Author: Lothian, Maria

20XX-20XX

HEALTH

WELLNESS

January 1—December 31, 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 biological 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.

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.

Inside
Medical Plans
Dental Plans
Vision Plans
Flexible Spending Accounts (FSAs)
Life and AD&D Insurance
Disability Insurance
Employee Assistance Program (EAP)
Voluntary Benefits
Valuable Extras
Cost of Benefits
Contact information
Enrollment
Go to http://www.website.com. There you will find detailed information about the plans available to you and instructions for enrolling.

Medical Plans

We are proud to offer you a choice among three different medical plans that provide comprehensive medical and prescription drug coverage. The plans also offer many resources and tools to help you maintain a healthy lifestyle. Following is a brief description of each plan.
Aetna HMO
With this plan, you select a primary care physician (PCP) from the participating network of providers who will coordinate your health care needs, refer you to specialists (if needed) and approve further medical treatment. Services received outside of the HMO’s network are not covered, except in the case of emergency medical care.
Aetna PPO
This plan gives you the freedom to seek care from the provider of your choice. However, you will maximize your benefits and reduce your out-of-pocket costs if you choose a provider who participates in the Aetna network. The calendar-year deductible must be met before certain services are covered.
Aetna HSA
Like the PPO plans, a High-Deductible Health Plan (HDHP) gives you the freedom to seek care from the provider of your choice. You will maximize your benefits and reduce your out-of-pocket costs if you choose a provider who participates in the Aetna network. In addition, the HDHP comes with a health savings account (HSA) that allows you to save pre-tax dollars1 to pay for any qualified health care expenses as defined by the IRS, including most out-of-pocket medical, prescription drug, dental and vision expenses. For a complete list of qualified health care expenses, visit www.irs.gov/pub/irs-pdf/p502.pdf.
Here’s how the plan works:
Annual Deductible: You must meet the entire annual deductible before the plan starts to pay for non-preventive medical and prescription drug expenses. NOTE: 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..
Coinsurance: Once you’ve met the plan’s annual deductible, you are responsible for a percentage of your medical expenses, which is called coinsurance. For example, the plan may pay 80 percent and you may pay 20 percent.
Out-of-Pocket Maximum: Once your deductible and coinsurance add up to the plan’s annual out-of-pocket maximum, the plan will pay 100 percent of all eligible covered services for the rest of the calendar year. NOTE: If you enroll one or more family members, you must meet the full FAMILY out-of-pocket maximum before the plan starts to pay covered services at 100 percent for any one individual.

Health Savings Account (HSA): You may contribute to your HSA through pre-tax payroll deductions to help offset your annual deductible and pay for qualified health care expenses. In addition, we will contribute $500 annually to your HSA if you enroll in employee-only coverage and $1,000 annually if you enroll yourself and one or more family members. 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.
Important: Your contributions, in addition to the company’s contributions, may not exceed the annual IRS limits listed below. Your HSA is yours for life. The money is yours to spend or save, regardless of whether you change health plans2, retire or leave the company. There is no “use it or lose it” rule. Your account grows tax free over time as you continue to roll over unused dollars from year to year. You decide how or if you want to spend your HSA funds. You can use them to pay for you and your dependents’ doctor’s visits, prescriptions, braces, glasses—even laser vision correction surgery.
1 Tax free under federal tax law; state taxation rules may apply
2 You must be enrolled in a qualified health plan to contribute to an HSA.

HSA Contribution Limit	2019
Employee Only	$3,500
Family (employee + 1 or more)	$7,000
Catch-up (age 55+)	$1,000

Medical Plans (Cont’d)
Following is a high-level overview of the coverage available. For complete coverage details, please refer to the Summary Plan Description (SPD).

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.
If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount.
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.
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 at 100% for any individual.
N/A
N/A
N/A

Dental Plans
We are proud to offer you a choice between two different dental plans. Delta Dental DHMO: With this plan, you choose a primary dental provider to manage your care. There are no charges for most preventive services, no claim forms and no deductibles. Reduced, pre-set charges apply to other services.
Delta Dental DPPO: This plan offers you the freedom and flexibility to use the dentist of your choice. However, you will maximize your benefits and reduce your out-of-pocket costs if you choose a dentist who participates in the Delta Dental network.
Following is a high-level overview of the coverage available.

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. Benefit; see schedule for details	N/A	50%; $1,000 Max. Benefit	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
We are proud to offer you a vision plan.
The Vision Service Provider (VSP) vision plan gives you the freedom to seek care from the provider of your choice. However, you will maximize your benefits and reduce your out-of-pocket costs if you choose a provider who participates in the Vision Service Provider (VSP) network.
Following is a high-level overview of the coverage available.

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

We provide you with an opportunity to participate in up to two different flexible spending accounts (FSAs) administered through Payflex. 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, Social Security and Medicare taxes.

Health Care FSA
For 2019, you may contribute up to $2,700 to cover qualified health care expenses incurred by you, your spouse and your children up to age 26. Some qualified expenses include:
Coinsurance / Copayments / Deductibles	Prescriptions / Dental treatment / Orthodontia	Eye exams/eyeglasses / Lasik eye surgery
For a complete list of eligible expenses, visit www.irs.gov/pub/irs-pdf/p502.pdf.
Limited-Purpose Health Care FSA (for HSA participants)
If you enroll in the HSA medical plan, you may only participate in a 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 2019, you may contribute up to $5,000 (per family) to cover eligible dependent care expenses ($2,500 if you and your spouse file separate tax returns). Some qualified expenses include: / Care of a dependent child under the age of 13 by babysitters, nursery schools, pre-school or daycare centers / Care of a household member who is physically or mentally incapable of caring for him/herself and qualifies as your federal tax dependent / For a complete list of eligible expenses, visit www.irs.gov/pub/irs-pdf/p503.pdf.

FSA Rules
YOU MUST ENROLL EACH YEAR TO PARTICIPATE
Because FSAs can give you a significant tax advantage, they must be administered according to specific IRS rules:
Health care FSA: Unused funds 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 can incur expenses through March 15, 201X, and must file claims by March 31, 201X.

Life and AD&D Insurance

Life/AD&D Insurance
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 through Anthem.

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.

Disability Insurance

Voluntary Benefits

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

Our benefit plans are here to help you and your family live well—and stay well. But did you know that you can strengthen your coverage even further? It’s true! Our voluntary benefits through Aflac are designed to complement your health care coverage and allow you to customize our benefits to you and your family’s needs. The best part? Benefits from these plans are paid directly to you! Coverage is also available for your spouse and dependents.
You can enroll in these plans during Open Enrollment—they’re completely voluntary, which means you are responsible for paying for coverage at affordable group rates.
Accident Insurance
Accident insurance can soften the financial impact of an accidental injury by paying a benefit to you to help cover the unexpected out-of-pocket costs related to treating your injuries.
Critical Illness
Did you know that the average total out-of-pocket cost related to treating a critical illness is over $7,0001? With critical illness insurance, you’ll receive a lump-sum benefit if you are diagnosed with a covered condition that you can use however you would like, including to help pay for: treatment (e.g. experimental), prescriptions, travel, increased living expenses, and more.
Hospital Indemnity Insurance
The average cost of a hospital stay is $10,0002—and the average length of a stay is 4.8 days3. Hospital indemnity insurance can help reduce costs by paying you or a covered dependent a benefit to help cover your deductible, coinsurance and other out-of-pocket costs due to a covered sickness or injury related hospitalization.
Cancer Indemnity
The Cancer Indemnity Plan pays a flat dollar amount to you when a covered person is diagnosed with internal cancer. Other benefits include payments, directly to you, for hospital confinement, medical imaging, radiation and chemotherapy, immunotherapy, transportation and lodging. The plan also includes a cancer screening wellness benefit.
1. MetLife Accident and Critical Illness Impact Study, October 2013 2. Costs for Hospital Stays in the United States, 2011. HCUP Statistical Brief #168. December 2013. Agency for Healthcare Research and Quality, Rockville, MD. 3. National Hospital Discharge Survey: 2010

Employee Assistance Program (EAP)

Life is full of challenges, and sometimes balancing it is difficult. We are proud to provide a confidential program dedicated to supporting the emotional health and well-being of our employees and their families. The employee assistance program (EAP) is provided at NO COST to you through The Holman Group.
The EAP can help with the following issues, among others:
Mental health
Relationships or marital conflicts
Child and eldercare
Substance abuse
Grief and loss
Legal or financial issues
EAP Benefits
Assistance for you and your household members
Up to three in-person sessions with a counselor per issue, per year, per individual
Unlimited toll-free phone access and online resources

Valuable Extras

We also offer the following additional benefits:

401(k) Retirement Plan / 529 College Savings Plan / Group Legal Plan	Home and Auto Group Insurance / Pet Insurance / Travel Assistance (Company-paid)

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.