Author: Lothian, Maria

MARCH 1, 20XX—FEBRUARY 28, 20XX

20XX—20XX

Welcome Your benefits are an important part of your overall compensation. We are pleased to offer a comprehensive array of valuable benefits to protect your health, your family and your way of life. This guide answers some of the basic questions you may have about your benefits. Please read it carefully, along with any supplemental materials you receive.

Eligibility
You are eligible for benefits if you work 30 or more hours per week. You may also enroll your eligible family members under certain plans you choose for yourself. Eligible family members include:
Your legally married spouse
Your registered domestic partner (RDP) and/or his/her children, where applicable by state law
Your children who are your natural children, stepchildren, adopted children or children for whom you have legal custody (age restrictions may apply). Disabled children age 26 or older who meet certain criteria may continue on your health coverage.
When Coverage Begins
New Hires: You must complete the enrollment process within 30 days of your date of hire. If you enroll on time, coverage is effective on the first of the month following your date of hire. If you fail to enroll on time, you will NOT have benefits coverage (except for company-paid benefits).
Open Enrollment: Changes made during Open Enrollment are effective January 1—December 31, 20XX.
To enroll online, go to http://www.website.com

Choose Carefully!
Due to IRS regulations, you cannot change your elections until the next annual Open Enrollment period, unless you have a qualified life event during the year. Following are examples of the most common qualified life events:
Marriage or divorce
Birth or adoption of a child
Child reaching the maximum age limit
Death of a spouse, RDP, or child
You lose coverage under your spouse’s/RDP’s plan
You gain access to state coverage under Medicaid or CHIP
Making Changes
To make changes to your benefit elections, you must contact Human Resources within 31 days of the qualified life event (including newborns). Be prepared to show documentation of the event such as a marriage license, birth certificate or a divorce decree. If changes are not submitted on time, you must wait until the next Open Enrollment period to make your election changes.

Required Information—When you enroll, you will be required to enter a Social Security number (SSN) for all covered dependents. The Affordable Care Act (ACA), otherwise known as health care reform, requires the company to report this information to the IRS each year to show that you and your dependents have coverage. This information will be securely submitted to the IRS and will remain confidential.

Medical Plans

ABC Company is proud to offer you a choice between three different medical plans.

Key Medical Benefits	Aetna HMO		Aetna PPO		Aetna HSA
	In-Network Only	Out-of-Network1	In-Network Only	Out-of-Network1	In-Network Only	Out-of-Network1
Deductible (per calendar year)
Individual / Family	None / None	N/A / N/A	$250 / $750	$750 / $2,250	$1,500 2 / $3,000 2	$3,000 / $6,000
Out-of-Pocket Maximum (per calendar year)
Individual / Family	None / None	N/A / N/A	$2,500 / $5,000	$5,000 / $15,000	$3,000 3 / $6,000 3	$6,000 / $9,000
Company Contribution to Your Health Savings Account (HSA) (per calendar year; prorated for new hires/newly eligible)
Individual / Family	N/A / N/A	N/A / N/A	$500 / $1,000	N/A / N/A	$500 / $1,000	N/A / N/A
Covered Services
Office Visits (physician/specialist)	$20 / $40 copay	N/A	$20 / $25 copay	30%*	10%*	30%*
Routine Preventive Care	No charge	N/A	No charge	30%	No charge	30%
Outpatient Diagnostic (lab/X-ray)	No charge	N/A	10%*	30%*	No charge	30%*
Complex Imaging	N/A	N/A	N/A	30%*	N/A	30%*
Chiropractic	$20 copay	N/A	$20 copay	30%*	$20 copay	30%*
Ambulance	$50 copay	N/A	$50 copay	30%*	$50 copay	30%*
Emergency Room	$100 copay	N/A	$100 copay	30%*	10%*	10%*
Urgent Care Facility	$20 copay	N/A	N/A	30%*	10%*	30%*
Inpatient Hospital Stay	$250 copay	N/A	10%*	30%*	10%*	30%*
Outpatient Surgery	$100 copay	N/A	N/A	30%*	10%*	30%*
Prescription Drugs (Tiers)
Retail Pharmacy (30-day supply)	$15 / $25 / $40	N/A	$15 / $25 / $40	$30 / $50 / $80	$15 / $25 / $40	30%*
Mail Order (90-day supply)	$30 / $50 / $80	N/A	$30 / $50 / $80	N/A	$30 / $50 / $80	Not covered

Coinsurance percentages and copay amounts shown in the above chart represent what the member is responsible for paying.
*Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay.
To be eligible for the HSA, you cannot be covered through Medicare Part A or Part B or TRICARE programs. See the plan documents for full details.
1. If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount.
2. If you enroll one or more family members, you must meet the full FAMILY deductible before the plan starts to pay expenses for any one individual.
3. If you enroll one or more family members, you must meet the full FAMILY out-of-pocket maximum before the plan starts to pay eligible covered services

Dental Plans

ABC Company is proud to offer you a choice between two different dental plans.

Key Dental Benefits	Delta Dental DHMO		Delta Dental DPPO
	In-Network Only	Out-of-Network1	In-Network Only	Out-of-Network1
Deductible (per calendar year)
Individual / Family	None / None	N/A / N/A	$50 / $150	$150 / $450
Benefit Maximum (per calendar year; Preventive, Basic, and Major Services combined)
Per Individual	None	N/A	$1,500	$1,500
Covered Services
Preventive Services	No charge	N/A	No charge	10%
Basic Services	See Schedule	N/A	10%	30%
Major Services	See Schedule	N/A	30%	50%
Orthodontia (Child only)	$1,000 Max; See Schedule	N/A	50%; $1,000 Max.	N/A

Coinsurance percentages shown in the above chart represent what the member is responsible for paying.
*Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay.
1. If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount.

Vision Plan

Life and AD&D

You have an opportunity to enroll in the (carrier) vision plan.

Key Vision Benefits	In-Network	Out-of-Network Reimbursement
Exam (once every 12 months)	$10	Up to $40
Materials Copay	$25	N/A
Lenses (once every 12 months)
Single Vision	No charge after materials copay	Up to $50
Bifocal		Up to $60
Trifocal		Up to $75
Frames (once every 24 months)	Covered up to $130	Up to $130
Contact Lenses (once every 12 months; in lieu of glasses)	Covered up to $170	Up to $130

Flexible Spending
Accounts (FSA)

ABC Company provides you with an opportunity to participate in two different Flexible Spending Accounts (FSAs) administered through (administrator name). FSAs allow you to set aside a portion of your income, before taxes, to pay for qualified health care and/or dependent care expenses. Because that portion of your income is not taxed, you pay less in federal income tax, Social Security tax, and Medicare tax.

Life Insurance provides your named beneficiary(ies) with a benefit in the event of your death. Accidental Death and Dismemberment (AD&D) Insurance provides specified benefits to you in the event of a covered accidental bodily injury that directly causes dismemberment (i.e., the loss of a hand, foot, or eye). In the event that your death occurs due to a covered accident, both the Life and the AD&D benefit would be payable.
Basic Life/AD&D (Company-paid)
This benefit is provided at NO COST to you.

Benefit Amount	2 Times your base salary plus commissions, up to a $50,000 maximum

Supplemental Life/AD&D (Employee-paid)
If you determine you need more than the basic coverage, you may purchase additional coverage through for yourself and your eligible family members.

Benefit Option		Guaranteed Issue*
Employee	$10,000 increments; minimum of $10,000 up to $500,000	$150,000
Spouse/RDP	$5,000 increments; minimum of $5,000 up to $250,000 (not to exceed 50% of your additional life coverage)	$10,000
Child(ren)	Under age 26 - Up to $10,000	$10,000

*During your initial eligibility period only, you can receive coverage up to the Guaranteed Issue amounts without having to provide Evidence of Insurability (EOI, or information about your health). Coverage amounts that require EOI will not be effective unless approved by the insurance carrier.

Health Care FSA
For 20XX, you may contribute up to $X,XXX to cover eligible health care expenses incurred by you, your spouse, and your children up to age 26. For a complete list of eligible health care expenses, visit www.irs.gov/pub/irs-pdf/p502.pdf NOTE: If you enroll in the HDHP HSA medical plan, you may only participate in the Limited Purpose Health Care FSA. This type of FSA allows you to be reimbursed for eligible dental, orthodontia, and vision expenses while preserving your HSA funds for eligible medical expenses.
Dependent Care FSA
For 20XX, you may contribute up to $X,XXX (per family) to cover eligible dependent care expenses ($2,500 if you and your spouse file separate tax returns). For a complete list of eligible expenses, visit www.irs.gov/pub/irs-pdf/p503.pdf.

Because FSAs can give you a significant tax advantage, they must be administered according to specific IRS rules:
Health Care FSA: Unused funds of up to $500 from one year can carry over to the following year. Carryover funds will not count against or offset the amount that you can contribute annually. Unused funds over $500 will NOT be returned to you or carried over to the following year.
Dependent Care FSA: Unused funds will NOT be returned to you or carried over to the following year.
You must file your 20XX claims by March 31, 20XX.

Disability Insurance

Disability insurance provides benefits that replace part of your lost income when you become unable to work due to a covered injury or illness.

Voluntary Short-Term Disability
Provided at NO COST to you/an affordable group rate through Anthem
Benefit Percentage	60%
Weekly Benefit Maximum	$600
When Benefits Begin	After 7th day of disability
Maximum Benefit Duration	13 weeks
Voluntary Long-Term Disability
Provided at NO COST to you/an affordable group rate through Anthem
Benefit Percentage	60%
Monthly Benefit Maximum	$10,000
When Benefits Begin	After 90th day of disability
Maximum Benefit Duration	Social Security Retirement Age

Cost of Benefits

Your contributions toward the cost of benefits are automatically deducted from your paycheck before taxes. The amount will depend upon the plan you select and if you choose to cover eligible family members.

Contact Information

Coverage	Carrier	Phone #	Website/Email
Medical	Aetna	(555) 555-5555	www.aetna.com
Dental	Delta Dental	(555) 555-5555	www.deltadental.com
Vision	Vision Service Plan (VSP)	(555) 555-5555	www.vsp.com
Flexible Spending Accounts (FSAs)	Ceridian	(555) 555-5555	www.ceridian.com
Life/AD&D	Anthem	(555) 555-5555	www.anthem.com/ca
Disability	Anthem	(555) 555-5555	www.anthem.com/ca
Employee Assistance Program (EAP)	The Holman Group	(555) 555-5555	www.theholmangroup.com
Voluntary Benefits	Aflac	(555) 555-5555	www.aflac.com

Benefits Website
Our benefits website http://www.samplebenefitswebsite.com can be accessed anytime you want additional information on our benefit programs.
Questions?
If you have additional questions, you may also contact:
My Benefits Champion
(555)555-5555
champion@hubinternational.com
HR Team
(555)555-5555
hradmin@sample.com

DISCLAIMER: The material in this benefits brochure is for informational purposes only and is neither an offer of coverage or medical or legal advice. It contains only a partial description of plan or program benefits and does not constitute a contract. Please refer to the Summary Plan Description (SPD) for complete plan details. In case of a conflict between your plan documents and this information, the plan documents will always govern. Annual Notices: ERISA and various other state and federal laws require that employers provide disclosure and annual notices to their plan participants. The company will distribute all required notices annually.