVINGS ACCOUNT (HSA) CONTRIBUTION For individuals who enroll in the CDHP N/A N/A State contribution to HSA: $250 for employee only; $500 for employee+child(ren), employee+spouse and employee+spouse+child(ren)
Only eligible expenses will apply toward the deductible and out-of-pocket maximum. Charges for non-covered services and amounts exceeding the maximum allowable charge (MAC) will not be counted. For PPO Plans, no single family member will be subject to a deductible or out-of-pocket maximum greater than the “employee only” amount. Once two or more family members (depending on premium level) have met the total deductible and/or out-of-pocket maximum, it will be met by all covered family members. For CDHP Plan, the deductible and out-of-pocket maximum amount can be met by one or more persons but must be met in full before it is considered satisfied. See the “Out of Pocket Maximums” section in the Member Handbook for more details. For CDHP Plan, coinsurance is after deductible is met unless otherwise noted. [1] Subject to maximum allowable charge (MAC). The MAC is the most a plan will pay for a covered service. For non-emergent care from an out-of-network provider who charges more than the MAC, you will pay the copay or coinsurance PLUS the difference between MAC and actual charge. [2] The following behavioral health services are treated as “inpatient” for the purpose of determining member cost-sharing: residential treatment, partial hospitalization/day treatment programs and intensive outpatient therapy. In addition to services treated as “inpatient,” prior authorization (PA) is required for certain outpatient behavioral health services including, but not limited to, applied behavioral analysis, transcranial magnetic stimulation, electroconvulsive therapy, psychological testing, and other behavioral health services as determined by the Contractor’s clinical staff. [3] Applies to certain antihypertensives for coronary artery disease (CAD) and congestive heart failure (CHF); oral diabetic medications, insulin and diabetic supplies; statins; medications for asthma, COPD (emphysema and chronic bronchitis), depression and osteoporosis medications. [4] Prior authorization (PA) required. When using out-of-network providers, benefits for medically necessary services will be reduced by half if PA is required but not obtained, subject to the maximum allowable charge. If services are not medically necessary, no benefits will be provided. [5] For PPO Plans, the deductible DOES NOT apply. [6] Select Substance Use Treatment Facilities are preferred with an enhanced benefit - PPO members won’t have to pay a deductible or coinsurance for facility-based substance use treatment; CDHP members must meet their deductible first, then coinsurance is waived. Copays for PPO and deductible/ coinsurance for CDHP will apply for standard outpatient treatment services. Call 855-Here4TN for assistance. August 2020 Learn more at tn.gov/partnersforhealth Covered Dental Services Here is a comparison of your deductibles, copays and share of coinsurance for 2021 under the dental options. The benefits listed are a sample of the most frequently utilized dental treatments. For a complete list of copays for the Cigna Prepaid option, please refer to the Patient Charge Schedule. Also, review the Cigna Certificate of Coverage for complete details on benefits, limitations, and exclusions. Both documents may be found on the website cigna.com/stateoftn. MAC—Maximum Allowable Charge is the highest dollar amount of reimbursement for specific dental procedures provided by DPPO network providers. The in-network dentists have agreed to not charge members or the plan more than the MAC. When a member receives dental services from an out-of-network provider, the out-of-network dentist will be paid by the plan for covered procedures according to the in-network MAC and respective plan coinsurance. The member then is responsible for all other charges by the out-of- network dentist. Review additional information on the ParTNers for Health website tn.gov/partnersforhealth.html under Other Benefits and Dental. CIGNA PREPAID OPTION METLIFE DPPO OPTION COVERED SERVICES GENERAL DENTIST SPECIALIST DENTIST IN-NETWORK OUT-OF-NETWORK Annual Deductible none $25 single; $75 family, $100 single; $300 family, per plan year [1] per plan year [1] Annual Maximum Benefit none $1,500 per person, per policy year Pre-existing Conditions covered some exclusions Office Visit $10 copay [2] no charge 20% of MAC Periodic Oral Evaluation no charge no charge 20% of MAC Routine Cleaning – Adult no charge no charge 20% of MAC Routine Cleaning – Child no charge $15 copay no charge 20% of MAC X-ray — Intraoral, Complete Series no charge $5 copay no charge 20% of MAC Amalgam (silver) Filling Two Surfaces $8 copay $10 copay 20% of MAC 40% of MAC Permanent teeth Endodontics — Root Canal Therapy Molar $125 copay [7] $600 copay [7] 20% of MAC 40% of MAC (excluding final restoration) Major Restorations — Crowns $190 copay, plus lab fees [3] [7] 50% of MAC [4] Extraction of Erupted Tooth (minor oral surgery) $15 copay $70 copay 20% of MAC 40% of MAC Implant (endosteal) $1,025 copay [7] $1,025 copay [7] 50% of MAC [4] [8] Removal of Impacted Tooth — Complete Bony $100 copay $120 copay 50% of MAC (complex oral surgery) Dentures — Complete Upper $310 copay, plus lab fees [3] [7] 50% of MAC [4] [8] Orthodontics $140 monthly copay for treatment equal or less 50% of MAC than 24 months. Then, full charge. [6] • Annual Deductible none none • Lifetime Maximum $3,360 copay ($140 x 24 months) for treatment $1,250 [5] fee only. Then, member pays full charge after initial 24 months. [6] • Waiting Period none 12 months • Age Limit none up to age 19 [1] Does not apply to diagnostic and preventive benefits such as periodic oral evaluation, cleaning and x-ray. [2] A charge may apply for a missed appointment when the member does not cancel at least 24 hours prior to the scheduled appointment. [3] Members are responsible for additional lab fees for these services. [4] A 6-month waiting period applies. (See #8 for additional information for dentures and implants.) [5] The orthodontics lifetime maximum is for a dependent member enrolled in the state group dental insurance program even if the member has been covered under different employing agencies. [6] Additional copays apply for specific orthodontic procedures. Cigna will not cover orthodontic procedures after a member’s effective date with Cigna Prepaid if orthodontic treatment began prior to the member’s effective date. Orthodontic treatment started under the prior Cigna Prepaid contract with the state will continue to be covered under the new Cigna Prepaid contract effective January 1, 2021. [7] Completion of crowns, bridges, dentures, implants, or root canal already in progress on member’s effective date of coverage with Cigna Prepaid will not be covered. [8] A 12-month waiting period applies to dentures and implants to replace one or more natural teeth missing before member’s effective date of coverage.
July 2020 Covered Vision Services Here is a comparison of discounts, copays and allowed amounts for 2021 under the vision options. Copays represent what the member pays. Allowances and percentage discounts represent the cost the carrier will cover. Actual costs and benefits may vary based upon the plan design selected. Exclusions and limitations may apply. Out-of-network member costs can be found in the Davis Vision Handbook at https://www.tn.gov/partnersforhealth/publications/publications.html.
SERVICE BASIC PLAN IN-NETWORK COSTS [1] EXPANDED PLAN IN-NETWORK COSTS [1] Eye Exam With Dilation as Necessary $0 copay $10 copay Retinal Imaging $39 copay $39 copay Contact Lens fit and Follow up (standard/specialty) 80% of charge $50/$60 copay Eyeglass Benefit—Frame Retail Frame 80% of balance over $55[2] 80% of balance over $150[2] Visionworks Frame Covered in full Covered in full The Exclusive Collection[3] In lieu of retail frame In lieu of retail and Visionworks frame (Fashion/Designer/Premier) $0/$15/$40 copay $0/$0/$0 copay Eyeglass Benefit—Spectacle Lenses Single Vision, Bifocal, Trifocal & Lenticular Lenses $0 copay $0 copay Progressive Lenses 80% of balance over $55; (Standard/Premium/Ultra/Ultimate) not to exceed $65/$105/$140/$175 out of pocket $50/$90/$140/$175 copay High-index (1.67/1.74) 80% of charge not to exceed $60/$120 $60 copay/$120 copay UV Treatment 80% of charge up to $15 $10 copay Tint (solid and gradient) 80% of charge up to $15 $15 copay Standard Polycarbonate (adults/children[4]) 80% of charge up to $35/$0 copay $30 copay/$0 copay Anti-reflective Coating 80% of charge up to $40/$55/$69/$85 $40/$55/$69/$85 copay (Standard/Premium/Ultra/Ultimate) Polarized 80% of charge up to $75 80% of charge up to $75 Plastic Photochromic Lenses 80% of charge up to $70 80% of charge up to $70 Scratch coating (standard plastic/premium scratch-resistant) $0 copay/80% of charge up to $30 $0 copay/$30 copay Scratch Protection Plan (single vision/multifocal $20 copay/$40 copay $20 copay/$40 copay lenses) Trivex Lenses 80% of charge up to $50 $50 copay Digital Single Vision (intermediate) lenses 80% of charge up to $30 $30 copay Blue Light Filtering 80% of charge up to $15 $15 copay Other Add-ons and Services 80% of charge 80% of charge Contact Lenses Conventional and Disposable 80% of balance over $55 80% of balance over $140 Visually Required[5] 80% of balance over $155 $0 copay Frequency of Vision Benefits Eye Exam Once every calendar year Once every calendar year Eyeglass Lenses Once every calendar year Once every calendar year Frames Once every two calendar years Once every two calendar years Contact Lenses Once every calendar year in lieu of eyeglasses Once every calendar year in lieu of eyeglasses Contact Lens Evaluation, Fitting and Follow-up Once every calendar year in lieu of eyeglasses Once every calendar year in lieu of eyeglasses
[1] Member pay will not be greater than the copay, but could be less based upon the actual charge. [2] $0 copay for eyeglass frames at Visionworks. [3] Collection is available at most participating eye care professional offices. Collection is subject to change. [4] Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with prescriptions 6.00 diopters or greater. [5] If visually required as first contact lenses following cataract surgery, or multiple pairs of rigid contact lenses for treatment of keratoconus. STATE OF TENNESSEE DENTAL BENEFIT OPTION
A Guide to your Cigna Dental Care® Prepaid Plan
Sponsored by the State of Tennessee I 2021
Offered by Cigna Health and Life 887429 e 07/20 Insurance Company or its affiliates IMPORTANT PLAN INFORMATION
We are pleased to provide information about the prepaid dental plan. This plan offers a full range of benefits through a network of participating dentists. Cigna is providing your prepaid dental benefit plan.1
NEW THIS YEAR FOR 2021
Implant Coverage Benefit (surgical placement of implants) limited to one implant per calender year with a replacement of 1 every 10 years Teledentistry will be at no cost
Important details You must select a network general dentist who will manage your overall dental care. Covered family members can choose their own network general dentists – near home, work or school. You may choose a network pediatric dentist for children under the age of 13.* If you need assistance in selecting a dentist, contact Cigna at 800.997.1617. › You will pay the copay amount listed on your Patient Charge Schedule (PCS) for covered dental services performed by your network dentist. › An Office Visit Fee Copay applies per patient, per office visit, and is in addition to any other applicable patient charges. Please refer to the Patient Charge Schedule. Visit Cigna.com/stateoftn – click on the dental tab to find a copy of the Patient Charge Schedule (PCS). › If your network general dentist does not perform the specialty care procedure you need, he/she can direct you to a participating network specialist. › Procedures not listed on your PCS are not covered and are the patient’s responsibility at the dentist’s usual fees. › Remember: If you seek covered services from a dentist who does not participate in the Cigna dental network for the State of Tennessee, your plan will not pay except in the case of an emergency, or as required by law. Participation Requirements: An agency must be participating in the State of Tennessee Sponsored Group Health Plan in order to qualify for participation in the State of Tennessee Voluntary Dental Program. Employee, Retiree, and/or Dependent participation in the State Sponsored Group Health Plan is not required to participate in the State Dental Program. Employee or Retiree participation in the Prepaid Dental Program is required for participation of eligible Dependents. Participation by those enrolled in the Prepaid Dental Program is on a calendar year basis, and enrollment may only be dropped by the Members during the Annual Enrollment Period for the beginning of the next calendar year or due to a special qualifying event. We will also allow dropping2 of your Prepaid enrollment if there is no participating general dentist within a 25-mile radius of your home. * Subject to state regulatory approval
The Cigna Dental Care Prepaid plan for the State of Tennessee Group Insurance Plan is not available in every state. Currently it is not available in Alaska, Idaho, Maine, Montana, New Hampshire, New Mexico, North Dakota, Puerto Rico, South Dakota, Vermont, West Virginia, Wyoming, and US Virgin Islands. What’s covered You can save money on a wide range of services, including: › Preventive care – cleanings, fluoride, sealants, bitewing x-rays, full-mouth x-rays and more. › Basic care – tooth-colored fillings (called resin or composite) and silver-colored fillings (called amalgam). › Major services – crowns, bridges, dentures, implants, root canals, oral surgery, extractions, treatment for periodontal (gum) disease and more. › Specialty care – provided at the specialist copay listed on your PCS only when performed by your network specialist dentist. › Orthodontic care – all plans include coverage for braces for children and adults.2 Check your plan materials. Plan materials can be found at Cigna.com/sites/stateoftn. › General anesthesia – when medically necessary. › Temporomandibular joint (TMJ) – diagnosis and treatment procedures, including cone beam x-ray and appliance. For more details review your enrollment materials at Cigna.com/sites/stateoftn.
Plan features: › No deductibles – you don’t have to reach a certain level of out-of-pocket expenses before your insurance kicks in. › No dollar maximums – you don’t have to worry about your coverage running out after your covered expenses reach a certain dollar amount. › There are no claim forms to file when using network dentists andno waiting periods for coverage. › Coverage for dental conditions that exist at the time you enroll in the plan are not excluded if they are otherwise covered under your PCS. Treatment started before your coverage begins will not be covered.3 For example, if you already have braces and receiving care for the braces, you will have to pay the full charge from the orthodontist. › There is a $10 office visit fee that you are required to pay in addition to any other copay outlined on your Patient Charge Schedule (PCS).
Savings you can see
MONTHLY PAYROLL DEDUCTIONS FOR 2021 Employee $13.84 Retiree $15.23 Employee + spouse $24.54 Retiree + spouse $27.01 Employee + child(ren) $28.75 Retiree + child(ren) $31.63 Employee + family $33.74 Retiree +family $37.10
Costs are subject to change. 3 YOUR QUESTIONS ANSWERED
Q: How does the Cigna Dental Care Prepaid Plan work? A: When you sign up in the Cigna Dental Care Prepaid Plan, you must select a network general dentist, who will handle your dental care needs. You then receive a Patient Charge Schedule (PCS), that lists the specific dental procedures covered by the plan and the amount you will pay the dentist (your copays). These copays apply only when you receive treatment from the dentists or dental specialists in the Cigna network for the State of Tennessee. If a dental procedure is not listed on your PCS, it is not covered and you will have to pay according to the dentist’s regular fees. If you receive a covered service from a dentist who does not participate in the Cigna Dental Care network for the State of Tennessee plan, your dental benefits may not be covered at all except in the case of an emergency or where required by law.4 You can take your PCS to dental appointments to discuss treatment options and costs with your dentist (but it is not required).
Q: How do I choose a dentist when I sign up for the plan? Can I change my network general dentist later on? A: You can find a network dentist by visitingCigna.com/sites/stateoftn where the instructions are posted on how to access the pre-effective myCigna.com log on process. This will allow you to view dental network information specific to the State of TN DHMO Prepaid Dental Plan. Or, if you are already a member, you can go to your personalized myCigna.com account. If you need help finding a dentist, you can call the customer service number below and request to have a list of providers mailed, emailed or faxed to you. You can change your network dentist at any time; changes made by the 15th of the month go into effect the first of the following month. If you need an immediate change, customer service can help 24/7. Remember, if you visit a non-network dentist, your treatment may not be covered at all.4 If you’d like to speak with someone, call customer service at 800.997.1617. You can also follow the phone prompts to use our automated Dental Office Locator. The automated system will speak the names of the dentists in your area, mail, email or fax a list of dentists to you.
Q: If I’m new to the Cigna Dental Care Prepaid Plan, can I keep my current dentist? A: That depends. If your current dentist participates in the Cigna Dental Care Network for the State of Tennessee plan, you can choose him/her as your network general dentist. You can look online at Cigna.com/sites/stateoftn to find out, or ask your dental office directly. Sometimes, Cigna’s online Dental Office Directory may show that your dental office is not accepting new patients even when their office says they are. If this happens, please contact customer service at 800.997.1617 for assistance. 4 Q: Do I need a referral to visit a dental specialist? A: Yes. If you require specialty care, your network general dentist will refer you to a network dental specialist – and handle any paperwork. Referrals are required for all network specialists, except orthodontists and pediatric dentists.
Q: Do I need to show my ID card when I arrive at the dentist’s office? A: No. ID cards are not required to use the plan. When you call to schedule your appointment, just let your selected network dental office know that you are covered under the Cigna Dental Care Prepaid Plan. If for some reason the dental office does not see your name on its list of Cigna Dental Care Prepaid Plan customers, they can call us to verify. You can also call customer service at 800.997.1617 if you need more help.
Q: When do I have to pay the dentist? A: Typically copays are due at the time services are received. However, it depends on the financial arrangement between you and your network dentist. We encourage you to discuss costs and payment arrangements for dental treatment with your dentist before you receive care. Most dentists will work with their patients to arrange payment plans for more costly treatments.
Q: Will my network dentist submit a claim to Cigna after I receive treatment? A: No. There are no claim forms required when receiving care from a network dentist.
Q: Are braces covered? A: Yes. A maximum benefit of 24 months of interceptive and/or comprehensive orthodontic treatment is covered as shown on your PCS. Cases beyond 24 months may require additional payments by the patient, which are based on the dentist’s contracted fee and may be different from the copay listed in the PCS. If you or your family member started treatment before you joined the Cigna Dental Care Prepaid Plan (called “orthodontics in progress”), this treatment3 is excluded.
Q: Are dental implants covered? A: Yes. Surgical placements of implants is covered as shown on your PCS. Limited to one implant per calendar year with a replacement of 1 every 10 years.
5 Q: What if I have a dental emergency and can’t get treatment from my network general dentist? A: Emergency services: If you are out of your service area or unable to contact your network general dentist, you may receive emergency services by any licensed dentist for unexpected but necessary services. Emergency services are limited to relieving severe pain, controlling excessive bleeding and eliminating serious and sudden (“acute”) infection. Routine restorative procedures or definitive treatment (e.g., root canal) are not considered emergency care and you should return to your network general dentist for these procedures. Emergency care out of your service area: For emergency covered services, you will be responsible for the Patient Charges listed on your PCS. Cigna Dental will reimburse you the difference, if any, between the dentist’s Usual Fee for emergency covered services and your Patient Charge, up to a total of $50 per incident (this amount may vary by state). To request reimbursement, send the dentist’s itemized statement to Cigna Dental at the address listed for your state on your plan materials. Emergency care after hours: There is a copay listed on your PCS for emergency care received after regularly scheduled office hours. This copay will be in addition to other copays that may apply.
6 HOW TO FIND A DENTIST It’s easy to find a Cigna network dentist or specialist.
Before you enroll, you can check to see if your dentist is in the Cigna Dental Care network for the State of Tennessee plan. Here’s how. Visit myCigna.com Enter the below information User ID: Dhmo01 Password: Stateoftn1 Click “Login”
Once you have logged into myCigna.com Step 1 Click on “Find Care & Costs” at the top of the screen. Step 2 The geographic location automatically populates based on your home address. If you would like to change the location, you must hover over the current location and click “Edit” to change. Step 3 Select one of the four blue search category boxes to search by Doctor by Type, Doctor by Name, Reason for visit or Locations. Step 4 From the Search Results page, you can further refine your results – by applying the provided filters. Click on a dentist’s name for more details, including multiple locations listing with map view.
Choose-a-dentist tools With your Cigna Dental Care Prepaid Plan, you get access to intuitive tools that make it easier to choose a dentist that’s right for you. Visit the myCigna® website or mobile app – anytime, just about anywhere to discover:5 › Brighter Score® feature. Use › Some network specialists offer this score to compare dentists, online appointment scheduling, so based on patient experience and you can book appointments online professional history. and then receive reminders. › Office reviews and comparisons. › Enhanced search and transparent Read verified patient reviews and pricing. Search by dentist or view dentist profiles, including procedures to estimate out-of- pictures and videos. pocket costs for your specific plan.
7 Once you’re enrolled, register for myCigna.com to find a dentist, access your claims, compare the cost of procedures and so much more. It’s easy to set up. Visit myCigna.com or download* the myCigna App today: › Select “Register” › Enter your name, address and date of birth › Confirm your identity with your Cigna ID number, Social Security number, or with the myCigna security questionnaire › Create a user ID and password › Review then select “Submit” Already have an ID but haven’t visited in a while? That’s ok! If you don’t remember your ID or password, just click “forgot user ID” or “forgot password” on the registration page and we’ll help you out.
You can also find a dentist 24/7/365 by calling the number on your ID card, or 800.997.1617. › Use the Dental Office Locator via Speech Recognition. › Speak with a customer service representative, who can send you a customized network directory listing via email for the Cigna Dental Care Network for the State of Tennessee plan. › Tell us which office you choose. Each covered family member can select his/her own network general dentist.
* The downloading and use of the myCigna app is subject to the terms and conditions of the app and the online store from which it is downloaded. Standard mobile phone carrier and data usage charges apply. 8 Under your plan, you have coverage for hundreds of dental procedures. This overview shows you a small sampling of covered services and what you will pay compared to your estimated cost without coverage. See savings below. You can find a full list of dental procedures on the Patient Charge Schedule available at Cigna.com/sites/stateoftn.
WHAT YOU’LL PAY7
COST WITH SAMPLING CIGNA DENTAL CARE ESTIMATED COST OF COVERED PREPAID PLAN WITHOUT DENTAL 6 PROCEDURES GENERAL COVERAGE SPECIALIST DENTIST Adult cleaning (two per calendar year, $0 $0 $70–$136 each additional cleaning $45) Child cleaning (two per calendar year, $0 $15 $53–$102 each additional cleaning $45) Periodic oral evaluation $0 $0 $40–$76 Comprehensive oral evaluation $0 $20 $62–$118 Topical fluoride (two per calendar year) $0 $0 $28–$53 X–rays – (bitewings) 2 films $0 $0 $33–$63 X–rays – panoramic film $0 $20 $84–$161 Sealant – per tooth $10 $10 $42–$80 Amalgam filling (silver colored) – $8 $10 $118–$226 2 surfaces Composite filling (tooth–colored) – $25 $25 $120–$231 1 surface, Anterior Composite filling (tooth–colored) – $40 $40 $150–$334 1 surface, Posterior Molar root canal $125 $600 $852–$1,640 (excluding final restoration) Periodontal (gum) scaling and root $45 $60 $179–$344 planing – 1 quadrant Periodontal (gum) maintenance $45 $45 $109–$209 Removal/extraction of erupted tooth $15 $70 $120–$231 Removal/extraction of impacted tooth $100 $120 $370–$712 Crown – porcelain fused to high $200 $200 $849–$1,634 noble metal Crown – porcelain/ceramic $190 $190 $849–$1,634 Occlusal appliance, by report $330 $455 $640–$1,233 (for treatment of TMJ) Surgical Placement of Endosteal Impant $1,025 $1,025 $2300–$4,000 Teledentistry $0 $0 $45 Note: Lab fees will be charged for certain procedures. 9 PLAN LIMITS
PROCEDURE LIMIT Exams Two per calendar year X-rays (routine) Bitewings: 2 per calendar year Full mouth: 1 every 3 calendar years. Panorex: 1 every X-rays (non-routine) 3 calendar years Crowns and inlays Replacement every 5 years Bridges Replacement every 5 years Adjustments Four within the first 6 months after installation Temporomandibular Joint (TMJ) treatment One occlusal orthotic device per 24 months Athletic mouth guard One athletic mouth guard per 12 months One implant per calender year with a replacement Surgical placement of implant of 1 per 10 years
Referrals are required for specialty care services except network pediatric dentists for children under age 13* and network orthodontists. The copays on your PCS also apply to covered network specialist care. If you go to a network specialist, there may be a different copay.
* Subject to state regulatory approval 10 Listed below are the services or expenses which are NOT covered under your Dental Plan and which are your responsibility at the dentist’s usual fees. There is no coverage for:
› Services for or in connection with an injury arising out of, or in the course of, any employment for wage or profit › Charges which would not have been made in any facility, other than a hospital or a correctional institution owned or operated by the United States government or by a state or municipal government if the person had no insurance › To the extent that payment is unlawful where the person resides when the expenses are incurred or the services are received › Services for the charges which the person is not legally required to pay › Charges which would not have been made if the person had no insurance › Due to injuries which are intentionally self-inflicted › Services not listed on the Patient Charge Schedule › Services provided by a non-network dentist without Cigna Dental’s prior approval (except emergencies, as described in your plan documents)4 › Services related to an injury or illness paid under workers’ compensation, occupational disease or similar laws › Services provided or paid by or through a federal or state governmental agency or authority, political subdivision or a public program, other than Medicaid › Services required while serving in the armed forces of any country or international authority or relating to a declared or undeclared war or acts of war › Services performed primarily for cosmetic reasons unless specifically listed on your PCS › General anesthesia, sedation and nitrous oxide, unless specifically listed on your PCS › Prescription medications › Procedures, appliances or restorations if the main purpose is to: a. change vertical dimension (degree of separation of the jaw when teeth are in contact); b. restore teeth which have been damaged by attrition, abrasion, erosion and/or abfraction; or restore the occlusion › Replacement of fixed and/or removable appliances (including fixed and removable orthodontic appliances) that have been lost, stolen or damaged due to patient abuse, misuse or neglect › Services considered to be unnecessary or experimental in nature or do not meet commonly accepted dental standards
11 › Procedures or appliances for minor tooth guidance or to control harmful habits › Services and supplies received from a hospital › The completion of crowns, bridges, dentures, root canal, or Orthodontic treatment already in progress on the effective date of your Cigna Dental coverage3 › Consultations and/or evaluations associated with services that are not covered › Endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a poor or hopeless periodontal prognosis › Bone grafting and/or guided tissue regeneration when performed at the site of a tooth extraction unless specifically listed on your PCS › Bone grafting and/or guided tissue regeneration when performed in conjunction with an apicoectomy or periradicular surgery › Intentional root canal treatment in the absence of injury or disease to solely facilitate a restorative procedure › Services performed by a prosthodontist › The completion of crowns, bridges, dentures, root canal, or Orthodontic treatment already in progress on the effective date of your Cigna Dental coverage3 › Any localized delivery of antimicrobial agent procedures when more than eight (8) of these procedures are reported on the same date of service › Infection control and/or sterilization › Services to correct congenital malformations, including the replacement of congenitally missing teeth › The replacement of an occlusal guard (night guard) beyond one per any 24 consecutive month period, when this limitation is noted on the PCS › Crowns, bridges and/or implant supported prosthesis used solely for splinting › Resin bonded retainers and associated pontics
Should any law require coverage for any particular service(s) noted above, the exclusion or limitation for that service(s) shall not apply. This document outlines the highlights of your plan. For a complete list of both covered and not-covered services, including benefits required by your state, see your insurance certificate or plan description. If there are any differences between the information contained here and the plan documents, the information in the legal plan documents takes precedence.
12 HOW TO ENROLL AND HOW TO SELECT A DENTIST
Enroll today Make sure that you don’t miss your opportunity to enroll for this important benefit. All you need to do is: 1. Review your plan materials and consider your family’s needs. 2. Contact your agency’s benefits coordinator for enrollment instructions. 3. Select a network general dentist for yourself and every member of your family who you are enrolling. Each family member may choose a different network general dentist. You may choose a network pediatric dentist for your child. Children can remain with a pediatric network dentist up to their 13th birthday.* Changes made by the 15th of the month will become effective the first of the following month. If care is needed prior to that 1st of the month after the selection, call 800.997.1617 and a Cigna customer service representative will contact your dental office and ask for an exception and an immediate appointment. Select a network general dentist 1. Complete the Dentist Selection Form below. Be sure to include the seven-digit Dental facility ID# for the network general dentist you select. The list of Cigna Dental Care Prepaid Plan network dentists is available at Cigna.com/sites/stateoftn or at myCigna.com, via our app, by calling customer service at 800.997.1617 or in the printed directory. To receive the most benefits from the Cigna Dental Care Prepaid Plan you must select and use a network general dentist. 2. Once completed return the signed form to the following address: Cigna Dental Care Prepaid Program Attn: Celeste Sims 730 Cool Springs Boulevard, Suite 500 Franklin, TN 37067
* Subject to state regulatory approval 13 Dentist Selection Form State of Tennessee PrePaid Plan – 2021
Please check one box to indicate Active or Retiree Please print
Name Last First Middle
Employee Edison number
Phone number
Dentist facility number
Date Signature
If eligible family members have a different dentist selection from yours, list the information below:
First name MI Last name (if different) Dentist facility ID#
14 NEED MORE? GET MORE. Cigna Dental Oral Health Integration Program®
What is the Cigna Dental Oral Health Integration Program? It’s a program that reimburses out-of-pocket costs for specific dental services used to treat or help prevent gum disease and tooth decay. The program is for people with certain medical conditions that may be impacted by dental care. There’s no additional cost for the program – if you qualify, you get reimbursed! Do I qualify? If you have a Cigna dental plan, you’re eligible for the program. It doesn’t matter if you have Cigna health insurance or not. The only requirement is that you’re currently being treated by a doctor for: › Heart disease › Maternity › Stroke › Chronic kidney disease › Diabetes › Organ transplants › Head and neck cancer radiation
How does it work? Once you register for the program, when you visit your dentist, you will pay your usual copay. As a reminder, your copay is the fixed amount you pay for covered services. Next, your dentist will send Cigna your information and we will review the claim and refund your copay for eligible services. Once we receive your claim, you can expect to be reimbursed in about 30 days.
Using the program is as easy as 1, 2, 3! Together, we can make sure proper dental care is given to those who need it most.
1 Participants fill out the online Registration Form onmyCigna.com . This is required only one time per qualifying medical condition. Or you can call the number on your ID card or policy. 2 Once you’re logged in on myCigna.com, click “Review my Coverage” then select “Dental” from the drop down menu. Next, from the “Related Links” section on the right side of the page, select “Cigna Dental Oral Health Integration Program Registration Form.” 3 Program participants simply visit their network general dentist for the covered service and pay the dentist their usual copay amount for that procedure. We’ll send reimbursement in about 30 days.
15 SPECIAL NOTICE Benefits Administration does not support any practice that excludes participation in programs or denies the benefits of such programs on the basis of race, color, national origin, sex, age or disability in its health programs and activities. If you have a complaint regarding discrimination, please call 615.532.9617. * Subject to state regulatory approval 1. Cigna Dental Care product designs may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans (including Dental HMO plans), and plans with open access features. The Cigna Dental Care Prepaid plan for the State of Tennessee Group Insurance Plan may not be available in every state. There are no out-of-network benefits, except for emergencies or where required by law. 2. Refer to your plan materials to see if your plan includes orthodontic coverage. The following orthodontic services are generally not covered: orthodontic treatment already in progress; incremental costs associated with optional/elective materials; orthognathic surgery applicances to guide minor tooth movement or correct harmful habits; and any services which are not typically included in orthodontic treatment. Coverage for treatment by a pediatric dentist ends on your child’s 13th* birthday. Effective on your child’s 13th* birthday, dental services generally must be obtained from a network general dentist. 3. California and Texas residents: Treatment for conditions already in progress on the effective date of your coverage are not excluded if otherwise covered under you Patient Charge Schedule. 4. A benefit is paid for covered out-of-network emergency dental care. Certain states mandate coverage for dental care received out-of-network. For example, in Minnesota, the plan will pay 50% of the value of your network benefit for covered out- of-network services. In Oklahoma, the plan will pay the same amount it pays network dentists for covered out-of-network services. You are responsible for any charges not covered by the plan. Other states may have similar mandates. Refer to your plan documents for cost and coverage details. 5. Actual features may vary by dentist. Online appointment scheduling is not available with network general dentists or pediatric dentists. These and other dentist directory features are for educational purposes only and should not be the sole basis for decision making. They are not a guarantee of the quality of care that will be provided to individual patients and you should consider all relevant factors when selecting a dentist. 6. You may be billed separate for lab fees. 7. NetMinder. DHMO data as of March 2019 and is subject to change. The Ignition Group makes no warranty regarding the performance of the data and the results that will be obtained by using. These are examples used for illustrative purposes only. Your actual costs and plan coverage will vary. Plan limitations and exclusions may apply. See your plan materials for details. Dentists who participate in Cigna’s network are independent contractors solely responsible for the treatment provided to their patient. They are not agents of Cigna. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. Cigna Dental Care plans are insured by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (KS & NE), Cigna Dental Health of Kentucky, Inc. (KY & IL), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are insured by Cigna Health and Life Insurance Company or Cigna HealthCare of Connecticut, Inc., and administered by Cigna Dental Health, Inc. Policy forms: HP-POL134 (TN). The Cigna name, logo and other Cigna marks are owned by Cigna Intellectual Property, Inc. Brighter Score is a trademark of Brighter, Inc. a Cigna Company. 887429 e 07/20 © 2020 Cigna. Some content provided under license. Dental Insurance
2021 Group Dental Member Handbook
For Active Employees and Retirees
State of Tennessee Welcome!
Why is having a good dental plan so important?
Because a healthier smile can be important to maintaining overall health.
Maintaining good oral health matters. Studies show that those with dental coverage are more likely to visit the dentist1. And of course, staying on top of your care is the key to preventing costly problems that can add up. Plus, going to the dentist regularly can help prevent problems that have been linked to diabetes or heart disease². That’s where a good dental plan comes in. The right coverage makes it easier to visit the dentist and helps lower your costs. You get support to keep up with dental cleanings and other preventive care that helps you avoid costly problems and live healthier. Now that’s something to smile about.
How can having MetLife Dental insurance benefit you? By making it easier to get the care you need and lowering your out-of-pocket costs.
Freedom of choice to go to any dentist. MetLife’s group dental insurance plan featuring the Preferred Dentist Program is a Dental Preferred Provider Organization (DPPO) plan. So you can visit any licensed dentist, in or out of the network, and receive benefits.
• Dentists in our network are participating dentists. If you prefer to go to a participating dentist, you can count on our large and constantly growing network. Plus, all participating dentists must meet rigorous selection standards3, so you know you are in good hands. • Find an in-network, participating dentist today at https://www.metlife.com/stateoftn/dental/plan/ For better savings, visit an in-network, participating general dentist or specialist. Visits are covered with any dentist you choose even if he or she is out of network, but you'll get the most competitive prices with an in- network provider. With MetLife Dental, you have a large network of providers in Tennessee and across the country.
Managing your dental benefits is easy! MyBenefits, https://www.metlife.com/mybenefits/stateoftn, is your secure self-service website. It’s available 24/7. You can use the site to get estimates on care or to check coverage and claim status. 4 • MetLife Mobile App It is easy to get the MetLife US Mobile app. Search “MetLife” on the iTunes Store® or Google Play® and download the MetLife US Mobile App. Then use your MyBenefits log in information to access these features. • Call 855-700-8001, representatives are available 7 a.m. - 10 p.m. CT, Monday through Friday. Increase your knowledge of oral health. Our large online Dental library, https://oralfitnesslibrary.com/ , gives you educational information and interactive tools on benefits, dental care and disease risk. These resources help you to take a more proactive role in your oral health.
An agency must be participating in the State of Tennessee Group Insurance Program in order to qualify for participation in the State of Tennessee Voluntary Dental Program. Employee, retiree and/or dependent participation in the State Group Insurance Program is not required to participate in the State Dental Program. Employee or retiree participation in the MetLife (DPPO) is required for participation of eligible dependents. Participation by those enrolled in the MetLife (DPPO) is on a calendar year basis. Enrollment may only be dropped by the members during the Annual Enrollment Period for the beginning of the next calendar year or due to a special qualifying event.
1 2013 US Survey of Dental Care Affordability and Accessibility; Empirica Research; July 2013. 2 American Dental Association; Dentists: Doctors of Oral Health. Accessed August 2019, www.ada.org/en/about-the-ada/dentists-doctors-of-oral-health 3 Certain providers may participate with MetLife through an agreement that MetLife has with a vendor. Providers available through a vendor are subject to the vendor’s credentialing process and requirements, not MetLife's. 4Certain features of the MetLife Mobile App are not available for all MetLife Dental Plans.
2 Maximum Allowed Charge (MAC) is the lowest of (1) the amount charged by the dentist or (2) the maximum amount that in-network dentists have agreed to accept as payment in full for the dental service. When a participant receives dental services from an in-network provider, the participant is responsible for the percentage of the MAC that MetLife does not pay.1 Even when a participant receives dental services from an out-of-network provider, MetLife will pay a percentage of the MAC. The participant is then responsible for everything over the percentage of the MAC paid by MetLife up to the charge submitted by the out-of- network dentist. 1 2021 State of Tennessee Benefit Summary
Coverage Type In-Network Out-of-Network Type A: Diagnostic and Preventive Services 100% of MAC 80% of MAC • Periodic Oral Evaluation: Two oral exams in any calendar year2 • Routine Cleaning: Two cleanings in any calendar year2 • Full-Mouth X-rays: One in 60 consecutive months • Bitewing X-rays: One in 12 consecutive months • Sealants to age 16 • Space Maintainers to age 15 Type B: Basic Services 80% of MAC 60% of MAC • Amalgam & Composite Fillings • Periodontal Maintenance: Two treatments in one year, includes two cleanings2 • Periodontics: Non-Surgical/Scaling and Root Planing
Type C: Major Services 50% of MAC 50% of MAC • Inlays/Onlays/Crowns • Implant Services • Crown Buildups/Post & Core • Dentures, complete or partial • Six-month waiting period applies to inlay/onlay restorations, dentures, crowns and implants; 12-month waiting period applies for initial placement of bridge or denture to replace one or more natural teeth.
Orthodontic Services 50% of MAC 50% of MAC • Only available for dependent children up to age 19 • 12-month waiting period
Deductible: Type B and C Services only • Individual $25 $100 • Family $75 $300 No single family member will be subject to a deductible greater than the “individual” amount. Annual Maximum Benefit (per person) $1,500 $1,500 Orthodontia Lifetime Maximum (per person) $1,250 $1,250 1Subject to any deductibles and benefit maximums. 2Additional oral exams, cleanings and periodontal maintenance allowed if dentally necessary and the dentist receives prior authorization from MetLife. Monthly Premiums The following monthly premiums are effective 1/1/2021 – 12/31/2021. Your premium may be paid through convenient payroll or retirement system deduction. Active Employee Premiums Retiree Employee Premiums
Employee Only $23.64 Retiree Only $30.52 Employee + Child(ren) $54.36 Retiree + Child(ren) $70.18 Employee + Spouse $44.72 Retiree + Spouse $57.74 Employee + Spouse + Child(ren) $87.50 Retiree + Spouse + Child(ren) $112.98 3 In-Network Savings* Example
You visit your dentist for a crown, which is a Type C service (major service). • MAC: $716 Maximum Allowable Charge In-Network Maximum Considered Fee Out-of-Network Dentist’s Usual Fee: $1,022 •
IN-NETWORK OUT-OF-NETWORK
When you receive care from a When you receive care from a participating dentist: non-participating dentist:
Dentist’s Usual Fee is: $1022 Dentist’s Usual Fee is: $1022
MAC is: MAC is: $716 $716 Your Plan Pays 50% of the Your Plan Pays 50% of the $716 MAC: $358 $716 MAC: $358
Your Out-of-Pocket Cost is the Your Out-of-Pocket Cost is the MAC Fee minus the amount your $358 Dentist’s Usual Fee minus the $664 plan pays ($716 - $358) amount your plan pays ($1022 - $358)
In this example, you save $306 ($664 minus $358) by using a participating dentist.
*Savings from enrolling in the MetLife Dental Preferred Provider Organization Insurance Program will depend on various factors, including the cost of the program, how often participants visit the dentist and the cost of services rendered. Please note: This is a hypothetical example that reviews a porcelain/ceramic crown (D2740). It assumes that the annual deductible has been met and the annual maximum benefit has not been reached. Actual costs and savings may vary.
Important answers to some common questions Where can I find information on the State of TN dental program? State of TN members can access MetLife dental by going to https://www.metlife.com/mybenefits/stateoftn which goes directly to a State specific website. Here you will need to create a username and password on MyBenefits. Once logged in, you have access to find an in-network, participating dentist, view claims, find claim forms, view plan details, and more.
How are claims processed? Dentists may submit your claims for you, so you have little or no paperwork. You can track your claims online and even receive email alerts when a claim has been processed. If you need a claim form, visit www.metlife.com/stateoftn or request one by calling 1-855-700-8001.
How do I find a participating dentist? There are thousands of general dentists and specialists to choose from nationwide — so you are sure to find one who meets your needs. You can find the names, addresses, languages spoken and telephone numbers of participating dentists in your area by searching our online Find a Dentist feature at https://www.metlife.com/mybenefits/stateoftn
Can my dentist apply for participation in the network? Yes. If your current dentist does not participate in the network and you would like to encourage him or her to apply, ask your dentist to visit www.metdental.com or call 1-866-PDP-NTWK (1-866-737-6895) for an application. The website and phone number is for use by dental professionals only.
How does MetLife coordinate benefits with other insurance plans? The coordination of benefits provision in dental benefits plans are a set of rules that are followed when a patient is covered by more than one dental benefits plan. These rules determine the order in which the plans will pay benefits. If the MetLife Dental benefit plan is primary, MetLife will pay the full amount of benefits that would normally be available under the plan. If the MetLife Dental benefit plan is secondary, most coordination-of-benefits provisions require MetLife to determine benefits after benefits have been determined under the primary plan. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan.
4 Can I get an estimate of how much I have to pay before receiving a service? Yes. You can ask for a pre-treatment estimate. Your general dentist or specialist usually sends MetLife a plan for your care and requests an estimate of benefits. The estimate helps you prepare for the cost of dental services. We recommend that you request a pre-treatment estimate for services in excess of $300. Simply have your dentist submit a request online at www.metdental.com or call 1-877-MET-DDS9 (877-638-3379). You and your dentist will receive a benefit estimate for most procedures while you are still in the office. Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment.
What is an Alternate Benefit? If MetLife determines that a service, less costly than the Covered Service the Dentist performed, could have been performed to treat a dental condition, MetLife will pay benefits based upon the less costly service if such service: 1. Would produce a professionally acceptable result under generally accepted dental standards; and 2. Would qualify as a Covered Service. For Example, MetLife will pay for a silver colored crown if a porcelain crown is placed on a rear molar. The silver crown is less likely to crack than a porcelain crown. NOTE: MetLife recommends your provider submit a pre-treatment estimate prior to dental procedures over $300.
What is “balance billing”? When a participant receives dental services from an out-of-network provider, MetLife will pay a percentage of the MAC. The participant is then responsible for everything over the percentage of the MAC paid by MetLife up to the actual charge by the out- of-network dentist. When a participant receives dental services from an in-network provider, the participant is responsible for the portion of the MAC that is not paid by MetLife.
What is an Explanation of Benefits (EOB)? An EOB statement is a summary of your processed claim(s) or pre-treatment estimate(s), including services rendered, costs and benefits paid.
Do I need an ID card? No. You are not required to show an ID card to your dentist as proof of coverage. MetLife provides all dental offices, in- network and out-of-network, with access to patient eligibility and benefit information. The information is available online and via a dedicated dental office toll-free number. All you need to do is notify your dentist office that MetLife is your dental provider when scheduling an appointment.
Will switching from another dental plan, including a separate MetLife dental plan, to the State of Tennessee MetLife group dental plan cause issues if I’m in the middle of a treatment plan? When switching your dental plan, some of the most common services that may be affected include orthodontics, endodontics and prosthodontic services. MetLife has transition-of-care guidelines for participants whose dental treatment is in progress during the benefit plan transition to the State of Tennessee MetLife group dental plan (DPPO). For Orthodontia, MetLife will apply payment history and treatment plan information to the participant’s MetLife dental plan, pro-rating the charges prior to the MetLife effective date and issue benefits from the effective date forward, under the MetLife dental plan. NOTE: Waiting periods may apply prior to benefits being paid Endodontic Treatments, Root canal – A tooth opened prior to, but completed after the MetLife effective date will be considered an eligible expense under the MetLife dental plan. NOTE: Waiting periods may apply prior to benefits being paid Prosthodontic Treatments, Crowns and Bridgework – Treatment (preparation and impressions) started prior to but placed after the MetLife effective date will be considered an eligible expense under the Metlife dental plan. NOTE: Waiting periods may apply prior to benefits being paid Partial or Full Denture – Final impressions for appliances completed prior to but delivered after the Metlife effective date will be considered eligible expenses under the MetLife dental plan, subject to MetLife plan frequency limits. NOTE: Waiting periods may apply prior to benefits being paid
Can my dependent child continue insurance beyond age 26? You may continue coverage for a child who is over age 26 if they are incapable of self-sustaining employment because of a mental or physical handicap as defined by applicable law. Proof of such handicap must be sent to Benefits Administration prior to the child’s 26th birthday. Annual proof may also be required.
5
I was previously enrolled in the State of Tennessee’s MetLife dental plan, but switched to the State of Tennessee’s prepaid dental plan last year. If I decide to enroll in the MetLife dental plan during the next Annual Enrollment or because of a special qualifying event, will the time previously enrolled in MetLife count toward the waiting periods. Yes. If you were previously enrolled in the State of Tennessee MetLife dental plan, and decide to rejoin MetLife later, any waiting periods satisfied previously will apply to your new coverage. Your waiting periods will not start over due to rejoining the MetLife plan. NOTE: If you or any dependents were covered with another MetLife Dental Plan through a previous Employer with a different Group Number who does not participate in the State of Tennessee's MetLife Dental Plan, Waiting Periods will apply.
Are there any benefits if I’m traveling internationally? Yes, dental referral services are provided by AXA Assistance USA, Inc. through the International Dental Travel Assistance Program.* Coverage will be considered under a participant’s out-of-network benefits. The program offers: • 24/7 multilingual assistance; • Toll-free calling within the U.S., or collect calling outside the U.S.; 855-700-8001 • Access to dental providers, based on strict credentialing criteria, in approximately 200 countries.
*International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. AXA Assistance provides referral services only. They are not affiliated with MetLife, and the services they provide are separate and apart from the benefits provided by MetLife. No enrollment action is required by the Member or any of the Member's dependents (if applicable). Enrollment is automatic when selecting the State of Tennessee MetLife Dental Plan.
Exclusions This plan does not cover the following services, treatments and supplies:
• Services performed primarily for cosmetic reasons. • Replacement of a lost or stolen appliance, an example being braces, retainers, partials, dentures etc. • Oral hygiene and dietary instructions, treatment for desensitizing teeth, prescribed drugs or other medication, experimental procedures, conscious sedation and extra oral grafts (grafting of tissues from outside the mouth to oral tissues). • Treatment to restore tooth structure lost from wear. • Services by a dentist beyond the scope of his or her license. • Dental services where charges for such services exceed the charge that would have been made and actually collected if no coverage existed. • Dental services for which the patient incurs no charge. • Services received without cost from any federal, state or local agency. This exclusion will not apply if prohibited by law. • Services that are deemed to be medical services. • Charges by any hospital or other surgical or treatment facility and any additional fees charged by the dentist for treatment in any such facility. • Treatment of injury or illness covered by Workers' Compensation or Employer's Liability Laws. • Services for congenital (hereditary) or developmental malformations. Such malformations include, but are not limited to, cleft palate, or upper and lower jaw malformations. This does not exclude those services provided under Orthodontic benefits, if covered. • Treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion or treatment to stabilize the teeth. For example: equilibration, periodontal splinting and double abutments on bridges. • Diagnosis or treatment for any disturbance of the temporomandibular joints (jaw joints) or myofacial pain dysfunction. • Athletic mouth guards.
Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions, limitations and terms for keeping them in force. Please contact your MetLife group representative or your plan administrator for costs and complete details.
L0819516925[exp0821][All States][DC,GU,MP,PR,VI] Metropolitan Life Insurance Company, 200 Park Avenue, New York, NY 10166 ©2020 MetLife Services and Solutions, LLC 6
Underwritten by HM Life Insurance Company.
Vision care plan for
2021 vision care plan State of Tennessee
from davisvision.com/stateoftn • (800) 208-6404
davisvision.com/stateofTN | 1 davisvision.com/stateofTN | 2 Contents Who we are 3 Your vision benefits 4 Frequency of vision benefits 4 Plan highlights 4 Basic plan offering 5 Expanded plan offering 6 Value-added services 7 The Davis Vision mobile app 9 The Exclusive Collection of Frames 10 Frequently asked questions 11 Buy glasses and contacts online 13 Your plan rates 14
Who we are Davis Vision is more than just a national vision care administrator. We are an advisor, partner, and leader serving over 23 million members. Davis Vision offers: • A broad array of paid-in-full options* • Freedom of choice and flexible benefits: - Use your allowance on any frame in-network - Frame options with economical out-of-pocket cost (Visionworks and The Exclusive Collection) - Popular lens options with savings based upon plan design • Extensive blended network of premier retailers nationally as well as independent optometrists and ophthalmologists, totaling over 96,000** points of access • NCQA-certified eye care professional credentialing process to ensure industry-leading standards for quality • 100% United States-based services and operations • One-year eyeglass breakage warranty on most plan materials with no additional cost based upon plan design We ensure economical out-of-pocket costs with a broad array of paid-in-full options and freedom of choice in eyewear. Members may select any frames or contact lenses and their allowance will apply, or they can choose frames that are covered in full through the Davis Vision Exclusive Collection based upon plan design.
*Actual costs and benefits may vary based upon plan design selected. Exclusions and limitations may apply. **As of mid-2020, CompuVision II Eye care professional report
davisvision.com/stateofTN | 3 Your vision benefits How to use the plan • Upon enrollment, Davis Vision will mail to your home address: - two ID cards, which can be used for you and your covered family members; - a summary of the benefits covered under the plan; and - a listing of network eye care professionals located close to your home. • The Davis Vision eye care professional network includes independent eye care professionals, as well as top national retailers including Visionworks, Costco, Sam’s Club, Walmart, and JCPenney Optical. To search the full eye care professional directory, go to davisvision.com/stateoftn or call (800) 208-6404. • Once you have selected an eye care professional, you may call them directly and schedule an appointment. • Please confirm that coverage for all services through the Davis Vision plan is an option with your eye doctor before services are performed.
Frequency of vision benefits* Service Frequency Eye exam Once every calendar year Eyeglass lenses Once every calendar year Frames Once every two (2) calendar years Contact lenses Once every calendar year (in lieu of eyeglasses) Contact lens evaluation, Once every calendar year (in lieu of eyeglasses) fitting, and follow-up
Plan highlights* Service Basic plan Expanded plan Eye exam $0 copay $10 copay Exclusive Collection (Fashion / Designer / Premier) $0 copay / $15 copay / $40 copay $0 copay - All tiers covered-in-full Visionworks frames Covered-in-full Covered-in-full Retail frame allowance 80% of balance over $55 80% of balance over $150
Please confirm all services are covered through the Davis Vision plan with your eye doctor before services are performed.
*Actual costs and benefits may vary based upon plan design selected. Exclusions and limitations may apply.
davisvision.com/stateofTN | 4 * Summary of benefits—effective 1/1/2021 Basic plan Rates listed on page 14
Service In-network member cost1 Out-of-network member cost1
Eye exam with dilation as necessary $0 copay 100% of balance over $35
Retinal imaging $39 copay 100% of charge Contact lens fit and follow-up 80% of charge 100% of charge (standard and premium) Eyeglass benefit—frame 100% of charge over $55 for Retail frame 80% of balance over $552 frames and lenses combined Visionworks frame Covered-in-full N/A The Exclusive Collection3 (in lieu of retail frame): $0 / $15 / $40 copay N/A Fashion / Designer / Premier selection Eyeglass benefit—spectacle lenses
Single vision, bifocal, trifocal and lenticular lenses $0 copay See above
80% of balance over $55; not to Standard progressive See above exceed $65 out-of-pocket 80% of balance over $55; not to Premium progressive See above exceed $105 out-of-pocket 1 80% of balance over $55; not to Member pay will Ultra progressive 100% of charge not be greater exceed $140 out-of-pocket than the copay, 80% of balance over $55; not to but could be less Ultimate progressive 100% of charge exceed $175 out-of-pocket based upon the actual charge. High-index 1.67 80% of charge not to exceed $60 100% of charge 2$0 copay for High-index 1.74 80% of charge not to exceed $120 100% of charge eyeglass frames at Visionworks. UV treatment 80% of charge up to $15 100% of charge 3Collection is Tint (solid and gradient) 80% of charge up to $15 100% of charge available at most participating Standard plastic scratch coating $0 copay 100% of charge eye care professional Premium scratch-resistant coating 80% of charge up to $30 100% of charge offices. Collection Standard polycarbonate (adult/children4) 80% of charge up to $35 / $0 100% of charge is subject to change. Anti-reflective coating 80% of charge up to $40 / $55 / 100% of charge (Standard / Premium / Ultra / Ultimate) $69 / $85 4Polycarbonate lenses are Polarized 80% of charge up to $75 100% of charge covered in full for dependent Plastic photochromic lenses 80% of charge up to $70 100% of charge children, Scratch protection plan: monocular $20 copay / $40 copay 100% of charge single vision/multifocal lenses patients and patients with Trivex lenses 80% of charge up to $50 100% of charge prescriptions 6.00 diopters or Digital single vision (intermediate) lenses 80% of charge up to $30 100% of charge greater.
Blue light filtering 80% of charge up to $15 100% of charge 5If visually Other add-ons and services 80% of charge 100% of charge required as first contact Contact lenses lenses following cataract surgery, Conventional and disposable 80% of balance over $55 100% of charge over $30 or multiple pairs of rigid contact Visually required5 80% of balance over $155 100% of charge over $80 lenses for treatment of keratoconus.
*Actual costs and benefits may vary based upon plan design selected. Exclusions and limitations may apply.
davisvision.com/stateofTN | 5 * Summary of benefits—effective 1/1/2021 Expanded plan Rates listed on page 14 Service In-network member cost1 Out-of-network member cost1 Eye exam with dilation as necessary $10 copay 100% of balance over $50 Retinal imaging $39 copay 100% of charge Contact lens fit and follow-up (standard and premium) $50 copay / $60 copay 100% of charge / 100% of charge Eyeglass benefit—frame Retail frame 80% of balance over $1502 100% of charge over $75 Visionworks frame Covered-in-full N/A The Exclusive Collection3 (in lieu of retail and Visionworks frame): Fashion selection $0 copay N/A Designer selection $0 copay N/A Premier selection $0 copay N/A Eyeglass benefit—spectacle lenses Single vision lenses $0 copay 100% of balance over $35 Bifocal lenses $0 copay 100% of balance over $55 Trifocal lenses $0 copay 100% of balance over $70
1 Lenticular lenses $0 copay 100% of balance over $70 Member pay will not be greater Standard progressive $50 copay 100% of balance over $55 than the copay, but could be less Premium progressive $90 copay 100% of balance over $55 based upon the actual charge. Ultra progressive $140 copay 100% of charge 2 Ultimate progressive $175 copay 100% of charge $0 copay for eyeglass frames High-index 1.67 $60 copay 100% of charge at Visionworks. High-index 1.74 $120 copay 100% of charge 3Collection is available at most UV treatment $10 copay 100% of balance over $10 participating eye care Tint (solid and gradient) $15 copay 100% of balance over $10 professional Standard plastic scratch coating $0 copay 100% of balance over $10 offices. Collection Premium scratch-resistant coating $30 copay 100% of balance over $10 is subject to change. Standard polycarbonate (adult/children4) $30 copay / $0 copay 100% of balance over $10 4Polycarbonate Anti-reflective coating lenses are $40 / $55 / $69 / $85 copay 100% of balance over $10 (Standard / Premium / Ultra / Ultimate) covered in full for dependent Polarized 80% of charge up to $75 100% of charge children, monocular Plastic photochromic lenses 80% of charge up to $70 100% of charge patients and patients with Scratch protection plan: single vision/multifocal lenses $20 copay / $40 copay 100% of charge prescriptions 6.00 diopters or Trivex lenses $50 copay 100% of charge greater. Digital single vision (intermediate) lenses $30 copay 100% of charge 5If visually Blue light filtering $15 copay 100% of charge required as first contact Other add-ons and services 80% of charge 100% of charge lenses following cataract surgery, Contact lenses or multiple pairs of rigid Conventional and disposable 80% of balance over $140 100% of charge over $55 contact lenses Visually required5 $0 Copay 100% of charge over $200 for treatment of keratoconus.
*Actual costs and benefits may vary based upon plan design selected. Exclusions and limitations may apply. davisvision.com/stateofTN | 6 Value-added services* • One-year breakage warranty included on all plan-covered eyeglasses (i.e., all spectacle lenses, Davis Vision Exclusive Collection frames and national retailer frames where our Exclusive Collection is not available). Location may or may not participate in offering The Exclusive Collection of frames. Please refer to an explanation of The Exclusive Collection below for greater detail. • Discounts on LASIK procedures. Visit qualsight.com/-state-of-tn or call (877) 515-3937 for information. • Savings up to 40% off premium hearing aids through Your Hearing Network. Visit davisvision.yourhearing.com or call (888) 809-0044 for more information on pricing and participating audiologists and otolaryngologists (ENT). • Partial reimbursements are available for services provided by an out-of-network eye care professional. Claim forms are available online at davisvision.com/stateoftn. (You will receive the full value of your benefit dollars if you select an in-network eye care professional.) Please note that out-of-network value-added services are not covered by benefit and member will be responsible for 100% of charge.
Value-added services1 Basic plan Expanded plan Member is responsible for Member is responsible for Laser vision correction (for select eye care 85% of retail price; 95% of 85% of retail price; 95% professionals) promotional price of promotional price
Member is responsible for Member is responsible for Additional pair of eyeglasses 70% of charge 60% of charge
Additional pair of conventional or disposable Member is responsible for Member is responsible for contact lenses 80% of charge 80% of charge
1 Member pay will not be greater than the copay, but could be less based upon the actual charge. Out-of-network value-added services are not covered by benefit and member will be responsible for 100% of charge
*Actual costs and benefits may vary based upon plan design selected. Exclusions and limitations may apply.
davisvision.com/stateofTN | 7 Envision a world with better hearing
Hearing tests are simple, painless and widely available. This hearing healthcare plan is accessible to you and your family members through your plan.
Recognizing the signs of hearing loss The signs of hearing loss can be vague and develop slowly, Quality or they can be obvious and begin suddenly. Regardless, Our highly skilled struggling to hear certain sounds or syllables is a telltale network of symptom of hearing loss. credentialed hearing If you recognize any signs of hearing loss in yourself or care professionals a loved one, its important to seek help. Get started by provide you with scheduling your free hearing exam with a Your Hearing quality care. Network Provider in your area today. Savings Significant savings including up to 40% $ off premium Start your hearing health journey today hearing aids. Hearing exam FREE Accessibility Trial period 60-day money back guarantee Your Hearing Follow-up care 1-year Network is a national Warranty 4-year service, including 1-year of loss and damage network with Batteries 4-year supply included with each hearing aid purchase licensed hearing care providers near you.
Hearing health care services administered by
Ready to schedule your consultation with a local hearing care professional today? Visit davisvision.yourhearing.com or call (888) 809-0044 for more information on hearing aid discounts.
davisvision.com/stateofTN | 8 Say hello to the Davis Vision mobile app
Register your member account at davisvision.com/member and then download the Davis Vision mobile app for your iOS or Android device.
Find an eye care professional Easily find an eye care professional based on your current location, or search by city, ZIP code, or name.
Check your eligibility and benefits Quickly check your current or duture eligibility status. Need a little more detail? You can also review your benefit.
Track your glasses Did you order glasses from an independent eye care professional? Conveniently check Need more information? their progress in the app. Go to davisvision.com/app to learn more and see the Request an ID card app in action. Need your member information? Find it and personalize it with your photo (optional).
Review your claims and status Check out your current claims and history. Plus, upload a photo of your receipt to easily submit an out-of-network claim.
Other tools and resources Be sight-savvy with these calculators, a frame try-on tool, a vision reference library, and more.
davisvision.com/stateofTN | 9 The Exclusive Collection of Frames Members are offered a selection of over 200 fashionable frames for little-to-no out-of-pocket cost. You’ll find the Exclusive Collection at participating in-network eye care professional locations. Our convenient tagging system is designed to streamline understanding of your member out-of-pocket cost. Actual costs and benefits may vary based upon plan design selected. Exclusions and limitations may apply.
Fashion/yellow tag—Functional and classic with designs for the whole family
Basic plan: $0 copay I Expanded plan: $0 copay
Designer/red tag—Stylish options with brands like Robert Mitchel®, Lucky Brand®, Jones NY®, and more Basic plan: $15 copay I Expanded plan: $0 copay
Premier/blue tag—Fashion-forward choices from brands like Perry Ellis®, Catherine Deneuve®, and Candies®
Basic plan: $40 copay I Expanded plan: $0 copay
You’ll find the Exclusive Collection at participating in-network eye care professional locations
davisvision.com/stateofTN | 10 Frequently asked questions How do I enroll? What information will my eye doctor need? To enroll, sign up within 31 calendar days from your When scheduling your appointment with an in- date of hire. If you do not enroll when initially eligible, network eye care professional, it’s best to have your you must wait until the next Annual Enrollment member number so they can quickly verify eligibility. period to enroll, unless you experience a special However, you can also use the head of contract’s qualifying event (SQE). first/last name and the state in which they live. For more details about the plan, log on to Where do I find my member number? davisvision.com/stateoftn or call (800) 208-6404. Your member number can be found on your Davis Is my family covered? Vision Member ID card, by logging in to your Davis Once enrolled, log into your member account, and Vision account, or by calling us at (800) 208-6404. click on “Check Eligibility” to see who is covered. You Do I get a member ID card? What happens if I can add (or drop) dependents to your plan during the lose it? Annual Enrollment period or in the case of a special Yes, the head of contract will receive a Member qualifying event (SQE). ID Card; covered dependents do not. However, When does my coverage end? you do not need the ID card to use your benefits. Please refer to the “Termination of Insurance” and Replacement cards can be ordered through your “Continuation” sections in either your Basic or online account or by calling (800) 208-6404. Expanded sample certificate to verify the date your What are your hours of operation? coverage will end upon terminating your benefit or Our customer care center is open seven days leaving employment. You may also ask your ABC, a week at convenient times for all areas of the HR Representative, or employer to assist you in this country and can be reached at (800) 208-6404. matter. The operating hours are: EST CST M–F 8 a.m.–11 p.m. M–F 7 a.m.–10 p.m. Sat. 9 a.m.–4 p.m. Sat. 8 a.m.–3 p.m. Sun. 12 p.m.–4 p.m. Sun. 11 p.m.–3 p.m.
Participation requirements means an agency must be participating in the State of Tennessee Sponsored Group Health Plan in order to qualify for participation in the State of Tennessee Voluntary Group Vision Insurance Program. An active Employee and/or Dependent’s participation in the State Sponsored Group Health Plan is not required to participate in the State Group Vision Insurance Program. A Retiree and/ or Dependent’s participation in the State Sponsored Group Health Plan is required to participate in the State Group Vision Insurance Program. Employee or Retiree’s participation in the State Group Vision Insurance Program is required for participation of eligible Dependents, except Dependents of Retirees may continue enrollment in the State Group Vision Insurance Program after the Retiree is no longer eligible for the State Group Health Insurance Plan and State Group Vision Insurance Program due to reaching the age for Medicare as long as the Dependents remain enrolled in the State Group Health Insurance Plan. Participation by those enrolled in the State Group Vision Insurance Program is on a calendar year basis, and enrollment may only be dropped by the participants during the Annual Enrollment Period for the beginning of the next calendar year or due to a special qualifying event (SQE).
davisvision.com/stateofTN | 11 What if my eye care professional is not Do I have to get all the services completed at in-network? the same time? The Basic Plan offers limited out-of-network As a Davis Vision member, you can get an eye benefit options, while the Expanded Plan offers exam and shop for eyewear at different times and more reimbursement options. (See plans on pages in different locations. For example, you may get 4 and 5 for more details.) To submit an out-of- your eye exam from an eye care professional and network claim, visit davisvision.com/stateoftn then use your prescription to shop for glasses at and click on “Access Benefits and Forms” to an in-network retailer at a later date within the download the Direct Reimbursement Claim Form. same plan year. Follow the instructions on the form to submit your claim. You must include either your eye care Does my whole family have to visit the professional’s signature or a detailed receipt. You same eye care professional? can request to add an eye care professional to No. Plan dependents can visit different eye care your network under “Find an eye care professional” professionals. For example, students who are at davisvision.com/stateoftn. away at school can locate a participating eye care professional near them.
Tip: Download the the Direct Can I get both glasses and contact lenses? Reimbursement Claim form from the No. Your plan benefits will cover eyeglasses or ! member portal and bring it with you to contact lenses, but not both. We are, however, your appointment for easy completion able to offer our members additional discounts of the eye care professional information on certain eyewear and eye care purchases even and for their signature. after the plan allowances have been used. Log in to your account to view plan details, or call us What is included in an eye examination? at (800) 208-6404. An eye exam takes roughly an hour and consists What if my glasses break? of a variety of checkups which include a health All eyeglasses come with a one-year breakage review, simple visual acuity tests, refraction warranty for repair or replacement of the frame test, visual field test, glaucoma test, slitlamp and/or lenses, which applies to all plan-covered evaluation and dilation. A comprehensive eye eyeglasses (i.e., all spectacle lenses, Davis Vision health exam can detect a number of eye diseases, Exclusive Collection frames, and national retailer as well as signs of systemic conditions such as frames where our Exclusive Collection is not diabetes, thyroid disease, high blood pressure and available). So, if your glasses break, simply return neurological impairments. Every eye exam our eye them to where you purchased them. care professionals administer is consistent with clinical guidelines published by the Eye American Can I use my insurance when shopping online? Optometric Association and the American Your Davis Vision benefits are available for in- Academy of Ophthalmology. network use online at visionworks.com. Online purchases for glasses or contacts at other sites What is a dilated retinal exam? are currently considered out-of-network. Your A Dilated Retinal Examination (DRE) is a benefits will work the same at visionworks.com as critical diagnostic procedure in the detection they would in-store at a Visionworks location. and management of diabetes, glaucoma, hypertension and many other ocular and/or systemic diseases (up to 30 altogether). It can lead to higher quality patient care, improved lifestyle through early detection and intervention, and possibly lower your overall health care costs. davisvision.com/stateofTN | 12 Buy eyewear online with your benefits You can use your vision care benefits to buy eyewear online from 1-800 Contacts, Befitting, Glasses.com, and Visionworks.
1-800 Contacts is one of the most recognized online contact lens retailers in the industry. They have an established reputation for their customer service, backed by an industry-leading Net PromoterScore of 76. Learn more: 1800contacts.com
Befitting.com has artificial intelligence-driven tools to find the perfect pair of eyeglasses with personalized, curated recommendations. Shop for single and progressive lenses, prescription sunglasses, and advanced blue light blocking lenses. Free shipping and returns are also included. Learn more: befitting.com
Glasses.com is one of the most trusted online stores for popular eyewear brands, including prescription glasses and sunglasses. Learn more: glasses.com
Look up your benefits and see the savings on thousands of different frames and contact lenses as you shop. Learn more: visionworks.com
What kind of brands do the online retailers carry? Are the benefits the same as other retail stores? All of the online retailers feature top brands of both Yes; you can use your full benefit. frames and contacts. Is the Davis Vision Exclusive Collection included? Do I need a prescription to order products online? No; the Exclusive Collection are not offered at Yes; you will need to enter your prescription at this time. the time of purchase, and require a recent valid prescription to purchase contact lenses online.
davisvision.com/stateofTN | 13 Basic plan premium rates* Employee/retiree rates Monthly Annually
Employee $3.07 $36.84
Employee + child(ren) $6.13 $73.56
Employee + spouse $5.82 $69.84 Employee + family $9.01 $108.12 Need further assistance? Give us a call: * Expanded plan premium rates (800) 208-6404
Employee/retiree rates Monthly Annually
Employee $5.56 $66.72
Employee + child(ren) $11.12 $133.44
Employee + spouse $10.57 $126.84 Employee + family $16.35 $196.20
* Actual costs and benefits may vary based upon plan design selected. Exclusions and limitations may apply. Eligibility for vision benefits may be affected by certain life events. Life event means one of the following: (1) your marriage or divorce; (2) the death of your spouse; (3) the birth or adoption of your Child; (4) the death of your Child; (5) a change in the employment status of your spouse; or (6) a change in your employment status or a qualifying event as defined by the State of Tennessee.
The Schedule of Benefits in this document reflects, unless otherwise approved by the State, the procedures that vision will cover as well as certain limitations and exclusions for these covered benefits. These services will be covered when a vision eye care professional provides them. These services must be necessary and must be provided in accordance with generally accepted vision practice standards. If the total benefit charge for a Member is less than the benefit cost-sharing, the Member shall pay the lesser charge. In addition to the limitations and exclusions shown in the Schedule of Benefits section, the Vision Plan does not pay for the following unless otherwise approved by the State:
General Limitations & Exclusions A. Treatment of injury or illness covered by Workers’ Compensation or Employer’s Liability Laws. B. Services received without cost from any federal, state or local agency. This exclusion will not apply if prohibited by law. C. Cosmetic surgery or procedures for purely cosmetic reasons. D. Charges by any hospital or other surgical or treatment facility and any additional fees charged by the vision for treatment in any such facility. E. Services by an eye care professional beyond the scope of his or her license. F. Vision services for which the patient incurs no charge. G. Vision services where charges for such services exceed the charge that would have been made and actually collected if no coverage existed. H. Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses.
I. Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear. DV-MKG21-0046v1 PDF 08/2020 J. Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available.
Optional Materials & Services If the materials and services rendered exceed the covered benefit, the difference for the actual materials or services rendered is due from the member. We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Davis Vision coverage is underwritten by HM Life Insurance Company, Pittsburgh, PA, under policy form series HMP 902-VIS or similar. The coverage or service requested may not be available in all states and is subject to individual state approval.
from (800) 208-6404 davisvision.com/stateoftn davisvision.com/stateofTN | 14 Disability Insurance 2021 Group Disability Member Handbook
For Active State Employees
State of Tennessee Welcome!
Financial experts have long recommended Disability Insurance as part of a sound financial plan should you be unable to work due to illness or injury. Your ability to earn an income is indeed one of your most valuable assets.
The following is a summary of the State Group Insurance Short and Long Term Disability Insurance Programs.
The Member Handbook provides only a brief overview of the STD and LTD plans. A complete description of the benefits, provisions, conditions, limitations, and exclusions will be included in the Certificate of Insurance. The Certificate of Insurance can be found on the ParTNersForHealth website http://www.tn.gov/partnersforhealth and on https://metlife.com/StateofTN . We recommend you review these documents. If any discrepancies exist between the information in this Member Handbook and the legal plan documents, the legal plan documents will govern.
Please note: Like most group disability insurance policies, MetLife group policies contain certain exclusions (state variations may apply), waiting periods, reductions, limitations and terms for keeping them in force. Ask your Agency Benefits Coordinator for complete costs and details.
How does the MetLife Disability Insurance benefit you? Disability insurance helps protect your income when you cannot work due to illness or injury; Replaces a percentage of your predisability income lost due to sickness, pregnancy or as a direct result Of accidental injury; Helps you to cover your essential living expenses if you are sick or hurt and cannot work. Examples of these expenses are car payments, mortgage payments, groceries, child care, tuition and more. Disability Insurance might be right for you if you… • Have little or no annual or sick leave saved up • Don’t have much in the way of savings or an emergency fund • Take part in high-risk activities
The Short and Long Term Disability Insurance Programs: STD - Two options to choose from: Option A: 60% of your weekly predisability salary; benefits start after 14 calendar days* Option B: 60% of your weekly predisability salary; benefits start after 30 calendar days*
LTD - Four options to choose from: Option 1: 60% of your monthly predisability salary; benefits start after 90 calendar days* Option 2: 60% of your monthly predisability salary; benefits start after 180 calendar days* Option 3: 63% of your monthly predisability salary; benefits start after 90 calendar days* Option 4: 63% of your monthly predisability salary; benefits start after 180 calendar days* *once all accrued paid leave (annual, sick leave and comp time) has been exhausted
Helpful tools: • FAQ’s and other tools can be found at https://metlife.com/StateofTN • For questions and additional information, please call MetLife’s State of Tennessee service line at 1-855-700-8001 (7am-10pm CT, Mon – Fri) or visit https://metlife.com/StateofTN
Please be sure to review the Short Term and Long Term Certificates for complete details about this Disability coverage from MetLife. You’ll find information about your plan’s benefit amounts, estimated rates, terms and conditions. As one of the nation’s leading providers of worksite disability benefits, MetLife will provide you with caring, compassionate and accurate claims service, if and when you experience a disability. https://metlife.com/StateofTN
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SHORT TERM DISABILITY INSURANCE COVERAGE OPTIONS
SHORT TERM DISABILITY INSURANCE OPTION A OPTION B All employees working not less than 30 hours/week; or seasonal employees hired prior to July 1, 2015 with 24 months of service and certified by their appointing authority to work at Eligibility least 1,450 hours per fiscal year (July-June); or deemed eligible by applicable federal law, state law, or action of the State Insurance Committee. % of Gross Annual Base 60% of salary paid weekly Salary1 Paid Weekly Maximum Weekly Benefit Up to $2,500
Minimum Weekly Benefit2 $25 Elimination Period 14 calendar days 30 calendar days Maximum Benefit Period 26 weeks Guaranteed Issue (no health questions asked) for New Hires who enroll within 30 days of eligibility date. A full Statement of Health is required for all new applicants and for current Evidence of Insurability (EOI)3 participants electing a higher plan of benefit during the 2021 Annual Enrollment period.
Pre-Existing Condition4 None
1 Annual salary will be based on your date-of-hire salary for new hires; thereafter, the gross base annual salary you make on September 1 of each calendar year determines the benefit you are eligible for beginning October 1 of each calendar year. 2 The Minimum Monthly Benefit will not apply if you are receiving 100% of Your Predisability Salary under the Policyholder’s paid leave policy. 3 MetLife will review your information and evaluate your request for coverage based upon your answers to the health questions, MetLife’s underwriting rules and other information you authorize us to review. In certain cases, MetLife may request additional information to evaluate your request for coverage. 4 Pre-existing Condition means a Sickness or accidental injury for which you: 1) received medical treatment, consultation, care or services; or took prescribed medication or had medications prescribed; in the 3 months before Your insurance under the certificate takes effect. SHORT TERM DISABILITY INSURANCE RATES The following monthly premiums are effective 1/1/2021 – 12/31/2021. Your premium will be paid through convenient payroll deduction. STD COST: PER $100 OF MEMBER’S COVERED MONTHLY SALARY Option A: 60%, 14 day elimination period $1.34 Option B: 60%, 30 day elimination period $1.08
Calculate your Monthly Premium for Short Term Disability Insurance – For this example, we’re using an employee earning $45,000 annually, selecting Option A.
STEPS EXAMPLE WORK SPACE 1. Determine your Covered Monthly Salary 1 (Annual Salary divided by 12.) $45,000 ÷ 12 = If your Annual Salary exceeds $216,666.84 enter $18,055.57 as your Covered $3,750 2 Monthly Salary. 2. Divide Covered Monthly Salary by $100 to get your per $100 of Covered $3,750 ÷ 100 = Monthly Salary $37.50 3. Calculate your approximate monthly premium (Multiply your per $100 of Covered Monthly Salary by the appropriate rate based $37.50 x $1.34 = on Option elected) $50.25
1 Annual salary will be based on your date-of-hire salary for new hires; thereafter, the gross base annual salary you make on September 1 of each calendar year determines the benefit you are eligible for beginning October 1 of each calendar year. 2 The amount of STD benefit may not exceed the Maximum Weekly Benefit established under the plan of $2,500 regardless of your annual salary amount. Therefore, the maximum covered monthly salary eligible for benefit is $18,055.57, or $216,666.84 annually. This will be the same for Option A or B
2 LONG TERM DISABILITY INSURANCE COVERAGE OPTIONS
LONG TERM DISABILITY INSURANCE
OPTION 1 OPTION 2 OPTION 3 OPTION 4 All employees working not less than 30 hours/week; seasonal employees hired prior to July 1, 2015 with 24 months of service and certified by their appointing authority to work at Eligibility least 1,450 hours per fiscal year (July-June); or deemed eligible by applicable federal law, state law, or action of the State Insurance Committee. % of Gross Annual Base Salary1 Paid 60% of salary paid monthly 63% of salary paid monthly Monthly Maximum Monthly Up to $7,500 per month Up to $10,000 per month Benefit (covers annual salary of $150,000) (covers annual salary of $190,476.24) Minimum Monthly Greater of 10% of benefit or $100 per month Benefit2 Elimination Period 90 calendar days 180 calendar days 90 calendar days 180 calendar days
Own Occupation 24 months 24 months 36 months 36 months Disabled prior to age 65, then to Social Security Normal Retirement Age (SSNRA); Age 65, 24 months; Maximum Benefit Age 66, 21 months; Age 67, 18 months, Age 68, 15 months; age 69+, 12 months Period Guaranteed Issue (no health questions asked) for New Hires who enroll within 30 days of Evidence of eligibility date. A full Statement of Health is required for all new applicants and for current Insurability (EOI)3 participants electing a higher plan of benefit during the 2021 Annual Enrollment period. Pre-Existing 3 months prior to effective date and 12 months from effective date Condition4
1 Annual salary will be based on your date-of-hire salary for new hires; thereafter, the gross base annual salary you make on September 1 of each calendar year determines the benefit you are eligible for beginning October 1 of each calendar year. 2 The Minimum Monthly Benefit will not apply if you are receiving 100% of Your Predisability Salary under the Policyholder’s paid leave policy. 3 MetLife will review your information and evaluate your request for coverage based upon your answers to the health questions, MetLife’s underwriting rules and other information you authorize us to review. In certain cases, MetLife may request additional information to evaluate your request for coverage. 4 Pre-existing Condition means a Sickness or accidental injury for which you: 1) received medical treatment, consultation, care or services; or took prescribed medication or had medications prescribed; in the 3 months before Your insurance under the certificate takes effect LONG TERM DISABILITY INSURANCE RATES - The following monthly premiums are effective 1/1/2021 – 12/31/2021. Your premium will be paid through convenient payroll deduction. Long Term Disability Insurance Cost is based on the plan Option you elect and your age as of September 1. Your age will be adjusted each subsequent year on September 1 and your cost will increase effective October 1 in each year that you age into the next cost bracket.
LTD: EMPLOYEE’S AGE (PER $100 OF COVERED MONTHLY SALARY) Under 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+ 30 Option 1, 60%, 90 day elimination $.20 $.20 $.40 $.59 $.75 $.92 $1.10 $1.46 $.97 $.97 period Option 2, 60%, 180 day elimination $.16 $.16 $.31 $.46 $.59 $.72 $.86 $1.14 $.76 $.76 period Option 3, 63%, 90 day elimination $.24 $.24 $.49 $.72 $.91 $1.12 $1.34 $1.78 $1.18 $1.18 period Option 4, 63%, 180 day elimination $.19 $.19 $.39 $.57 $.72 $.89 $1.06 $1.41 $.94 $.94 period
3 Calculate your Monthly Premium for Long Term Disability Insurance – For this example we are using an employee making $45,000 annually, selecting Option 3.
STEPS EXAMPLE WORK SPACE 1. Determine your Covered Monthly Salary (Annual Salary3 divided by 12)
For Option 1 & 2, if your Annual Salary exceeds $150,000, enter $45,000 ÷ 12 = $3,750 $12,500. For Option 3 & 4, if your Annual Salary exceeds $190,476.24, enter $15,873.02.4
2. Divide Covered Monthly Salary by $100 to get your per $100 of $3,750 ÷ 100 = $37.50 Covered Monthly Salary 3. Look up applicable cost, from the LTD chart on the previous page, based on Option elected and your age as of September 1 of current $1.12 year 4. Calculate your approximate Monthly Premium (Per $100 of coverage from Step 2 x Rate found on table above, from Step 3 for a $37.50 x $1.12 = $42.00 52-year-old member selecting Option 3.)
3 Annual salary will be based on your date-of-hire salary for new hires; thereafter, the gross base annual salary you make on September 1 of each calendar year determines the benefit you are eligible for beginning October 1 of each calendar year. 4 The amount of LTD benefit may not exceed the Maximum Monthly Benefit established under the plan of $7,500 for Options 1 or 2, or $10,000 for Options 3 or 4, regardless of your annual salary amount. Therefore, if you select Option 1 or 2, the maximum covered monthly salary eligible for benefit is $12,500, or $150,000 annually. If you select Option 3 or 4, the maximum covered monthly salary eligible for benefit is $15,873.02, or $190,476.24 annually.
How to file a Disability Claim
• Call the MetLife Claims Center at the dedicated number: 1-855-700-8001
• The Claims Center is available 7:00 am – 10:00 pm CT, Monday – Friday
• You can also file an Online Claim at https://mybenefits.metlife.com/MyBenefits
• You can file a Paper Claim by downloading a form from https://mybenefits.metlife.com/MyBenefits. Send your completed claim form to the MetLife Claim’s office address and / or fax number below.:
Metropolitan Insurance Company PO Box 14590 Lexington, KY 40512 Fax: 1-800-230-9531 • You can track the status of your claim online or on the MetLife US App. Search "MetLife" on iTunes® App Store or Google Play to download the app.
Information we may need from you
• Personal Information - Name, address, telephone number, social security number, employee identification number and job title.
• Job Information - Workplace location and address, work schedule, supervisor’s name and telephone number, and date of hire.
• Sickness/Injury Information - Last day worked, nature of the illness/absence, how, when, and where the injury occurred, when the disability commenced and actual or approximate date you anticipate returning to work (if known).
• Treatment Provider Information - Name, address, telephone number, and fax number for each treating Health Care Provider.
• Authorization to Release Your Medical Information - the release of your medical information to MetLife may be required. You should inform your Health Care Provider(s) that MetLife will be administering your claim or leave and that you authorize the release of your medical information to the MetLife claims office.
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Important answers to some common questions
What do the terms “Disabled” and “Disability” mean? How are they defined?
For Short Term Disability “Disabled” or “Disability” means that, due to sickness, or as a direct result of accidental injury: You are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; and You are unable to earn more than 80% of Your Predisability Salary at Your Own Job at the State of Tennessee.
For purposes of determining whether a Disability is the direct result of an accidental injury, the Disability must have occurred within 90 days of the accidental injury and resulted from such injury independent of other causes.
If your occupation requires a license, the fact that you lose your license for any reason will not, in itself, constitute Disability.
For Long Term Disability “Disabled” or “Disability” means that, due to sickness, or as a direct result of accidental injury:
• During the Elimination Period and the next 24 months for LTD Plans 1 & 2 (the next 36 months for LTD Plans 3 & 4) of Sickness or accidental injury: • You are unable to perform the duties of your Own Occupation and you are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; or • You are unable to earn more than 80% of your Predisability Salary at your Own Occupation and you are receiving Appropriate Care and Treatment and complying with the requirements of such treatment. • After such period: • You are unable to perform the duties of any occupation for which you are reasonably qualified taking into account your training, education and experience and you are receiving Appropriate Care and Treatment and complying with the requirements of such treatment; or • You are unable to earn more than 60% of your Predisability Salary from any employer in your Local Economy at any gainful occupation for which you are reasonably qualified taking into account your training, education and experience and you are receiving Appropriate Care and Treatment and complying with the requirements of such treatment.
For purposes of determining whether a Disability is the direct result of an accidental injury, the Disability must have occurred within 90 days of the accidental injury and resulted from such injury independent of other causes.
What is my Predisability Salary, and when is it determined? Your gross, base annual salary is defined as your Predisability Salary. The gross base annual salary you make on September 1 of each calendar year determines the benefit you are eligible for beginning October 1 of each calendar year.
For new hires, annual salary will be based on your date-of-hire salary, and coverage will be effective after you complete one full calendar month of employment.
Annually, there will be a benefit and premium level adjustment. If your salary has changed from the prior year, your benefit and premium will change accordingly using the gross base annual salary you make on September 1. This adjustment will become effective on October 1.
When do Short Term Disability benefit payments begin and how long do they continue? If the claimant meets the applicable definition of Disability, benefit payments will begin after the end of the elimination period and once all accrued paid leave (annual, sick leave and comp time) is exhausted. The elimination period begins on the day you become disabled and is the length of time you must wait while being disabled before you are eligible to receive a benefit. Your elimination periods for Short Term Disability are as follows and will depend on which plan is chosen:
• Option A: 14 calendar days; • Option B: 30 calendar days;
The maximum benefit period is 26 weeks. The benefit period starts once the elimination period has been satisfied, but the benefit payments will not start until all accrued paid leave (annual, sick leave and comp time) has been exhausted. Please note – every disability is different, and for numerous reasons, not every disability may last for the maximum period. For a full list of Frequently Asked Questions (FAQ’s) please visit https://metlife.com/StateofTN
Important answers to some common questions
When do Long Term Disability benefit payments begin and how long do they continue? If the claimant meets the applicable definition of Disability, benefit payments will begin after the end of the elimination period and once all accrued paid leave (annual, sick leave and comp time) is exhausted. The elimination period begins on the day you become disabled and is the length of time you must wait while being disabled before you are eligible to receive a benefit. Your elimination periods for Long Term Disability are as follows and will depend on which option is chosen:
• Option 1: 90 calendar days; • Option 2: 180 calendar days; • Option 3: 90 calendar days; • Option 4: 180 calendar days
Your plan’s maximum benefit period is dependent on your age on your date of disability. Monthly payments may last to a maximum benefit period of age 65, or your Social Security Normal Retirement Age (SSNRA), after you satisfy the Elimination Period. If you are age 65 or older on the date of disability, your maximum benefit period is as follows:
• Age 65, 24 months • Age 66, 21 months • Age 67, 18 months • Age 68, 15 months • Age 69+, 12 months
The benefit period starts once the elimination period has been satisfied, but the benefit payments will not start until all accrued paid leave (annual, sick leave and comp time) has been exhausted. Please note –every disability is different, and for numerous reasons, not every disability may last for the maximum period.
I have “Leave” time accrued. Does this affect my Short Term and Long Term Disability benefit? Yes. You must use all of your accrued leave. This includes all sick, annual, and any compensatory leave before your disability payments begin. You will not be paid from two different sources for your disability. Your disability payment will begin after your pay from any accrued leave ends.
Every Employee’s situation is different. Consider how much accrued sick and annual leave you have when deciding whether to purchase Short Term and/or Long Term Disability Insurance.
Will using days from the “Sick Leave Bank” impact my STD and LTD benefit payments? You are NOT required to use days from the Sick Leave Bank. However, if you withdraw days from your Sick Leave Bank, any Sick Leave Bank days that extend beyond the STD benefit start date will be an offset to the STD benefit. You will not be paid from two different sources for your disability. Your disability payment from MetLife will begin after your pay from the Sick Leave Bank ends.
How does Short Term and Long Term Disability work with FMLA? If you are on FMLA due to your own disability, you may be eligible to receive disability benefits if you meet the definition of disability per the plan. If you are on FMLA for any other reason, such as care of a family member, for example, you are not eligible to receive disability benefits. While on FMLA leave, you will be billed for disability coverage just as you are for other benefits, such as Dental or Life.
Can I receive benefits if I return to work part-time? Yes, as long as you are disabled and meet the terms of your Disability plan, you may qualify for adjusted Disability benefits.
Are there any Limitations for Pre-Existing Conditions? For Short Term Disability: No. For Long Term Disability: Yes. If you become disabled within the first 12 months of your coverage becoming effective, the plan will not cover a sickness or accidental injury for which you received treatment, consultation or care, or took medications or were prescribed medications in the 3 months prior to your participation in the plan.
For a full list of Frequently Asked Questions (FAQ’s) please visit https://metlife.com/StateofTN
6
Important answers to some common questions
Are there any exclusions to my Short Term and Long Term Disability coverage? Yes. Short Term and Long Term Disability insurance do not cover any disability which results from or is caused or contributed to by: • War, whether declared or undeclared, or act of war, insurrection, rebellion or terrorist act; • Active participation in a riot; • Intentionally self-inflicted injury or attempted suicide; or • Commission of or attempt to commit a felony; Short Term Disability insurance does not cover any disability caused or contributed to by elective treatment or procedures, such as: • Cosmetic surgery or treatment primarily to change appearance; • Reversal of sterilization; • Liposuction; • Visual correction surgery; or • In vitro fertilization, embryo transfer procedure or artificial insemination. However, pregnancies and complications from any of these procedures will be treated as a Sickness.
For a complete list of exclusions, please refer to the Certificate of Insurance.
For a full list of Frequently Asked Questions (FAQ’s) please visit https://metlife.com/StateofTN
L1018508985[exp12/21][All States][DC,GU,MP,PR,VI] © 2019 Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10266
PREGNANCY QUESTIONS – SHORT TERM DISABILITY
Is there a difference in the amount of disability time allowed for a cesarean delivery versus a normal delivery? Generally: • Normal vaginal delivery disability period is 6 weeks from date of delivery, and • Cesarean delivery disability period is 8 weeks from date of delivery
Can I receive disability benefits for any period of time prior to my expected date of delivery? In many cases, women are able to work up until their delivery. However, there are times when problems may arise and there is a need to take leave before the child is born. Ante-partum time (before delivery) of up to 2 weeks is allowed without medical documentation. However, if your first day absent is more than 2 weeks before delivery, then medical documentation must be sent to MetLife.
What if I have problems with my pregnancy and need to be out of work earlier or longer than expected? You should start a claim for disability. MetLife will notify your doctor and request medical information to evaluate your disability. MetLife will use the medical information to make a claim decision.
When are benefits payable? The benefit period will begin the day after you satisfy the elimination period of either 14 or 30 calendar days. However, benefits are only payable after all accrued paid leave (annual, sick leave and comp time) has been exhausted.
When should I file my disability claim? Typically, you should file your claim on the last day worked. However, you should check your employer’s plan documents and the FAQs on the MetLife Disability website for more information: https://metlife.com/StateofTN
How do I file my disability claim? MetLife offers claim filing through the internet, via telephone, or paper. However, you should check your employer's plan documents and the FAQs on the MetLife Disability website for more information: https://metlife.com/StateofTN
How will I know when a decision about my claim has been made? A MetLife case manager will call you and provide a letter outlining the claim decision.
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What information does my doctor need to provide to MetLife for my disability? Your doctor will need to confirm your pregnancy and provide dates (due/delivery date). The doctor will also need to advise if there is anything else that the case manager should be aware of to assist with the handling of your disability claim.
What are some example disability claims due to pregnancy? (For illustrative purposes only.) Notes: • Disability Period minus Elimination Period = Benefit Period • Benefit Period minus Accrued Paid Leave after Elimination Period = Payable Benefit Period Example No. 1 Normal Delivery with no pre or post time disabled, 30 Day Elimination Period, and 6 weeks of accrued leave available: Disability Period = 6 weeks (begins on the date of delivery in this example) Elimination Period = 4 weeks (30 calendar days) Benefit Period = 2 weeks (14 calendar days) Accrued Leave = 6 weeks (30 work days) Payable Benefit = No Benefits Payable Period
Weeks 1 2 3 4 5 6 Total Disability Period (6 weeks) Elimination (4 weeks) Period Benefit (2 weeks) Period Accrued Leave (6 weeks) Payable Benefit Period (0 weeks)
Example No. 2 Cesarean Delivery with no pre or post time disabled, 30 Day Elimination Period, and 1 week of accrued leave available: Disability Period = 8 weeks (begins on the date of delivery in this example) Elimination Period = 4 weeks (30 calendar days) Benefit Period = 4 weeks (28 calendar days) Accrued Leave = 1 week (5 work days) Payable Benefit = 4 weeks (28 calendar days) Period
Weeks 1 2 3 4 5 6 7 8 Total (8 Disability Period weeks) (4 Elimination Period weeks) Benefit (4
Period weeks) Accrued (1 week) Leave Payable (4 Benefit weeks) Period
An elimination period of 14 days in example No. 1 would still offer a payable benefit period of 0 weeks due to the amount of accrued leave. In example No. 2 a 14 day elimination period would offer a payable benefit period of 6 weeks. Each pregnancy is different and your disability period may vary from these examples. These examples illustrate the basic 8
anticipated benefit for normal pregnancy. If you have considerable accrued sick or annual leave, this short term disability policy may not provide significant value for a normal delivery; but it may provide significant value in the event of unforeseen circumstances. Contact MetLife directly to discuss your specific situation.
If I receive other income will it reduce my disability benefits? Benefits payable during the payable benefit period may be reduced by other sources of income, e.g. worker's compensation, unemployment insurance, and sick leave bank. See the certificate of coverage for a comprehensive list of other sources of income which may reduce the STD benefit.
What type of benefit does MetLife manage for State of TN employees who are pregnant? MetLife manages short-term disability insurance benefits for State of TN employees enrolled in the short-term disability insurance program. This includes employees who are unable to perform their job for the State of TN due to child-delivery or pregnancy complications.
For more information about a claim or benefits, contact MetLife at 1-855-700-8001, Monday - Friday, 7 AM - 10 PM, Central Time
Payable Benefit Period Calculation – Short Term Disability Examples
1. Disability Period - The period of time the member is deemed disabled per the plan definition. The disability period begins on the first day of disability and includes the elimination period and the benefit period. The disability period ends the day before returning to work or the end of the approved disability period, whichever occurs first. The Disability Period is calendar day based.
2. Elimination Period - The portion of the disability period during which the Short Term Disability (STD) plan does not pay benefits. The elimination period begins on the first day of disability and continues for the consecutive 14 or 30 calendar-day period of time outlined in the plan in which the member is enrolled. Elimination Period is calendar day based.
3. Benefit Period - The portion of the disability period during which benefits may be payable. The benefit period starts on the calendar day after the elimination period has been satisfied and extends for the length of time approved by MetLife for the member’s specific disability, not to exceed the maximum benefit period of 26 calendar weeks.
4. Accrued Paid Leave – The amount of paid time off the member has accrued with his or her employer. This includes annual leave, sick leave, and compensatory time. Use of accrued paid leave begins on the date of disability and runs concurrently with both the elimination period and disability period. All accrued paid leave must be used before disability benefit payments may begin. Accrued leave is work day/work hour based. 5. Payable Benefit Period – The period of time the member may be paid after the elimination period has been satisfied and all accrued paid leave has been used.
To determine the benefit period payable by the STD plan: Disability Period minus Elimination Period = Benefit Period Benefit Period minus Accrued Paid Leave after Elimination Period = Payable Benefit Period
(Continued on next page)
9
EXAMPLES below
Condition A – requires 6 weeks to recover Short-Term Disability Timeline – Plan Option A
Situation Scenario: • Member’s approved Disability Period = 6 weeks • Member’s Accrued Paid Leave = 1 week • Elimination Period = 14 calendar days • Member Payable Benefit Period = 4 weeks
Payment details: • 1 week Accrued Paid Leave from the State of TN • 4 weeks STD pay from the STD plan with MetLife • Member will have 1 week during the Elimination Period that is not paid by the State of TN or the STD plan with MetLife
NOTE: The Maximum Benefit Period Duration for STD is 26 Weeks. However, each disability is different, and for numerous reasonsnot all disabilities will result in the full 26 week benefit period being approved. These examples are for illustrative purposes only. Every disability may be different. Accrued leave is per work day and is hourly based. Accrued leave varies by individual. Elimination Period is calendar day based. Benefits payable during the payable benefit period may be reduced by other sources of income, e.g. worker's compensation, unemployment insurance, and sick leave bank. See the certificate of coverage for Higher Ed or State employees for a comprehensive list of other sources of income which may reduce the STD benefit.
10
Condition B – requires 30 weeks to recover Short-Term Disability Timeline – Plan Option B Situation Scenario: • Member’s approved Disability Period = 30 weeks • Member’s Accrued Paid Leave = 5 weeks • Elimination Period = 30 calendar days • Member Payable Benefit Period = 25 calendar weeks Payment details: • 5 week Accrued Paid Leave from the State of TN • 25 weeks STD pay from the STD plan with MetLife
NOTE: The Maximum Benefit Period Duration for STD is 26 Weeks. However, each disability is different, and for numerous reasons not all disabilities will result in the full 26 week benefit period being approved. These examples are for illustrative purposes only. Every disability may be different. Accrued leave is per work day and is hourly based. Accrued leave varies by individual. Elimination Period is calendar day based. Benefits payable during the payable benefit period may be reduced by other sources of income, e.g. worker's compensation, unemployment insurance, and sick leave bank. See the certificate of coverage for Higher Ed or State employees for a comprehensive list of other sources of income which may reduce the STD benefit. The Member Handbook provides only a brief overview of the STD and LTD plans. A complete description of the benefits, provisions, conditions, limitations, and exclusions will be included in the Certificate of Insurance. The Certificate of Insurance can be found on the ParTNersForHealth website http://www.tn.gov/partnersforhealth and on
https://metlife.com/StateofTN . We recommend you review these documents. If any discrepancies exist between the information in this Member Handbook and the legal plan documents, the legal plan documents will govern.
Please note:Like most group disability insurance policies, MetLife group policies contain certain exclusions (state
variations may apply), waiting periods, reductions, limitations and terms for keeping them in force. Ask your Agency
Benefits Coordinator for complete costs and details.
L0819516914[exp1221][All States][DC,GU,MP,PR,VI] Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166 © 2020 MetLife Services and Solutions, LLC
11
Introduction to health savings accounts
A health savings account (HSA) allows you to save money for qualified medical expenses that you’re expecting, such as contact lenses or monthly Contribution limits prescriptions, as well as unexpected ones — for this year and the future. There are contribution limits, set Why have an HSA? by the Internal Revenue Service (IRS) and adjusted annually. You own it The money is yours until you spend it, even deposits made by others, such as These limits are: an employer or family member. You keep it, even if you change jobs, health • $3,600 for individual coverage plans or retire. in 2021 Tax savings • $7,200 for family coverage HSAs help you plan, save and pay for health care, all while saving on taxes. in 2021 • The money you deposit is federal income tax-free. • $1,000 extra if you’re 55 or older, also known as catch-up • Savings grow income tax-free. contributions • Withdrawals for qualified medical expenses are also income tax-free. These contribution limits include It’s not just for doctor visits any seed funds provided by your Once you’ve contributed to your account, you can use the funds in your HSA employer, so be sure to factor to pay for qualified medical expenses such as: that in when planning your own contribution amount. • Dental care, including extractions and braces • Vision care, including contact lenses, prescription sunglasses and LASIK surgery • Prescription medications • Certain over-the-counter drugs and medications • Chiropractic services • Acupuncture
Save for the future Your HSA rolls over from year to year, so you can continue to grow your savings and use it in the future - even into retirement. Intro to HSAs
Who can open an HSA? You can have an HSA if you are enrolled in a qualifying consumer-driven Contributions add up health plan (CDHP) or Local CDHP plan offered by the State Group Insurance quickly. Program. When Marcus started his new In addition, you must meet the following requirements as defined by the IRS: job, he decided to open an HSA and contribute $100 per month. • Be covered under a consumer-driven health plan (CDHP) on the first day of Because he hasn’t had many a given month. medical expenses, he decided • Not be covered by any other health coverage except what is permitted not to touch the balance during (dental, vision, disability and some other types of additional coverage his first year. Here’s how his are permissible). contributions added up: • Not be enrolled in Medicare, Social Security benefits, TRICARE or TRICARE Monthly contribution: $100 for Life. Annual contribution: $1,200 • Have not received Department of Veterans Affairs (VA) benefits within the Annual income tax savings1: $452 past three months, except for preventive care. If you are a veteran with 1 a disability rating from the VA, this exclusion does not apply. If you are 25% federal | 5% state | 7.65% FICA eligible for VA medical benefits, but did not receive benefits during the Use the HSA Calculator on preceding three months, you can enroll in and make contributions to your optumbank.com/tennessee HSA. If you receive VA benefits in the future, then you are not entitled to help determine your to contribute to your account for another three months. However, if your contributions and see how veteran’s hospital care or medical service was for a service-connected much you can save on taxes. disability, you may contribute to your HSA. • Have not received care from the Indian Health Services (IHS) within the past three months. Download the • Not be claimed as a dependent on someone else’s tax return. Optum Bank app. • You do not qualify for a medical flexible spending account (FSA), if you are Enjoy an easier way to manage your enrolled in the CDHP/HSA. You may, however, have a limited purpose FSA health savings account. You can (L-FSA) for vision and dental expenses only. pay bills, view transactions, upload Other restrictions and exceptions also apply. Consult a tax, legal or financial receipts and more! Download today advisor to discuss your personal circumstances. on your Apple or Android device. Open your account Check with your employer or benefits specialist to learn about your company’s application process. You may be able to sign up through your employer or enroll at optumbank.com/tennessee. You cannot use your HSA to pay for medical expenses you had before you opened your account — so be sure to open your HSA as soon as you are eligible.
And be sure to save your receipts! For a full list of qualified medical expenses, visit irs.gov.
Have questions? Visit optumbank.com/tennessee or download the mobile app.
Health savings accounts (HSAs) are individual accounts offered or administered by Optum Bank®, Member FDIC, and are subject to eligibility requirements and restrictions on deposits and withdrawals to avoid IRS penalties. State taxes may apply. Fees may reduce earnings on account. This communication is not intended as legal or tax advice. Federal and state laws and regulations are subject to change. Apple, the Apple logo, Apple Pay, Apple Watch, iPad, iPhone, iTunes, Mac, Safari, and Touch ID are trademarks of Apple Inc., registered in the U.S. and other countries. iPad Pro is a trademark of Apple Inc. Android, Google Play and the Google Play logo are trademarks of Google LLC. Data rates may apply. © 2020 Optum Bank, Inc. All rights reserved. WF3212079 204277-072020 OHC Investing opportunities for your HSA
Investing your health savings account (HSA) dollars has many potential tax benefits. It can be a way to save for long-term health care needs and financial What if you have goals. HSAs are triple tax advantaged, making them an effective savings and unexpected medical investment account. Not only are HSA contributions tax-advantaged, but all costs? interest and investment growth is also income tax-free. No problem! If you’re investing Investing basics in the Optum Bank mutual Once your HSA reaches the investment threshold of $1,000, you may choose funds, you can easily move to invest a portion of your HSA dollars. Optum Bank makes investing easy for your investment funds back you by offering self-directed mutual funds. into your HSA.
You can choose from a variety of mutual funds that have been reviewed and approved by the State of Tennessee Department of Treasury.
And remember, any investment earnings are income tax-free. Start investing today With Optum Bank self-directed mutual funds: 1. Sign in to your HSA and set up your investment account by choosing the Optum Bank self-directed mutual funds option within the Investment Options section. 2. Choose the funds you want to invest in. 3. Decide on the amount you want to move into your investment account. The minimum amount that can be transferred at one time is $100. 4. Want to make future investing easier? You can choose to set up recurring transfers/sweeps. You choose a certain threshold amount, and any funds over that amount will be moved to your investment account. You can manage your investments easily on optumbank.com/tennessee. Investments are not FDIC insured, are not guaranteed by Optum Bank®, and may lose value.
Mutual fund investment options are made available through the services of an independent investment advisor and shares are offered through Charles Schwab & Co., Inc., a registered broker-dealer. Orders are accepted to effect transactions in securities only as an accommodation to HSA owner. Optum Bank is not a broker-dealer or registered investment advisor, and does not provide investment advice or research concerning securities, make recommendations concerning securities, or otherwise solicit securities transactions. Health savings accounts (HSAs) are individual accounts offered or administered by Optum Bank®, Member FDIC, and are subject to eligibility requirements and restrictions on deposits and withdrawals to avoid IRS penalties. State taxes may apply. Fees may reduce earnings on account. This communication is not intended as investment, legal or tax advice. Federal and state laws and regulations are subject to change. © 2020 Optum Bank, Inc. All rights reserved. WF3212079 204282-072020 OHC Protecting your health savings account (HSA)
Important information about procedures for opening a new account
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to verify and record information that identifies each person who opens an account. This is called the Customer Identification Process (CIP). What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will let us identify you. We may also ask to see your driver’s license or other identifying documents.
For faster enrollment, make sure your information is complete and correct Always use the most correct and current information when you enroll in an HSA. Questions? Talk to us. Visit optumbank.com/tennessee Here are a few tips: 866-600-4984, 24/7, excluding • Use your current residential address, not a PO box or a non-U.S. address. major U.S. holidays. • You must be at least 18 years old. • Use your full legal name. – Don’t use your nickname (for example, “Becky” for “Rebecca”). DON’T FORGET: – Use your middle initial. • Carefully complete your enrollment application. – Don’t use the Americanized version of your name (for example, “Sue Young” rather than “Soon Yong”). • Always respond if we ask – Don’t use a different spelling of your name (for example, “Caren” for “Karen”). for additional information. • Use your correct Social Security number. • Have your Medical ID card containing your Group/Employer number handy.
Next steps if your information doesn’t pass We’ll send you a letter within ten business days. It will explain the Customer Identification Process (CIP) issue and request the documentation needed to confirm your identity or address. • If you don’t respond within 30 days, we’ll send you a second letter. • If you don’t respond within 45 days, we’ll send you a third and final letter.
Health savings accounts (HSAs) are individual accounts offered or administered by Optum Bank®, Member FDIC, and are subject to eligibility requirements and restrictions on deposits and withdrawals to avoid IRS penalties. State taxes may apply. Fees may reduce earnings on account. Flexible spending accounts (FSAs) and health reimbursement accounts (HRAs) are administered by OptumHealth Financial Services and are subject to eligibility and restrictions. This communication is not intended as legal or tax advice. Federal and state laws and regulations are subject to change. © 2020 Optum Bank, Inc. All rights reserved. WF3212079 204287-072020 OHC Take care of your financial health
Make the most of your Optum Bank flexible spending account We keep it simple
Your health and your money are two of your most important assets. You’ve enrolled in an Optum Bank flexible spending account (FSA) — a great first step toward taking care of them both. Now use this guide to help you save hundreds, or even thousands of dollars per year with your Optum Bank FSA.
Paying for expenses. The Optum Bank payment Mastercard® is the fastest, most convenient way to pay for FSA-eligible expenses. With it there’s no need to pay cash for out-of-pocket expenses, no waiting for reimbursements and there are no paper forms to complete. Plus card transactions happen in real time so your account balance is always up to date.
You’ll receive two payment cards by mail. Keep one for your own use and share the other with a spouse or dependent, or save it as a backup. The Optum Bank payment Or you can pay for eligible expenses with your own cash, check or credit card. Then ® you can submit a claim to be reimbursed. Submit claims by signing into your account Mastercard makes it easy at optumbank.com/tennessee. You can also submit your reimbursement request to pay for eligible health on the mobile app or by submitting a paper claim form with documentation by email, care expenses. mail or by fax.
You can choose how you want to be reimbursed — with a check or by direct deposit into your bank account. Direct deposit is quicker and easier. If you choose check reimbursements, you’ll need to have a minimum of $25 in claims before we issue a check.
Save your receipts! It’s very important to save all itemized receipts when you use your Optum Bank payment Mastercard®. Receipts must include the date, the service or product obtained, what you paid and the name of the provider. From time to time, we may ask you to send us a receipt to confirm that you used the debit card for an eligible expense.
Saving itemized receipts is a requirement of the IRS. Failure to provide documentation of a payment card purchase when requested may lead to your card being deactivated and your expense reported to your employer as a taxable expense. We’re everywhere you go The Optum Bank mobile app is the easiest way to check your balance, submit and review claims, and get messages—even when you’re in line at the pharmacy. You can snap a photo of a receipt using your device’s camera and upload it to your account to document your claim.
Information at your fingertips. Here are a few of the things you can do faster and easier online:
• View account balances and upcoming payments • Receive notices of claim denials with information on how to repay your account or submit receipts • Sign up to use our mobile app • Change your reimbursement method from check to direct deposit Questions? • Manage your personal information, such as your email address, bank Visit optumbank.com/tennessee. account for direct deposit and dependent information • Download service forms • Sign up for text alerts (normal texting charges from your carrier apply)
We make the Optum Bank dependent care FSA just as easy. If you have a dependent care FSA too, you can use the mobile app and website to manage your account. An important difference, though, from a medical FSA is that you cannot be reimbursed from a dependent care FSA until enough money has been withdrawn from your paycheck to fund the account. You can find the balance available for claims reimbursement on our website and through our mobile app. Please note, the dependent care FSA does not include the use of the Optum Bank payment Mastercard®. Contribution limits Your employer’s plan sets an annual limit on the amount you can contribute to your FSA. Be sure to check your plan documents to learn your contribution limits. Don’t leave money behind Your FSA funds are available on day one of your plan. If you have a dependent care FSA, funds are available as they accumulate from your payroll deductions. Your medical FSA and limited purpose FSA have a carry over feature that allows you to carry over up to $500 into the next flexible benefits plan year. Any balance greater than $500 remaining in your account on December 31st each year will be forfeited.
The dependent care FSA does not have a carry over feature. All flexible benefit plans require that you file claims by April 30th of the following year; otherwise, the claim will be denied.
Run-out period. The run out period gives you extra time to gather and submit claims for eligible health and dependent care expenses you incur during the previous plan year.
Changing contributions. If you get married or divorced, or if you have a baby — you may be able to change the amount you contribute to your FSA. This is called a change in family status. If you have a change in status, your benefits representative can help you change your contributions. For specific details, check your employer’s plan document. We’re always here If you have questions about managing your Optum Bank FSA you can go to optumbank.com/tennessee or call 866-600-4984, 24/7, excluding major U.S. holidays, to speak to a highly trained account representative.
optumbank.com/tennessee
Flexible spending accounts (FSAs) are administered by OptumHealth Financial Services and are subject to eligibility and restrictions. Federal and state laws and regulations are subject to change.
© 2020 Optum Bank, Inc. All rights reserved. WF3212079 204279-072020 OHC Dependent Care OptumFlexible Bank Spending dependent Accounts care flexible spending accounts
Save for day care, child care, preschool, summer day camps and adult day care.
Save on taxes. You may be able to use your account With an Optum Bank dependent care flexible spending account (DC-FSA), you to pay for: can save for day care, child care, nursery school and preschool tax-free. If you are • Nursery school and preschool working, you are able to use your account to pay for the care of your child under • Eligible child care the age of 13 or to care for qualifying dependent adults, like elderly parents, who • Before and after school programs can’t care for themselves. • Babysitters How it works. • Adult day care for an elderly dependent You can enroll in a dependent care FSA as long as you and your spouse are working, For a full list of eligible expenses, looking for work or are a full-time student. contact your benefits representative. With a dependent care FSA, you choose how much to contribute, up to a maximum of $5,000 per household, per year. Your employer deducts this amount from each paycheck, before taxes. You don’t have to pay federal, state or payroll taxes on the money credited to your account, although a couple of states do tax contributions. You save money as you lower your income taxes.
Dependent care funds are deposited every pay period. The money you contribute to your dependent care FSA is deducted from your paychecks and deposited into your account. The total funds you contribute annually are not immediately available at the beginning of the plan year. This is an important difference between a dependent care FSA and a medical FSA. As soon as you have money in your dependent care FSA, you can use it to pay for eligible dependent care expenses. Please note, an Optum Bank payment Mastercard® is not provided for a dependent care FSA.
Start saving today. Sign up for an Optum Bank dependent care FSA during benefits enrollment. Important things to know about your account.
How to enroll. Things to consider: • What dependent care services will you need during the year? • How often will you use these services? • How much will everything cost?
Support and account information. Your account information is available anytime at optumbank.com/tennessee.
Changing your contributions. In special situations — if you have a baby, adopt a child or become responsible for an adult — you may be able to adjust the amount you contribute to your dependent care FSA. This is called a change in status. If you have a change in status, your benefits representative can help you adjust your contributions. If you leave employment, you will have 90 days to continue to file claims against your remaining balance, and any claims that you file must be for the current plan year until your last date of employment.
Health accounts can affect your taxes. Depending on your taxable income, a dependent care FSA may save you more money than the tax credit on your income tax filing. You can’t claim a dependent care tax credit on your federal income tax return for services that were reimbursed by your dependent care FSA. Consult a tax advisor to see what option is best for you.
It’s simple to manage your account. Optum Bank gives you the resources you need to make the most of your health care dollars. Access your account anytime at optumbank.com/tennessee or through our mobile app.
optumbank.com/tennessee
Flexible spending accounts (FSAs) are administered by OptumHealth Financial Services and are subject to eligibility and restrictions. Federal and state laws and regulations are subject to change.
© 2020 Optum Bank, Inc. All rights reserved. WF3212079-204278-072020 OHC Pete saves more with two health accounts. Using an Optum Bank limited purpose flexible spending account
Pete wears contacts. Now he needs new eyeglasses and dental surgery.
What is the advantage of having an Optum Bank limited purpose FSA? A limited purpose flexible spending account (L-FSA) is like a medical flexible spending account (FSA), except that eligible expenses are limited to dental and vision. By limiting FSA reimbursements to dental and vision care expenses, you (and your eligible dependents) can have both a limited purpose FSA and a health savings account (HSA). Participating in both plans allows you to maximize your savings and It’s easy to pay for expenses. tax benefits. The Optum Bank payment Mastercard® is Pete’s health accounts work together. fast and convenient. • Use it at any dental clinic or vision Pete has an HSA that he uses to plan, save and pay for current and future qualified center that accepts Mastercard®. health care expenses. His employer also offers a limited purpose FSA. Although HSA funds can be used as well, Pete decides to contribute to a limited purpose FSA to • No paper claims forms. No cover eligible dental and vision expenses for the year. This allows him to preserve his out-of-pocket costs. No waiting HSA dollars for future medical expenses. for reimbursements. Pete reviews the list of eligible expenses and determines what he needs to contribute • Card transactions happen in real time. to his limited purpose FSA to cover his family’s vision and dental needs. Pete’s annual Or, Pete can pay with cash, a personal election is deducted before taxes and may be withdrawn throughout the plan year. check or credit card, and then submit a His full election amount is available for reimbursement at the start of the plan year. claim online at optumbank.com/tennessee Pete can save an additional $941 in taxes. or on the mobile app. Pete can also ask Optum Bank to deposit reimbursements Pete estimates that new eyeglasses and dental work will cost about $2,500. He for claims directly into his savings or decides to have this amount deducted from his paycheck over the year, before taxes. checking account. With a $2,500 election to his limited purpose FSA, his tax savings add up. Even if he leaves a few dollars in his account at the end of the year, he may save more in taxes.
Saved Saved Saved Total $625 $191 $125 savings $941
Federal tax Payroll tax State tax at 25% at 7.65% at 5%
Hypothetical example is for illustration purposes only. Costs, circumstances and tax rates may vary. Here’s what you should know about your Optum Bank limited purpose It’s simple for Pete to manage FSA and how it works with your HSA. his limited purpose FSA. • The total amount you decide to contribute to your limited purpose FSA is Optum Bank gives Pete available at the start of the plan year or shortly after you enroll. The funds you the resources he needs to contribute to your HSA are available as they are deposited. make the most of his health • Your FSA contribution amount cannot be changed unless there is a change care dollars. He can sign in in status. A change in contribution amount to your HSA does not require a to his account any time at status change. optumbank.com/tennessee • Unused funds in your limited purpose FSA greater than $500 are forfeited at or through the mobile app. He the end of the plan year, but any balance of $500 or less can be carried over can upload a receipt, check into the next plan year. If you leave the company, COBRA may apply. Your his balance or get messages. HSA funds rollover year after year and are yours to keep, even if you leave the company or retire.
Examples of a limited purpose What expenses are not covered FSA eligible expenses under a limited purpose FSA? • Visits to the dentist • Dental whitening procedures and kits • Co-pays and out of pocket cost for • Insurance premiums Dental and Vision services • Medical expenses, including • Braces deductibles, co-insurance, and co-pays • Eye exams • Alcohol and drug rehab expenses • Contact lenses • Prescription medicines • Lasik eye surgery • Over-the-counter medicines • Prescription eyeglasses • Cosmetic procedures • Reading glasses • Expenses for services incurred after • Some transportation and travel the plan year ends, except where a expenses for person receiving dental grace period or carryover applies or vision care • Expenses reimbursed by an insurance or other health plan
optumbank.com/tennessee
Pete is a fictitious individual used to illustrate Optum Bank programs and services.
Health savings accounts (HSAs) are individual accounts offered or administered by Optum Bank®, Member FDIC, and are subject to eligibility requirements and restrictions on deposits and withdrawals to avoid IRS penalties. State taxes may apply. Fees may reduce earnings on account. This communication is not intended as investment, legal or tax advice. Federal and state laws and regulations are subject to change. Flexible spending accounts (FSAs) are administered by OptumHealth Financial Services and are subject to eligibility and restrictions. Federal and state laws and regulations are subject to change.
© 2020 Optum Bank, Inc. All rights reserved. WF3212079 204280-072020 OHC
How to review your health account balance
Review your balance at optumbank.com/tennessee There are several places your balance displays in your Optum Bank account profile.
Account dashboard 1. Sign in to optumbank.com/tennessee. 2. The view you see upon logging-in is your account dashboard. 3. On the left-hand side, a list of all of your health accounts will appear. This may include, but is not limited to, a health savings account (HSA), and/or a flexible spending account (FSA) depending on which account types you have. 4. The dollar amount displayed under Total Funds is the total balance of all of your health accounts, if you have more than one. 5. Below this, each of your accounts is listed with its respective available balance. Click Account Overview to navigate to details of each account. How to review your health account balance
Pay or Reimburse an Expense 1. Sign in to optumbank.com/tennessee. 2. In the top navigation bar, select Payments.
optumbank.com/tennessee
Health savings accounts (HSAs) are individual accounts offered or administered by Optum Bank®, Member FDIC, and are subject to eligibility requirements and restrictions on deposits and withdrawals to avoid IRS penalties. State taxes may apply. Fees may reduce earnings on account. Flexible spending accounts (FSAs) are administered by OptumHealth Financial Services and are subject to eligibility and restrictions. This communication is not intended as legal or tax advice. Federal and state laws and regulations are subject to change. © 2020 Optum Bank, Inc. All rights reserved. WF3212079 204285-072020 OHC Optum Bank payment Mastercard®
Your flexible spending account (FSA) or health savings account (HSA) with Optum Bank includes a Optum Bank payment Mastercard®.
The Optum Bank payment Mastercard® is a fast and easy way to pay for eligible medical expenses without turning in paper claim forms. Use it at the pharmacy, pay at the doctor’s office or write your payment card number on your provider bill. Just remember to keep your receipt, because transactions may have to be validated or substantiated per IRS guidelines.
Things to know if you have an FSA What information is required How are cards processed? by the IRS on a receipt? • If you use the Optum Bank payment Mastercard® at an IIAS approved pharmacy, the eligible prescriptions should be automatically recognized. • Date of service The IIAS approved pharmacy list is available at: https://www.sig-is.org/. • Type of service (prescription, Vendors like Wal-Mart, Target, Walgreens and CVS are all approved copayment, dental etc.) vendors. You can spot these pharmacies when your receipt has FSA eligible • Name of the provider and items marked on it. name of individual serviced • Optum Bank may have received copay information based on your • Cost of the item or service employer’s medical, dental, and vision plan. These copay amounts will • Tip: An Explanation of Benefits accept payment card transactions at doctor’s offices and medical facilities. meets these IRS requirements. No documentation is required for these expenses. • Any other purchases will need additional information.
How will I know if I need to submit a receipt to Optum Bank for an FSA claim? • You will get an email notification from Optum Bank within 7 business days letting you know that a receipt is needed. A second email notification will be sent at 30 days. Questions? • If a purchase cannot be substantiated or does not meet eligibility Call 866-600-4984 to speak to a requirements, Optum Bank will ask for the funds to be returned and highly trained account representative. will credit your plan. The information on how to do this is included in the email notification that you will receive. • Your card will be deactivated due to IRS requirements if no response is received from you within 45 days. During this time, you cannot use your Optum Bank payment Mastercard® but you can continue to file manual claims. In order to reactivate your card, you will either need to submit correct paperwork or repay the expense. Failure to prove a payment card transaction may result in the transaction being reported to your employer to include as taxable income on your W-2 form or deducted from your paycheck if you are a state employee not employed by a higher education institution. Things to know if you have an HSA Do I need to keep receipts for HSA qualified medical expenses? • While you do not need to submit HSA receipts to Optum Bank, you will want to keep your receipts in the event that you are audited by the IRS. The IRS will want documentation that you have used your HSA for qualified medical expenses. Failure to prove a payment card transaction may result in the transaction being reported to your employer to include as taxable income on your W-2 form. • You can easily upload receipts and access them later at optumbank.com/ tennessee or by using the mobile app.
What if I forget my card at home? • You can pay for HSA qualified medical expenses out-of-pocket, and request reimbursement at a later date. You can get reimbursed through ACH, check disbursement, or with cash from an ATM if your HSA offers ATM access*. • There is no time limit for reimbursing yourself with your HSA. The qualified medical expense just needs to occur after your HSA was opened
*You can use your Mastercard® at any ATM that displays the Mastercard® acceptance mark. Please note: You’ll need your PIN. There’s a $300 per 24-hours limit on ATM withdrawals. There is a $2.50 ATM withdrawal fee. Access fees may also be charged by the ATM. ATM access is not available on all HSA products.
optumbank.com/tennessee
Health savings accounts (HSAs) are individual accounts offered or administered by Optum Bank®, Member FDIC, and are subject to eligibility requirements and restrictions on deposits and withdrawals to avoid IRS penalties. State taxes may apply. Fees may reduce earnings on account. This communication is not intended as legal or tax advice. Federal and state laws and regulations are subject to change.
Flexible spending accounts (FSAs) are administered by OptumHealth Financial Services and are subject to eligibility and restrictions. Federal and state laws and regulations are subject to change.
© 2020 Optum Bank, Inc. All rights reserved. WF3212079 204281-072020 OHC YES, YOU CAN CHECK YOUR ACCOUNT BALANCE HERE
Paying for health care can be confusing and time-consuming. Download the You have to figure out what’s covered by your accounts, remember your balance, and determine where to pay your bills and keep track of your receipts Optum Bank app today! — a challenge when you’re not in front of a computer. The Optum Bank mobile app makes it easy. It has the tools you need when you’re on the go.
• Track your balance, recent transactions and contribution limits. App features do not apply to all products. Some app features may be available in later releases. • Capture and submit receipts, and add receipts to specific expenses. Health savings accounts (HSAs) are individual accounts • Pay bills, track payments and reimburse yourself. offered or administered by Optum Bank®, Member FDIC, and are subject to eligibility requirements and restrictions • Search for qualified medical expenses. on deposits and withdrawals to avoid IRS penalties. State taxes may apply. Fees may reduce earnings on account. • Make a health savings account (HSA) contribution through mobile check Flexible spending accounts (FSAs) are administered by OptumHealth Financial Services and are subject deposit or a bank transfer. to eligibility and restrictions. This communication is for general use only and is not intended for guidance • Get a quick account snapshot anytime and sign in using facial recognition. purposes or as legal or tax advice. Federal and state laws and regulations are subject to change. • If you have an HSA, see how you can maximize your account by viewing Apple, the Apple logo, Apple Pay, Apple Watch, iPad, your progress through the 5 Stages of Health Saving and Spending. iPhone, iTunes, Mac, Safari, and Touch ID are trademarks of Apple Inc., registered in the U.S. and other countries. iPad Pro is a trademark of Apple Inc. Android, Google Play and the Google Play logo are trademarks of Google LLC. Data rates may apply. © 2020 Optum Bank, Inc. All rights reserved. WF3212079 204283-072020 OHC If you need help… Contact your agency benefits coordinator.He/she has received special training in our insurance programs. For additional information about a specific benefit or program, refer to the chart below.
BENEFITS CONTACT PHONE WEBSITE Plan Administrator Benefits Administration 800.253.9981 or 615.741.3590 — tn.gov/partnersforhealth M-F, 8-4:30 Health Insurance BlueCross BlueShield of Tennessee 800.558.6213 — M-F, 7-5 bcbst.com/members/tn_state Cigna 800.997.1617 — 24/7 cigna.com/stateoftn Health Savings Account Optum Bank 866.600.4984 — 24/7 optumbank.com/Tennessee Pharmacy Benefits CVS Caremark 877.522.8679 — 24/7 info.caremark.com/stateoftn Behavioral Health, Substance Use and Optum Health 855.HERE4TN — 24/7 here4TN.com Employee Assistance Program (855.437.3486) Wellness Program ActiveHealth Management 888.741.3390 — M-F, 8-8 http://go.activehealth.com/ wellnesstn Disability Insurance MetLife 855.700.8001 — M-F, 7-10 metlife.com/StateOfTN Dental Insurance Cigna 800.997.1617 — 24/7 cigna.com/stateoftn MetLife 855.700.8001 — M-F, 7-10 metlife.com/StateOfTN Vision Insurance Davis Vision 800.208.6404 — M-F, 7-10, Sat, davisvision.com/stateofTN 8-3 Sun, 11-3 Basic Client Code: 8155 Expanded Client Code: 8156 Life Insurance Securian Financial (Minnesota Life) 866.881.0631 — M-F, 7-6 lifebenefits.com/stateoftn
OTHER PROGRAMS Edison Tennessee Department of Finance password reset for higher education www.edison.tn.gov & Administration 800.253.9981 — M-F, 8-4:30; state call Edison help desk at 866.376.0104 — M-F, 7-4:30 Flexible Benefits medical & dependent care Optum Bank 866.600.4984 — 24/7 optumbank.com/Tennessee transportation & parking (state employees only) Benefits Administration 800.253.9981 — M-F, 8-4:30 tn.gov/partnersforhealth
Online resources... Visit the ParTNers for Health website at https://www.tn.gov/PartnersForHealth. It has information about all the benefits described in this guide. Enrollment forms and handbooks referenced in this guide are located on our website or you can get copies from your agency benefits coordinator.
The ParTNers for Health website also includes a green “Help” button, or live-chat feature, that is operational during normal business hours.
In Zendesk at https://benefitssupport.tn.gov/hc/en-us, you can search the help center, find articles or submit questions. To access Zendesk, you can also click the blue “Questions?” button on the website. Follow us on social media...