Municipal School Districts of Shelby County

Transcription

A Quick Look at Your Benefits and Enrollment
Open Enrollment
April 20 – May 15
This brochure represents the 2015–2016 benefits for the

Arlington Community Schools

Bartlett City Schools

Collierville Schools

Lakeland School System

Millington Municipal Schools
Pre-enrollment opportunities will be held at each school district.
Look to your school district’s
website for more information
about meetings and
1
opportunities to enroll.
Benefits covered inside this booklet include:

Page 4: _____________________________________ Medical

Page 5: _____________________________________ Dental

Page 7: _______________________________ Vision

Page 9: ___________________________ Basic/Supp Life

Page 15: ______________________________________ FSA

P age 16: ________________________STD /Cancer/Accident

Page 20: ______________________________________LTD

Page 25: ______________________________________EAP

Page 26: _______________________________ Rates

Page 28: __________________Convenient Resources/Tools

Page 29__Biometric Screenings/Hlth&Wellness Clinics


Page 30______Supplemental Retirement Opportunities
Page 32__________________________Legal Notices
Welcome to Meritain Health!
Meritain Health
Enroll with Meritain Health today to take your next step
towards a healthier, balanced tomorrow.
Meritain Health knows how important it is for healthcare consumers like you to really understand how your plan works. In this way, you
can make the changes you want in your health and in your life.
Healthcare benefits provide the support you need to reach your healthy balance.
Chances are, you try every day to restore a healthy balance to your life, but time gets away from you, or other details come first.
Meritain Health is here to help you focus, to support you every step of the way. Think of the benefits and programs as an important
resource in the protection of your body, mind and spirit!
Protecting your healthy balance with preventive care.
Question: Which is better: Taking an hour or two out of your busy day to have your annual checkup—or missing hidden symptoms
and paying the price in sick days, copays and missed events?
Answer: Nothing makes more sense in these busy times than preventing illness before it happens. That’s why your plan offers excellent
benefits for preventive services.
Early detection, proper nutrition, and routine exercise are the key to living
a long and healthy life, and will also help to control long-term healthcare costs.
Your employer encourages you to take the necessary steps—available to you
right now—to ensure early detection and treatment of diseases.
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www.myMERITAIN.com
Benefit Highlights
Meritain Health
Built into your health plan are preventive benefits that cover:

Well-child care

Physical exams

Mammogram

Bone density test

Prostate blood exam

Pap smear

Fecal occult
Healthcare for you and your family:
When sickness or injury throw you off balance.
Knowing that you’re in good hands when you’re sick is one of the most comforting feelings there is. You can be assured that your
health plan has everything you’ll need to get the right care if something goes wrong.
Balancing healthcare costs: What you pay and what the plan pays.
After you pay your annual deductible and any up-front copays, the plan begins to pay a percentage of your provider’s charges,
for example 80%. The remaining percentage, for example 20%, is your responsibility—your “out-of-pocket” costs. You’re
protected from financial hardship by a maximum out-of-pocket amount each year—the most you’ll have to pay before the
plan covers costs at 100%. (Copays do not always apply to the out-of-pocket maximum. This varies by plan).
It's important when selecting a plan, to consider what your maximum financial risk is for the three plan options listed in
this brochure. In addition, factoring in your current health needs ensures you apply for the plan option that will benefit you
and your family the most. For more detailed information, see your summary plan description (SPD).
What are Copays/Deductibles/Major Medical
Copay is a set amount that you or your dependent is expected to pay at the time services are rendered. Examples where a copay
might apply would be at your physician's office or at the pharmacy.
Deductible is set amount you or your dependent is expected to pay before the plan plays on services that usually occur outside of a
doctor's office. These type of services could be considered Major Medical. Examples of Major Medical services are In-Patient
or Out-Patient Surgery, Diagnostic and Imaging test such as CAT Scans or MRIs. For a complete list, please see your plan's SPD.
Save when you visit network providers.
This plan offers a provider network of doctors and other healthcare professionals who have agreed to accept lower amounts than their
standard charges, just for members of this plan. These lower amounts are negotiated and predetermined. That means when you see a
network provider, your share of costs is based on a lower charge—so your costs are lower, too. Network providers are conveniently
located in both urban and rural areas. Lower costs and convenient doctors and clinics are important ways that Meritain Health can support your efforts to stay well and have a healthy lifestyle—or to get care as simply as possible when you’re sick.
Remember: If you go outside the network, you may still have benefits, but your share of costs will be higher, and the amount you pay will
not be based on a lower rate.
Nationwide provider access at a discount.
When you and your family seek healthcare services, you have access to Aetna’s broad national provider network of healthcare providers
and facilities. Aetna’s network contains more than 850,000 participating physicians and ancillary providers, with 6,900 hospitals. When
you visit providers in the Aetna network, you will receive services at strong, negotiated rates, helping you to save on the cost of healthcare.
Locate your preferred providers.
With Aetna’s comprehensive provider participation, many of your preferred doctors may already be in the Aetna network. To verify
whether or not a doctor or healthcare facility participates, visit http://www.aetna.com/docfind/custom/mymeritain/.Your network
is Aetna Choice® POS II.
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www.myMERITAIN.com
Summary of Benefits
EPO
Network Only
***WELLNESS (Routine Care)
Physical Exams (As required by
ACA)
Well Child Care (Including
Immunizations)
Mammogram (Test and
Reading)
Pap Smears (Test and Reading)
Prostate Blood Test (Test and
Reading)
Fecal Occult Screening (Test
and Reading)
**Annual Health Fund Provided
to Employees and Dependents
Basic Plan
Out-of Network
In-Network
HRA Plan
In-Network
Out-of Network
Plan pays 100% (No Ded)
Plan pays 100% (No
Ded)
Not Covered
Not Covered
Plan pays 100% (No
Ded)
Plan pays 100% (No
Ded)
Plan pays 100% (No
Ded)
Plan pays 100% (No
Ded)
Plan pays 100% (No
Ded)
Not Covered
Not Covered
Not Applicable
Plan pays 50% (after Ded)
Plan pays 50% (plus Ded)
Not Applicable
$500 Individual
$750 Individual plus one
$1,000 Family
This is a change from last
year’s benefits
MAJOR MEDICAL
*Deductible (Ded)
$500/Individual
$750/Individual plus one
$1,000/Family
$500/Individual
$750/Individual plus one
$1,000/Family
$1,000/Individual
$1,500/Individual plus one
$2,000/Family
$1,500/Individual
$2,250/Individual plus
$3,000/Family
$3,000/Individual
$6,000/Family
Plan Payment (Coinsurance)
Out-of-Pocket Maximum*
(Including Deductible)
Plan pays 100%
$2,000/Individual
$5,500/Family
Plan pays 80%
$2,500/Individual
one
$7,500/Family
Plan pays 50%
$7,500/Individual
$22,500/Family
Plan pays 80%
$3,500/Individual
$10,500/Family
Plan pays 50%
$10,500/Individual
$31,500/Family
Lifetime Maximum per Family
Member
HOSPITAL BENEFITS
In-Patient
Unlimited
$500 Copay per
admission, plus Ded
Plan pays 80%(after Ded)
Out-Patient
$250 Copay per visit, plus
Ded
Emergency Room
Ded
$150 Copay per visit
(plus Ded)
Paid at the Participating
Provider level of benefits
Paid at the Participating
Provider level of benefits
Medical Emergency
(Copay
Waived if Admitted)
Medical Emergency
(Copay Waived If
Admitted)
Plan pays 100% (after
Ded)
Ded)
Plan pays 100% after $20
Copay per visit
Copay per visit
Copay per visit
Copay per visit
80% (after Ded)
$10 Generic
$25 Preferred
$50 Non-Preferred
$10 Generic
$25 Preferred
$50 Non-Preferred
$10 Generic
$25 Preferred
$50 Non-Preferred
$500 Copay (plus Ded) per
admission
per visit
Plan pays 100%; after
$25 Copay per visit
ADDITIONAL MEDICAL
BENEFITS
Physical Therapies including
Chiropractic (60 visits max)
Copay per visit
Plan pays 100%; after
$35 Copay per visit
Home Health Care
(Precertification)
Ded) (60 visits max)
(60 visits max)
(60 visits max)
(60 visits max)
Extended Care Facility
(60 visits max)
Ded)
Ded
Ded)
Ded)
Plan pays 100% (No
Ded)
Ded
Ded)
Ded)
(60 visits max)
(60 visits max)
(60 visits max)
Ded
SURGICAL/PHYSICIAN
BENEFITS
In-Patient
Out-Patient
PHYSICIAN'S OFFICE VISIT
SPECIALIST OFFICE VISIT
DIAGNOSTIC X-RAY &
LABORATORY SERVICES
PRESCRIPTION DRUG CARD
(Copay)
MENTAL/NERVOUS &
SUBSTANCE
ABUSE
In-Patient
Physician’s Office Visit
Hospice (Precertification)
Urgent Care
Ambulance Services
Medical Supplies and Durable
Equipment
*Deductibles and Out of Pocket Expenses Accumulate on a calendar year basis.
**The HRA Fund pays at the back end of the deductible and is funded 50% for enrollments beginning September 1. On January 1, the fund will be funded the full amount listed in this summary and any funds remaining at
the end of the calendar year will be added to it. Please note that the fund cannot exceed 100% of the total deductible
***For a detailed listing of preventive services, please visit the U.S. Department of Health and Human Services website at: https://www.healthcare.gov/what‐are‐my‐preventive‐care‐benefits.
The plan document is the governing document; therefore any discrepancies which may be found are not binding. The Plan Document may be found by going to your district’s Employee Portal and looking
under “Documents/Links”.
4
www.myMERITAIN.com
Dental Benefits Design - Met Life
Meritain Health
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Type A – cleanings,
oral examinations
100% of
Negotiated Fee*
80% of
Negotiated Fee*
60% of
Negotiated Fee*
100% of R&C
Fee**
Type A – cleanings,
oral examinations
100% of R&C
Fee**
80% of R&C Fee**
Type B – fillings
60% of R&C Fee**
Type C –bridges
and dentures
100% of
Negotiated Fee*
80% of
Negotiated Fee*
50% of
Negotiated Fee*
50% of
Negotiated Fee*
50% of R&C Fee**
Type D –
orthodontia
(Adult & Child)
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$50.00
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Family
$75.00
$150.00
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$2,000
Type B – fillings
Type C –bridges
and dentures
Type D –
orthodontia
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50% of R&C Fee**
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* Negotiated Fee refers to the fees that participating dentists
have agreed to accept as payment in full, subject to any
copayments, deductibles, cost sharing and benefits maximums.
Negotiated Fee fees are subject to change.
**R&C Fee refers to the Reasonable and Customary (R&C)
charge, which is based on the lowest of (1) the dentist’s actual
charge, (2) the dentist’s usual charge for the same or similar
services, or (3) the charge of most dentists in the same
geographic area for the same or similar services as determined
by MetLife.
†
Applies only to Type B & C Services.
5
50% of R&C Fee**
50% of
Negotiated Fee*
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80% of R&C Fee**
*Negotiated Fee refers to the fees that participating dentists have
agreed to accept as payment in full, subject to any copayments,
deductibles, cost sharing and benefits maximums. Negotiated
Fee fees are subject to change.
**R&C Fee refers to the Reasonable and Customary (R&C)
charge, which is based on the lowest of (1) the dentist’s actual
charge, (2) the dentist’s usual charge for the same or similar
services, or (3) the charge of most dentists in the same
geographic area for the same or similar services as determined
by MetLife.
†
Applies only to Type B & C Services.
Dental Benefits (continued)
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Type A – Preventive
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How Many/How Often
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Type C - Major Restorative
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6
www.myMERITAIN.com
IN-NETWORK BENEFITS
Healthy eyes and clear vision are an
important part of your overall health and
plan helps you care
quality of life. Your
o vision
v
for your eyes while saving you money by
offffering:
Eye Examination
Every September 1, Covered in full
after $10 copayment
Eyeglasses
Spectacle Lenses
For standard single-vision, lined bifocal, or trifocal
lenses after $20 copayment
Every other September 1, Covered in full
Paid-in-full eye examinations, eyeglasses and
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Any Fashion or Designer frame from Davis Vision’s
Collection/1 (value up to $175)
Frames
OR
Frame Collection: Your
o
ou plan includes a selection of
designer, name brand frames that are completely
covered in full./1
Contact Lens Collection: Select from the most popular
contact lenses on the market today with Davis Vision’s
Contact Lens Collection./1
One-year eyeglass breakage warranty included on
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$130 retail allowance toward any frame from provider,
plus 20% offf balance/2
Contact Lenses
Every September 1,
Contact Lens
Evaluation, Fitting
& Follow Up Care
Collection Contacts: Covered in full after $20
copayment
OR
Non Collection Contacts:
Standard Contacts: 15% discount/2
Specialty Contacts/3: 15% discount/2
How to locate a Network Provider...
Just log on to the Open Enrollment section of our
Member site at davisvision.com and click “Find a
Provider” to locate a provider near you including:
Any contact lenses from Davis Vision’s Contact Lens
Collection/1
Contact Lenses
(in lieu of
eyeglasses)
OR
$150 retail allowance toward provider supplied
contact lenses, plus 15% offf balance/2
ADDITIONAL DISCOUNTED LENS OPTIONS & COA
ATINGS
T
Without
Davis Vision
$40
$64
$62
$154
$123
MOST POPULAR OPTIONS
Savings based on in-network usage and average retail values.
Scratch-Resistant Coating
Polycarbonate Lenses
6WDQGDUG$QWL5HÀHFWLYH$5&RDWLQJ
Standard Progressives (no-line bifocal)
//5
Plastic Photosensitive (Transitions® )
Contact your Human
Resources department
today to enroll.
For more details about the plan, just log on to
the Open Enrollment section of our Member site
at davisvision.com or call 1.877.923.2847 and
enter Client Code 3148
With
Davis Vision
$0
$0/4-$30
$0
$0
$65
/RZHUFRVWVDQGPRUHEHQH¿WVSee the savings!
Without
Davis Vision
With
Davis Vision
$100
$10
Bifocals
$80
$20
$40
$0
$123
$65
Frame
$150
$0
Total
o
$493
$95
Service
Eye Examination
Lenses
/5
Transitions®
1/
The Davis Vision
i
a most participating independent provider locations. Collection
Collection is available at
is subject to change. Collection is inclusive of select toric and multifocal contacts.
2/
Additional discounts not applicable at Wa
allmart or Sam’’s Club locations.
3/
Including, but not limited to toric, multifocal and gas permeable contact lenses.
4/
For dependent children, monocular patients and patients with prescriptions of 6.00 diopters or greaterr.
5/
Trransitions® is a registered trademark of Trransitions Optical Inc.
Davis Vision
i
corre
has made every effort to correctly
summarize your vision plan features. In the event of a
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contract or insurance policy will prevail.
Employee Contributions
20-Pay
Employee
Employee plus Spouse
Employee plus Family
$3.70
$7.07
$11.48
OE00757 6/9/14
7
www.myMERITAIN.com
7
ADDITIONAL OPTIONS
WITHOUT
WITH
DAVIS VISION DAVIS VISION
FRAMES
Fashion Frame (from the Davis Vision Collection)
$125
$0
Designer Frame (from the Davis Vision Collection)
$175
$0
Premier Frame (from the Davis Vision Collection)
$225
$25
All Ranges of Prescriptions and Sizes
$90
$0
Plastic Lenses
$33
$0
Oversized Lenses
$20
$0
Tinting of Plastic Lenses
$20
$0
$40
LENSES
Value for our Members
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pocket cost to members and their families. Our
goal is 100% member satisfaction.
Convenient Network Locations
A national network of credentialed preferred
providers throughout the 50 states.
Freedom of Choice
Access to care through either our network
of independent, private practice doctors
(optometrists and ophthalmologists) or select
retail partners.
Value-Added Features:
Replacement contacts through LENS123®
mail-order contact lens replacement service,
saving both time and money.

Laser Vision Correction discounts of up to
25% off the provider’s Usual & Customary
fees, or 5% off advertised specials,
whichever is lower.
$0
/1
Polycarbonate Lenses
$64
$0 or $30
Ultraviolet Coating
$28
$12
6WDQGDUG$QWL5HÀHFWLYH$5&RDWLQJ
$62
$0
Premium AR Coating
$80
$13
Ultra AR Coating
$113
$25
Intermediate-Vision Lenses
$150
$30
Standard Progressive Addition Lenses
$154
$0
Premium Progressives (Varilux® /2, etc.)
$248
$40
High-Index Lenses
$120
$55
Polarized Lenses
$103
$75
Plastic Photosensitive Lenses
$123
$65
Scratch Protection Plan (Single vision | Multifocal lenses)
$20 | $40
1/
Polycarbonate lenses are covered in full for dependent children, monocular patients and patients with
prescriptions 6.00 diopters or greater.
2/
Varilux® is a registered trademark of Societe Essilor International
Contact Info
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For more details about the plan, just log on to
the Open Enrollment section of our Member site
at davisvision.com or call 1.877.923.2847 and
enter Client Code 3148.
You may receive services from an out-of-network provider, although you will
UHFHLYHWKHJUHDWHVWYDOXHDQGPD[LPL]H\RXUEHQH¿WGROODUVLI\RXVHOHFWD
provider who participates in the network. If you choose an out-of-network
provider, you must pay the provider directly for all charges and then submit
a claim for reimbursement to:
Vision Care Processing Unit
P.O. Box 1525
Latham, NY 12110
OUT-OF-NETWORK REIMBURSEMENT SCHEDULE
Eye Examination up to $30 | Frame up to $30
Spectacle Lenses (per pair) up to:
Single Vision $25, Bifocal $35, Trifocal $45, Lenticular $60
Elective Contacts up to $75, Medically Necessary Contacts up to $225
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Basic & Supplemental Life - MetLife
Meritain Health
Explore the coverage that makes it easy to give yourself and your loved ones more
security today…and in the future
Basic Term Life and Accidental Death and Dismemberment Insurance (AD&D)
Your employer provides you with Basic Term Life and Accidental Death and Dismemberment
insurance coverage in the amount of 2 times your base annual earnings.
Supplemental Term Life Insurance Coverage Options
For You
$10,000 increments to the maximum of the lesser of 5 times your
annual salary or $500,000
For Your Spouse^
$5,000 to $250,000 in $5,000 increments, not to exceed 50% of
your Supplemental Term Life coverage amount
For Your Dependent Children*^
$10,000 or $20,000
*Child(ren)’s Eligibility: Dependent children ages from 15 days to 26 years old are eligible for coverage.
^Please note: Employees must be enrolled in the Supplemental life coverage to be eligible to add spouse and/or
dependent child coverage
Per Pay Period (20 Pay Periods) for Supplemental Term Life Insurance and
Accidental Death and Dismemberment Insurance
You have the option to purchase Supplemental Term Life Insurance. Listed below you will find your
Per Pay Period Cost (20 Pay Periods) as well as those for your spouse (based on your age and the
amount of coverage you want). Rates to cover your child(ren) are also shown.
Age
Per Pay Period Cost
(20 Pay Periods)
Per $1,000 of Coverage
Spouse Per Pay Period Cost
(20 Pay Periods)
Per $1,000 of Coverage
Under 30
$0.048
$0.048
30 – 34
$0.060
$0.060
35 – 39
$0.066
$0.066
40 – 44
$0.084
$0.084
45 – 49
$0.120
$0.120
50 – 54
$0.178
$0.178
55 – 59
$0.322
$0.322
60 – 64
65 – 69
$0.487
$0.926
$0.487
$0.926
70 +
$1.495
$1.495
†
Cost for your Child(ren)
† Covers all eligible children
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$0.133
Use the table below to calculate your premium based on the amount of life insurance you will need.
Example: $100,000 Supplemental Life Coverage
1. Enter the rate from the table (example age 36)
2. Enter the amount of insurance in thousands of dollars
(Example: for $100,000 of coverage enter $100)
3. Per Pay Period premium (1) x (2)
$0.066
$
100
$6.60
$
Repeat the three easy steps above to determine the cost for each coverage selected.
Features
This insurance offering from your employer and MetLife comes with a variety of added features that can provide
assistance to you and your family members today and during a difficult time.
Accelerated Benefits Option1
For access to funds during a difficult time
You can receive up to 80% of your Basic and Supplemental Term Life insurance proceeds to a maximum of
$500,000 in the event that you become terminally ill and are diagnosed with less than 12 months to live. This
can go a long way toward helping your family meet medical and other related expenses at this difficult time.
The Accelerated Benefit Option is also available to spouses partners insured under Dependent Life
insurance plans. This option is not available for dependent child coverage.
Conversion
For protection after your coverage terminates
You can generally convert your Group Term Life insurance benefits to an Individual Whole Life insurance
policy if your coverage terminates in whole or in part due to your retirement, termination of employment, or, a
change in your employee class. Conversion is available on all Group Life insurance coverages. Please note
that conversion is not available on AD&D coverage. If you experience an event that makes you eligible to
convert your coverage, you can speak with a MetLife representative by calling 1-877-275-6387. Please
contact your plan employer for more information.
Waiver of Premiums for Total Disability (Continued Protection)
Offering continued coverage when you need it most
If you become Totally Disabled, you may qualify to continue certain insurance. You may also be eligible for
waiver of your Basic and Supplemental Term Life and Personal Accidental Death and Dismemberment
insurance premium until you reach age 65, die or recover from your disability, whichever is sooner, should you
become unable to work due to a Total Disability.
Total Disability or Totally Disabled means you are unable to do your job and any other job for which you are
fit by education, training or experience, due to injury or sickness. The Total Disability must begin before age
60, and your waiver will begin after you have satisfied a 9-month waiting period of continuous disability. The
Waiver of Premium will end when you turn age 65, die or recover. Please note that this benefit is available
after you have participated in the Supplemental Term Life Plan for one year and it is only available to you.
This one-year requirement applies to new participants in the plan.
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Portability
So you can keep your coverage even if you leave your current employer
Should you leave your employer for any reason, and your Basic and Supplemental and Dependent Term Life
and Personal and Supplemental and Dependent Accidental Death and Dismemberment insurance under this
plan terminates, you will have an opportunity to continue group term coverage (“portability”) under a different
policy, subject to plan design and state availability. Rates will be based on the experience of the ported
group and MetLife will bill you directly. Rates may be higher than your current rates. To take advantage of
this feature, you must have coverage of at least $10,000 up to a maximum of $2,000,000.
Portability is also available on coverage you’ve selected for your spouse and dependent child(ren). The
maximum amount of coverage for spouses is $250,000; the maximum amount of dependent child coverage
is $20,000. Increases, decreases and maximums are subject to state availability.
Generally, there is no minimum time for you to be covered by the plan before you can take advantage of the
portability feature. Please see your employer or certificate for specific details.
Please note that if you experience an event that makes you eligible for portable coverage, please call a
MetLife representative at 1-888-252-3607 or contact your plan employer for more information.
Will Preparation Service2
To help ensure your decisions are carried out
Like life insurance, a carefully prepared Will (Simple, Complex or Living) along with a Power of Attorney are
important. With a will, you can define your most important decisions such as who will care for your children
or inherit your property.
Living Will:
 Ensures your wishes are carried out, and protects your loved ones from making these very
difficult and personal medical decisions by themselves.
 Also called an “advanced directive,” it is a document authorized by statutes in all states. A
person appoints someone as his/her proxy or representative to make decisions on maintaining
extraordinary life-support if the person should become incapacitated so that he or she is unable
to communicate his or her wishes.
Powers of Attorney:

Allows you to plan ahead by designating someone you know and trust to act on your behalf in
the event of unexpected occurrences or if you become incapacitated. It is a written document
that grants an individual the power to act on the grantor’s behalf.
By enrolling for Supplemental Term Life coverage, you will have access to Hyatt Legal Plans’ network of
12,000 participating attorneys. When you enroll in this plan, you may take advantage of face-to-face access
to a participating plan attorney to prepare or update a will, living will or powers of attorney.* When you use a
participating plan attorney there will be no charge for the services*. To obtain the legal plan’s toll-free
number and your company’s group access number please contact your employer or your plan administrator
for this information.
* You also have the flexibility of using an attorney who is not participating in the Hyatt Legal Plans’ network and being reimbursed for
covered services according to a set fee schedule. In that case you will be responsible for any attorney’s fees that exceed the
reimbursed amount.
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MetLife Estate Resolution ServicesSM—ERS3
Personal service and compassion to help your beneficiaries and others manage your estate during
their time of need
MetLife Estate Resolution Services—is a valuable service offered under the plan. When your estate
representative uses a participating Hyatt Legal plan attorney there will be no charge for the services. A Hyatt
Legal Plan attorney will consult face-to-face with your beneficiaries or by telephone regarding the probate
process for your estate. The attorney will also handle the probate of your estate for your executor or
administrator. This can help alleviate the financial and administrative burden upon your loved ones in their
time of need.
Transition Solutions4
Assistance identifying solutions for your financial situations
Transition Solutions is a service designed to help provide assistance in making financial decisions based on
the major events in your life including changes in employment, retirement or your benefits status. Contact
your employer or plan administrator for more information.
Delivering The Promise®
For support when beneficiaries need it most
Delivering The Promise® is a service designed to provide beneficiaries with the support and assistance they
need during an especially difficult time. Services include assistance filing life insurance claims and
consultation to help with the financial details and questions that arise upon the loss of a loved one.
MetLife’s Center for Special Needs Planning5
Comprehensive Planning Assistance for Dependents with Special Needs
MetLife’s Center for Special Needs Planning is a service that works with families who have dependents with
special needs. To help them prepare for the complex financial, social, emotional, and educational issues
facing them, MetLife’s Center for Special Needs Planning helps families with financial planning strategies.
Funeral Planning Guide
Provides beneficiaries a resource that outlines your final wishes. It highlights details of pertinent information
including: how to plan for funeral costs, the death claim process, personal funeral preferences and more.
Total Control Account®7
For immediate access to death proceeds
The Total Control Account® settlement option provides your loved ones with a safe and convenient way to
manage the proceeds of a life or accident policy for claim payments of $5,000 or more, backed by the financial
strength and claims paying ability of Metropolitan Life Insurance Company. They'll have the convenience of
immediate access to any or all of their proceeds, through an interest bearing account with unlimited draftwriting privileges. The Total Control Account gives beneficiaries time to decide what to do with their proceeds,
which can be very helpful to them during a difficult time.
What’s Not Covered?
Like most insurance plans, this plan has exclusions. Supplemental and Dependent Life Insurance do not
provide payment of benefits for death caused by suicide within the first two years (one year in North Dakota
or Colorado) of the effective date of the certificate, or payment of increased benefits for death caused by
suicide within two years (one year in North Dakota or Colorado) of an increase in coverage.
Please note that a reduction schedule may apply. Please see your employer or certificate for specific details.
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-----------------------Accidental Death & Dismemberment (AD&D) coverage complements your Basic and Supplemental
Life coverage insurance and helps protect you 24 hours a day, 365 days a year.
Accidental Death & Dismemberment Coverage Options
This valuable coverage is available to you even if you already have accident insurance. It provides benefits
beyond your disability or life insurance for losses due to covered accidents — while commuting, traveling by
public or private transportation and during business trips. MetLife’s AD&D insurance pays you benefits if you
suffer a covered accident that results in paralysis or the loss of a limb, speech, hearing or sight, or brain
damage or coma. If you suffer a covered fatal accident, benefits will be paid to your beneficiary.
Supplemental AD&D Coverage Amounts for You
Your Supplemental AD&D amount is equal to your Supplemental Term Life amount.
Supplemental AD&D Coverage Amounts for Spouse and Child(ren)
You can choose to cover your dependent spouse and child(ren) with AD&D coverage. Your dependents will
be eligible for coverage amounts equal to their amounts of Dependent Term Life coverage.
Covered Losses
This AD&D insurance pays benefits for covered losses that are the result of an accidental injury or loss of life.
The full amount of AD&D coverage you select is called the “Full Amount” and is equal to the benefit payable for
the loss of life. Benefits for other losses are payable as a predetermined percentage of the Full Amount, and
will be listed in your coverage in a Table of Covered Losses. Such losses include loss of limbs, sight, speech
and hearing, various forms of paralysis, brain damage and coma. The maximum amount payable for all
Covered Losses sustained in any one accident is capped at 100% of the Full Amount.
Standard Additional Benefits Include
Some of the standard additional benefits included in your coverage that may increase the amounts payable
to you and/or defray additional expenses that result from accidental injury or loss of life are:
 Air Bag Benefit
 Seat Belt Benefit
 Common Carrier Benefit
 Child Care Center Benefit
 Child Education Benefit
 Spouse Education Benefit
 Hospitalization Benefit
What Is Not Covered?
Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or
contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused
by an external wound accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the
voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a
doctor or an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug,
medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or riot;
committing or trying to commit a felony; any poison, fumes or gas, voluntarily taken, administered or absorbed;
service in the armed forces of any country or international authority, except the United States National Guard;
operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the
purpose of descent from such aircraft while in flight (except for self-preservation); or operating a vehicle or
device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs.
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Additional Coverage Information
How To Apply
*
Complete your enrollment and be sure to indicate your Beneficiary. Act Now During the Enrollment
Period!
Note: Even if you wish to keep your existing level of coverage, you must complete your enrollment.
*All applications are subject to review and approval by Metropolitan Life Insurance Company based upon its underwriting rules.
For Employee Coverage
Enrollment in this Supplemental Term Life insurance plan is available without providing a Statement
of Health form as long as:
For Annual Enrollment effective the Summer of 2015 only:
 Your enrollment takes place before the enrollment deadline, and
 You are increasing coverage to an amount equal to/less than 3 times your basic annual earnings,
or
 You are enrolling for coverage to an amount equal to/less than 3 times your basic annual earnings
For all other Annual Enrollments:
 Your enrollment takes place before the enrollment deadline, and
 You are continuing the coverage you had in the last year
For New Hires:
 Your enrollment takes place within 31 days from the date you become eligible for benefits, and
 You are enrolling for coverage equal to/less than 3 times your basic annual earnings
If you do not meet all of the conditions stated above, you will need to provide additional medical
information by completing a Statement of Health form.
For Dependent Coverage
You must be covered the Supplemental Life in order to obtain coverage for your spouse and child(ren).
Your spouse and dependent children do not need to provide a Statement of Health form as long as
they are not home or hospital confined and not receiving or applying to receive disability payments
and:
For Annual Enrollment effective the Summer of 2015 only:
 The enrollment takes place prior to the enrollment deadline, and
 Your spouse and/or child(ren) is/are continuing coverage she/he/they had in the last year
 You are increasing coverage for your spouse to an amount equal to/less than $20,000, or
 You are enrolling your spouse for coverage equal to/less than $20,000, or
 You are increasing/enrolling your child(ren) for coverage
For all other Annual Enrollments:
 The enrollment takes place prior to the enrollment deadline, and
 Your spouse and child(ren) is/are continuing coverage she/he/they had in the last year
For New Hires
 The enrollment takes place within 31 days from the date you become eligible for benefits, and
 You are enrolling your spouse for coverage equal to/less than $20,000, or
 You are enrolling your child(ren) for coverage
If you do not meet all of the conditions stated above, you will need to provide additional medical
information by completing a Statement of Health form.
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Health & Dependent Care FSA - American Fidelity
Are out-of-pocket medical expenses squeezing your budget?
Flexible Spending Account (Health)
A Health FSA can save you money by allowing you to set aside part of your pay, on a pre-tax basis, to
reimburse yourself for eligible medical, dental and vision expenses such as co-payments, medical deductibles,
prescriptions, and much more. Expenses incurred for you, your spouse, and other qualifying individuals are
eligible for reimbursement. The maximum amount you may set aside is $2,500 per plan year.
Flex Debit Card
A flex debit card allows you to use Flexible Spending Account funds to pay for eligible medical, dental and vision
expenses instead of paying out-of-pocket. It gives you direct access to your FSA funds and helps you avoid
waiting on reimbursement checks!
What Else Should I Know?





The card cannot be used until your plan year begins.
The card is only for eligible medical, dental and vision expenses.
Dependent daycare expenses are not eligible.
The card cannot be used for over-the-counter drugs filled with a prescription; you will need to file a manual claim.
Save your receipts!
There is a fee for replacement cards.
Are you saving money with Dependent Day Care?
Dependent Day Care FSA
A Dependent Day Care FSA allows you to set aside pre-tax dollars to reimburse yourself for incurred eligible
dependent care expenses. You may allocate up to $5,000 per plan year for reimbursement of dependent day
care services ($2,500 if you are married and file a separate tax return).
For a complete list of eligible expenses for the Health FSA and Dependent Day Care FSA, talk to your American
Fidelity representative when enrolling.
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Accident Only Insurance
Limited Benefit Accident Only Insurance Whether a weekend warrior with an active lifestyle or the stay at‐
home type, accidents can happen anytime, anywhere, without warning. Being prepared for the unexpected can make all the difference. American Fidelity’s Accident Only Insurance policy provides you a solution for those unforeseen accidents that life sometimes delivers. Our Limited Benefit Accident Only Insurance is designed to help pay for the unexpected medical expenses an individual may incur for the treatment of covered injuries received in an accident. How the Plan Works Our Accident Only Insurance policy pays according to a wide‐ranging schedule of benefits. In addition, the policy provides 24‐hour
coverage for accidents that occur both on and off the job. All benefits are only paid as a result of Injuries received in an Accident that occurs while coverage is in force. All treatment, procedures, and medical equipment must be diagnosed, recommended and treated by a Physician. All benefits are paid once per Covered Person per Covered Accident unless otherwise specified in the Limitations and Exclusions section.1 Premium and amount of Benefits may vary dependent upon Plan selected. 1
American Fidelity Assurance Company Coverage Feature Plan Options: Enhanced and
Enhanced Plus
Choose the plan to meet your financial needs. Four Choices of Coverage: Individual, Individual and Spouse, Individual and Child, or Family Choose the coverage that fits your lifestyle. Wide‐Ranging
Schedule of Benefits
Covers all types of coveredinjuries.
Wellness Benefit After the policy has been in force for 30 days, you receive a benefit for an annual routine exam, including immunizations and preventive testing once per policy per Receive a benefit when emergency treatment i n a
Emergency room occurs within
72 hours of a covered accident. Accident Emergency Treatment Benefit
Benefit Paid Directly to
Guaranteed Renewable
24‐Hour Coverage
Portable
Optional Accident Disability Income Rider This rider covers you 24‐hours a day and pays a Monthly Benefit Amount when a Covered Person becomes Totally Disabled due to Injuries received in a Covered Accident after the Elimination Period. The monthly benefit will be paid directly to you to use as you see fit. What It Means For You Additional Coverage Options
Payroll Deducted
Use the benefit however best fits your financial needs. Keep your coverage aslong as
premiums are paid as required.
You are covered on or off the job. You own the policy. Take thecoverage
with you if you choose toleaveyour
current job. Your premiums will remain the same. Enhance the base plan by adding an optional rider. Enjoy the convenienceofhavingyour
Premiums deducted straight from your paycheck. Limitations, exclusions and waiting periods apply. Refer to your policy for complete details. This product is inappropriate for people who are eligible for Medicaid coverage. The company has the right to change premiums by class(AO‐03Series). 16
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Cancer Insurance
Limited Benefit Cancer Indemnity Insurance Policy A cancer diagnosis may be overwhelming. Even with a good medical plan, the out‐of‐pocket costs of cancer treatment, such as travel, childcare, and loss of income, are considerable and may not be covered. American Fidelity Assurance Company Coverage Feature Plan Options
What It Means For You Choose the plan to meetyourfinancial
needs. American Fidelity’s Cancer Insurance can help offer financial protection so you can focus your attention on fighting cancer. We offer plans that can help assist with out‐of‐pocket costs often associated with a cancer diagnosis. Three Choices of Coverage: Individual, Single Parent Family, or Family
Wide‐Ranging
Schedule of Benefits
Choose the coverage that fits your lifestyle. How the Plan Works Benefit Paid Directly to You Use the money however best fits your financial needs. Keep your coverage aslong as
premiums are paid as required.
Our plan is designed to help cover expenses if you are diagnosed with a covered Cancer. With over 20 benefits available to you, this plan provides benefits for the treatment of cancer, transportation, hospitalization and more. We provide the money directly to you, to be used however you see fit. Optional Riders Guaranteed Renewable
Diagnostic and Prevention Benefit Receive a benefit for visiting your doctor for a cancer screening test, which helps Transportation and Lodging
Receive benefits if you travel more than 50 miles from yourhomeusing
the most direct route forcovered
treatment. Portable You own the policy. Take the coverage with you if you choose to leave your current job. Your premiums will remain the same. Additional Coverage Options Enhance the base plan by choosing from a selection of optional riders. Payroll Deducted Enjoy the convenience of having your premiums deducted straight from your paycheck. Enhance your base plan with the following riders: •
Critical Illness Rider Includes a cancer benefit and a heart attack/stroke benefit
•
Hospital Intensive Care Unit Rider Covers a wide range oftreatments.
Limitations, exclusions and waiting periods apply. Please refer to your policy for complete details. This product is inappropriate for people who are eligible for Medicaid coverage. The company has the right to change premiums by class. The premium and amount of benefits provided vary dependent upon the plan selected. 17
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Critical Illness Insurance
Limited Benefit Hospital Indemnity Insurance Policy Surviving a critical illness, such as a heart attack or stroke, can come at a high price. With advances in technology to treat these diseases, the cost of treatment rises more and more every year. Even with medical insurance, the out‐of‐pocket expenses associated with a critical illness can affect anyone’s finances. American Fidelity Assurance Company’s Limited Benefit Critical Illness Insurance can be the solution that helps you and your family focus on recovery, and may help you with paying bills. Our plan can assist with the expenses that may not be covered by standard medical insurance. How the Plan Works If you are diagnosed with a covered Critical Illness, such as a heart attack or stroke, this plan is designed to pay a lump sum benefit amount to help cover expenses. Also, this plan offers a Recurrent Diagnosis Benefit that can provide an additional 50% of the Critical Illness benefit amount after the second occurrence date of the specified Critical Illness. Guaranteed Renewable You are guaranteed the right to renew your base policy until age 75 as long as you pay premiums when due or within the premium grace period. We have the right to increase premiums by class. Optional Benefit Riders Enhance your base plan with these riders: • Sudden Death D ue to a Cardiac Arrest Benefit Rider • Hospital Confinement Benefit Rider 18
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American Fidelity Assurance Company
Coverage Feature What It Means For You Plan Options Choose from three lump sum benefit amounts: $15,000, $20,000 or $25,000. Four Choices of Coverage: Individual, Individual & Spouse, Single Parent Family, or Family Choose the coverage that fits your lifestyle.
WellnessBenefit
Receive a benefit for your annual screening test. Benefit Paid Directly to You Use the benefit however best fits your financial needs. Multiple Critical Illness Benefits You will be covered for 10 different critical illnesses. Portable You own the policy. Take the coverage with you if you choose to leave your current job. Your premiums will remain the same. Additional Coverage Options Enhance the base plan byadding an
optional rider. Payroll Deducted Enjoy the convenience of having your premiums deducted straight from your paycheck. Limitations, exclusions and waiting periods apply. Please refer to your policy for complete details. This product is inappropriate for people who are eligible for Medicaid coverage. The company has the right to change premiums by class. The premium and amount of benefits provided vary dependent upon the plan selected. Short-Term Disability Income Insurance
American Fidelity Assurance Company How do you pay for your mortgage, bills, food and other monthly expenses? If your paycheck stopped today, could you maintain your current lifestyle? American Fidelity’s Short‐Term Disability Income Insurance is designed to help protect you if you become disabled and cannot work due to a covered Accidental Injury or Sickness. How the Plan Works If you become disabled due to a covered accident or sickness, Short‐ Term Disability Income Insurance will pay up to 60% of your monthly income once you have satisfied the elimination period. Disability benefits will be payable up to the benefit period stated in your policy. Coverage Feature Benefit Paid Directly to You, Regardless of Other Coverage AgeatEntry
Eligibility All full‐time employees and employees of members on active service working 25 hours or more per week. Applicant’s eligibility for this program may be subject to insurability. It is your responsibility to see the American Fidelity representative once you have satisfied your employer’s waiting period. 19
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Use the money however best fits your financial needs, regardless of other insurance. Your premiums will bebasedonthe date your policy becomeseffective.
Accidental Death Benefit Receive a benefit if you die as the direct result of an Accidental Injury and death occurs within 90 days after the date of the Accidental Injury. Affordable Premiums
Your monthly premiumscouldbe
paid with only one hour ofa week’s paycheck. Payroll Deducted Enjoy the convenience of having your premiums deducted straight from your paycheck. Physician Benefit
Receive a benefit if you receive
treatment by a Physiciandue toa
covered Injury. Accidental Death Benefit Receive a benefit if death occurs as a direct result of an Injury within 90 days after the Injury. GuaranteedIssue
First‐time eligible employees may
Be able to receive coveragewithout
being subject to insurability. Age at Entry Premiums Premiums will be based on the date your policy becomes effective. Benefits Begin (Elimination Period) For the Short‐Term Disability Income plan, benefits can begin on the eighth day or 15th day, depending on the plan selected at the time of application. Benefits are payable for a covered Injury or Sickness up to 90 days or 180 days, based on the plan your employer has selected. Refer to your employer’s plan and your Certificate for details regarding benefit amounts and more. What It Means T oYou MaximumBenefitof60% Protect up to 60% of yourpaycheck.
Of Your Monthly Gross
Income Standard Insurance Company
Voluntary Long Term Disability Coverage Highlights
Municipal Schools of Shelby County
I Voluntary
Long Term Disability (LTD) Insurance
Long Term Disability insurance is designed to pay a monthly benefit to you in the event you cannot work because
of a covered illness or injury. This benefit replaces a portion of your income, thus helping you to meet your
financial commitments in a time of need. Standard Insurance Company (The Standard) has developed this
document to provide you with information about the optional coverage you may select through Municipal Schools
of Shelby County.
I Eligibility Requirements
Policy
• A minimum number of eligible employees must apply and qualify for the
proposed plan before Voluntary LTD coverage can become effective
Employee
• A regular employee of Municipal Schools of Shelby County, other
than Superintendents
• Actively working at least 20 hours each week
• A citizen or resident of the United States or Canada
• Temporary and seasonal employees, full-time members o' the armed forces,
leased employees and independent contractors are not eligible
Premium
• You pay 100 percent of the premium for this coverage through easy payroll deduction
I Benefit Amount
Benefit Percentage
Your monthly benefit is 60 percent of the first $8,333 of your insured
predisability earnings reduced by deductible income
Plan Maximum
Monthly Benefit
$5,000
Plan Minimum
Monthly Benefit
$100 or 10 percent of the LTD benefit before reduction by deductible income,
whichever is greater
Note:
• All late applications (applying 31 days after becoming eligible), requests for coverage increases and
reinstatements are subject to medical underwriting approval. Employees eligible but not insured under
the prior LTD insurance plan are also subject to medical underwriting approval.
I Disability Needs Calculator
Your family has a unique set of circumstances and financial demands. To help you figure out the amount of
Disability insurance you may need if you become unable to work, The Standard has created a Disability Needs
Calculator found at: http:l/www.standard.com/calculators/dineeds.html
I Employee Coverage Effective Date
To become insured, you must satisfy the eligibility requirements listed above, serve an eligibility waiting
period, receive medical underwriting approval (if applicable), and be actively at work (able to perform all
normal duties of your job) on the day before the scheduled effective date of insurance. If you are not actively
at work on the day before the scheduled effective date of insurance, your insurance will not become effective
until the day after you complete one full day of active work as an eligible employee.
Please contact your human resources representative for more information regarding the requirements that must be
satisfied for your insurance to become effective.
20
www.myMERITAIN.com
Standard Insurance Company
I Understanding Your Plan Design
Benefit Waiting
Period
If your claim for LTD benefits is approved by The Standard, benefits become
payable after you have been continuously disabled for 180 days and remain disabled.
Benefits are not payable during the benefit waiting period.
Own Occupation
Definition of
Disability
For the benefit waiting period and the first 24 months for which LTD benefits are
paid, you are considered disabled when you are unable as a result of physical
disease, injury, pregnancy or mental disorder to perform with reasonable
continuity the material duties of your own occupation AND are suffering a loss of
at least 20 percent of your indexed predisability earnings when working in your
own occupation. You are not disabled merely because your right to perform your
own occupation is restricted, including a restriction or loss of license.
Any Occupation
Definition of
Disability
After the own occupation period of disability, you will be considered disabled if you
are unable as a result of physical disease, injury, pregnancy or mental disorder to
perform with reasonable continuity the material duties of any occupation.
Maximum Benefit
Period
If you become disabled before age 62, LTD benefits may continue during
disability for five years. If you become disabled at age 62 or older, the benefit
duration is determined by your age when disability begins:
Age
62
63
64
65
66
67
68
69+
Deductible Income
Maximum Benefit Period
3 years 6 months
3 years
2 years 6 months
2 years
1year 9 months
1year 6 months
1year 3 months
1year
Deductible income is income you receive or are eligible to receive while LTD
benefits are payable. Deductible income includes, but is not limited to:
• Sick pay, annual or personal leave pay, severance pay or other forms of
salary contribution (including donated amounts) paid
• Benefits under any workers' compensation law or similar law
• Amounts under unemployment compensation law
• Social Security disability or retirement benefits, including benefits for your
spouse and children
• Disability benefits from any other group insurance
• Disability or retirement benefits under your employer's retirement plan
• Benefits under any state disability income benefit law or similar law
• Earnings from work activity while you are disabled, plus the earnings you
could receive if you work as much as your disability allows
• Amounts due from or on behalf of a third party because of your disability, whether by
judgment, settlement or other method
• Any amount you receive by compromise, settlement or other method as a result
of a claim for any of the above
21
www.myMERITAIN.com
I
Benefit Calculation
Example
The LTD benefit amount is determined by multiplying your insured
predisability earnings by the specified benefit percentage. This amount is
then reduced by deductible income. In the example below, the LTD benefit
amount is 60 percent of insured predisability earnings. If your monthly
earnings before becoming disabled were $4,500, and you now receive a
monthly Social Security disability benefit of $1,200 and a monthly retirement
benefit of $900,your monthly LTD benefit would be calculated as follows:
Insured predisability
earnings LTD benefit
percentage
Less Social Security disability
benefit “less” retirement benefit
Amount of LTD benefit
$4,500
X 60%
$2,700
$1,200
-$900
$600
I Additional
Features
Please see your human resources representative for additional information about the features and benefits
below. 24 Hour Coverage 24-hour LTD plans provide coverage for disabilities occurring on or off the job.
Rehabilitation Plan
If you are participating in an approved Rehabilitation Plan, The Standard may
include payment of some of the expenses you incur in connection with the plan
including but not limited to; training and education expenses, family (child and
elder) care expenses, job related expenses and job search expenses.
Reasonable
Accommodation
Expense Benefit
If your employer makes an approved work-site modification that enables you to
return to work while disabled, The Standard will reimburse your employer up to a preapproved amount for some or all of the cost of the modification.
Rehabilitation
Incentive Benefit
If you agree to participate in a rehabilitation plan that prepares you to return to
work (plan must be approved by The Standard), you may be eligible to receive an
additional benefit equal to 1O percent of your predisability earnings. When added
to any other amount you receive from The Standard, your total benefit cannot
exceed the maximum benefit allowed by the policy.
Employee Assistance
Program
Includes an Employee Assistance Program and WorkLife Services to offer support,
guidance and resources to help you and your household members resolve personal
issues.
Survivors Benefit
If you die while LTD benefits are payable, and on the date you die you have been continuously
disabled for at least 180 days, a survivors benefit equal to three time your unreduced LTD
benefit may be payable (any survivors benefit payable will first be applied to any
overpayment of your claim due to The Standard).
Lifetime
Security Benefit
Your LTD benefit (amount in effect when the claim closes) payments will continue
beyond the regular plan Maximum Benefit Period if you are unable to perform two
or more Activities of Daily Living or are suffering severe cognitive impairment.
I Exclusions
Subject to state variations, you are not covered for a disability caused or contributed to by any of the following:
• Your committing or attempting to commit an assault or felony, or your active participation in a violent disorder
or riot
• An intentionally self-inflicted injury, while sane or insane
• War or any act of war (declared or undeclared, and any substantial armed conflict between organized
forces of a military nature)
• The loss of your professional or occupational license or certification
• A preexisting condition or the medical or surgical treatment of a preexisting condition unless on the date
you become disabled, you have been continuously insured under the group policy for a specified period
22of time, and you have been actively at work for at least one full day after the end of the exclusion period
www.myMERITAIN.com
I Preexisting Condition Provision
A preexisting condition is a mental or physical condition whether or not diagnosed or misdiagnosed:
• For which you or a reasonably prudent person would have consulted a physician or other licensed medical
professional; received medical treatment, services or advice; undergone diagnostic procedures, including
self- administered procedures; or taken prescribed drugs or medications
• Which, as a result of any medical examination, including routine examination, was discovered or suspected
Preexisting Condition
Period
The 90-day period just before your insurance becomes effective
Exclusion Period
12 months
I Limitations
LTD benefits are not payable for any period when you are:
• Not under the ongoing care of a physician in the appropriate specialty as determined by The Standard
• Not participating in good faith in a plan, program or course of medical treatment or vocational
training or education approved by The Standard, unless your disability prevents you from
participating
• Confined for any reason in a penal or correctional institution
• Able to work and earn at least 20 percent of your indexed predisability earnings, but you elect not to work
during the first 24 months after the end of the benefit waiting period the responsibility to work is limited to
work in your own occupation; thereafter , the responsibility to work includes work in any occupation
In addition, payment of LTD benefits is limited in duration:
• If you reside outside the United States or Canada
• If your disability is caused or contributed to by mental disorders, substance abuse or the environment, chronic
fatigue conditions, chronic pain conditions, carpal tunnel or repetitive motion syndrome or temporomandibular
joint disorder or craniomandibular joint disorder
I When Benefits End
LTD benefits end automatically on the earliest of:
• The date you are no longer disabled
• The date your maximum benefit period ends
• The date you die
• The date benefits become payable under any other LTD disability insurance plan under which you
become insured through employment during a period of temporary recovery
• The date you fail to provide proof of continued disability and entitlement to benefits
I When Insurance Ends
Insurance ends automatically on the earliest of the following:
• The last day of the last period for which you make a premium contribution (except if premiums are waived
while disabled)
• The date your employment terminates
• The date the group policy terminates
• The date you cease to be a member (insurance may continue for limited periods under certain circumstances)
• If applicable, the date your employer ceases to participate under the group policy
I Group Insurance Certificate
If coverage becomes effective, and you become insured, you will receive a group insurance certificate containing
a detailed description of the insurance coverage including the definitions, exclusions, limitations, reductions and
terminating events. The controlling provisions will be in the group policy. Neither the information presented in
this summary nor the certificate modifies the group policy or the insurance coverage in any way.
23
www.myMERITAIN.com
Rates
If you have questions regarding how to determine your earnings, please contact your human resources representative.
Premiums for this coverage will be deducted directly from your paycheck.
Your Age
Rate
(as of September 1)
%
<25
0.065
25-34
0.082
35-44
0.120
45-54
0.270
55-64
0.594
65+
0.680
To calculate your per pay period payroll deduction, use the
formula indicated below:
1. Enter your average monthly earnings,
not to exceed $8,333, on Line 1.
Line 1:
2. Select your rate from the rate table
and divide this by 100.
Line 2:
3. Multiply Line 1 by the amount
shown on Line 2.
Line 3:
4. To calculate your bi-weekly premium,
multiply Line 3 by 10 and divide by 20.
Line 4:
The amount shown on Line 4 is your estimated per pay period
payroll deduction.
For more than 100 years we have been dedicated
to our core purpose: to help people achieve
financial well- being and peace of mind. We have
earned a national reputation for quality products
and superior service by always striving to do what
is right for our customers.
Headquartered in Portland, Oregon. The Standard
is a nationally recognized provider of group
Disability, life, Dental and Vision insurance and
Individual Disability insurance. We provide
insurance to more than 24,800 groups, covering
over 8 million employees nationwide.• Our first
group policy, written in 1951 and still in force today,
stands as a testament to our commitment to
building long-term relationships.
To learn more about products from The
Standard, Contact your human resources
department or visit us at www.standard.com.
·As of June 30, 2013. Based on internal data developed by Standard Insurance Company.
1100 SW Sixth Avenue
Portland OR 97204
GP190-LTD/S399,GP399-LTD/TRUST,GP899-LTD,
GP209-LTD, GP608-LTD,GP190-LTD/ASSOC/S399,
GP190-LTDITRUST/S399,
GP491-LTDITRUST/S399
24
www.myMERITAIN.com
Your Employee Assistance Program
Meritain Health
Life situations can become very stressful, but we can help.
When we begin to experience personal problems, reaching out to family, friends, or others can be very supportive and satisfying.
However, if additional help is needed, your employer has made available to you and your immediate family a professional counseling
service that can help you resolve these problems. The program is called CONCERN and it is your employee assistance program.
The need for the program.
Your employer knows that employees have many stresses when facing changes in life. The way employees manage these stresses can
have a significant impact on their work as well as their personal life. When employees are effectively managing personal issues, they are
generally much more productive.
What does CONCERN cost?
The services of CONCERN are a company-paid resource. There is no cost to you or your dependents if services are used.
If you and your counselor decide that additional services are required beyond short-term CONCERN counseling, and these referral
services are used, you will be responsible for any costs not covered by insurance
CONCERN Counselors.
The professional staff are master’s degreed counselors or clinical social workers. They are licensed and were required to have at least
three years of clinical experience before joining CONCERN.
When can I use CONCERN?
Services are available when you need them. It is recommended that you use the program in early stages of problem development
because it is easier to solve a problem in these early stages.
CONCERN counselors can help you through a crisis or they can help you to manage common problems that anyone can experience.
Common problems include family or marital difficulties, relationship problems, grief, emotional or psychological stress, financial and
legal worries, alcohol or drug abuse, gambling problems, or a combination of the above. Some problems are big, some are small. You
can bring any size problem to CONCERN.
How does CONCERN work?
If you need to talk over a problem with a CONCERN counselor, simply call for an appointment. During your first visit or two, the
counselor will listen and try to gain a clear understanding of your problem, help you sort out options, and develop a problem-resolution
plan with you. Help can usually be found through continued short-term counseling at CONCERN. If additional or specialized help is
needed, your counselor will put you in touch with a qualified professional or a support group best suited to help. Your counselor will
remain available to you until you feel the difficulties are under control.
How confidential is the service?
Strict confidentiality is maintained by CONCERN. The employee or dependent calls to make his own appointment. No one will know
of your participation unless you tell them or give your counselor permission to speak with someone. CONCERN complies with all
state and federal laws regarding confidentiality.
To make an appointment call 901.458.4000 or 1.800.445.5011.
25
www.myMERITAIN.com
Pay Period Rates for 2015 - 2016
2015‐2016 Rates 20 pays
Meritain Health
For employees who received their Biometric Screening in early 2015, please see the discounted medical premiums listed below. For employees who did not receive the screenings, you have until December 31, 2015 to receive your screening in order to continue receiving the discounted medical premiums in red. MEDICAL PLANS
HRA (Health Reimbursement Arrangement)
EMPLOYEE
EE + ONE
FAMILY
$
$
$
92.47
198.82
267.47
$
$
$
BIOMETRIC SCREENING DISCOUNTED PREMIUMS
67.47
173.82
242.47
BASIC
EMPLOYEE
EE + ONE
FAMILY
$
$
$
121.79
253.14
343.25
$
$
$
96.79
228.14
318.25
EMPLOYEE
EE + ONE
FAMILY
$
$
$
139.91
295.37
402.16
$
$
$
114.91
270.37
377.16
AETNA
EPO (Exclusive Provider Organization)
PER PAY PERIOD RATES (20 DEDUCTIONS)
COVERAGE TIER
DENTAL PLANS
METLIFE
COVERAGE TIER
PLAN 1‐DPPO $2000
EMPLOYEE
EE + ONE
FAMILY
PER PAY PERIOD RATES
(20 DEDUCTIONS)
$
21.71
$
45.61
$
65.15
PLAN 2‐DPPO $1500
EMPLOYEE
EE + ONE
FAMILY
$
$
$
15.05
31.60
45.14
VISION PLAN
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www.myMERITAIN.com
DAVIS VISION
COVERAGE TIER
VISION EMPLOYEE
EE + ONE
FAMILY
PER PAY PERIOD RATES
(20 DEDUCTIONS)
$
3.70
$
7.07
$
11.48
Convenient Tools and Resources
Meritain Health
Visit your personalized member website, myMERITAIN.com, to find the benefits
information you need.
Once enrolled as a Meritain Health member, you will have access to myMERITAIN.com. When you log in, you’ll find everything you need to
know about your benefits—from eligibility, to enrollment, to what’s covered. It’s another way we’re working with you to help you get the most
from your benefits—so you can live a life that’s balanced and informed.
Registration is easy!
If you’re already registered to access your online account, simply enter
www.myMERITAIN.com into your browser and login from the homepage. If you’re not yet
registered, it’s OK. Registration is an easy 4-step process.
1. Go to www.myMERITAIN.com.

Click on Create a new user account and follow the instructions.
You will need to fill in your:
o
Group ID (you can find this on your ID Card).
o
Member ID (you can find this on your ID Card, as well.
Enter with no spaces or dashes).
o
Date of birth.
o
Name.
o
Zip code.
o
Email address.
2. The system will display your username, which is your member ID. You will be
asked to change your password. Enter and re-enter your new password, which
you will need to create.
3. You will automatically be logged into your myMERITAIN account. The next time you login, use the same username and
password from Step 3.
Important Contact Information.
Meritain Health Customer
Service www.myMERITAIN.com
1.800.925.2272
Medical benefits In-network providers
Aetna Provider Line
www.aetna.com/docfind/custom/mymeritain
1.800.343.3140
Aetna Choice® POS II providers
Scrip World Customer Service
1.866.475.7589
Prescription drug benefits
Meritain Health Medical Management
1.800.242.1199
Precertification
Healthy MeritsSM
1.877.348.4533
Health and wellness program details
Meritain Health Disease Management
1.888.610.0089
Support for chronic conditions
Met Life - www.metlife.com/mybenefits
1.800.GET.MET8
Dental - benefits/providers
Davis Vision - www.davisvision.com
1.800.999.5431
Vision - benefits/providers
Concern EAP
1.800.445.5011
1.901.458.4000
Employee Assistance Program
American Fidelity
1.800.465.2129
FSA Administration
http://www.afadvantage.com/for-individuals/afeslanding-pages/ municipal-schools-of-shelby-
1.901.458.9252
Short-term disability/accident/cancer
Standard - www.standard.com
1.800.348.3226
Long-Term disability
Employee Benefits
1.901.202.0855
Benefit administration
27
100% Enrolled with American Fidelity
Meritain Health
All eligible employees will enroll by using American Fidelity’s benefit enrollment tool.
New health reform regulations have made it essential that every eligible employee enroll or waive coverage. American Fidelity is helping us achieve
the 100% goal. Pre-Enrollment starts April 13th with representatives of American Fidelity scheduling times at each school location to enroll
employees. Representatives will be able to explain all the benefits offered and assist employees’ enrollment.
Regular enrollment begins April 20 - May 15.
Benefits become effective September 1, 2015.
Please look to your school district’s webpage for information on scheduling your enrollment opportunity. Please make sure you bring the following
with you when you meet with American Fidelity to enroll:

Social Security card of all family members you will enroll

If applicable, Spouse Affidavit Form, enclosed in this brochure
Once you receive your ID cards, please show them to your providers the first time you are seen.
Medical: The card shows Meritain Health as your health plan administrator.
Dental: MetLife does not issue ID cards, but you may register at www.metlife.com/mybenefits to review providers.
Vision: The card shows Davis Vision. A list of providers is included.
Card front
Sample ID Card
■ Your healthcare plan includes a network of providers you can visit for healthcare services. When you
visit providers in this network, you will receive the best service rate. Call the provider information
number for participating providers.
Plan: Aetna Choice POS II
Name:
COPAY:
John Smith
ID #:
123456789
Effective Date: 00-00-00
Group #:
12345
Div: 001
Group Name: ABC Company
Coverage:
Medical EMP/FAM
RxBin: 001234 RxPCN: ABC
RxGrp: RX1234
Customer Care: 800-xxx-xxxx
Pharmacy Help Desk: 800-xxx-xxxx
Office Visit:
Emergency Room:
Urgent Care Facility:
Specialist:
$xx
$xx
$xx
$xx
■ Your name, identification number, medical group number and your group name, are used to identify
you and your covered dependents’ benefits.
Generic Copay:
$xx
Formulary Copay:
$xx
Non-Formulary Copay: $xx
■ Your medical copays are conveniently listed for you and your providers.
■ Your pharmacy coverage information is listed on the front of your card, and includes the Scrip World
customer service number and prescription copays.
Card back
For Pre-Certification call: 999.999.9999
Failure to comply with your plan's pre-certification
requirements may result in a reduction of benefits.
For an Aetna provider: 800-xxx-xxxx
Network Link: www.myMERITAIN.com
* Aetna participating doctors, dentists and
hospitals are independent providers and are
neither agents nor employees of Aetna.
SUBMIT ALL CLAIMS TO:
Meritain Health
P.O. Box 99999
City, State, zip
Benefit/Claim Customer Service:
800-xxx-xxxx
■ Please ensure that you precertify with Meritain Health Medical Management, if required.
■ All claims should be submitted to Meritain Health at this address.
■ You or your provider can call Meritain Health to verify eligibility of benefits or check on your claims status.
EDI: WebMD - #99999
24/7 Nurse line: 800-xxx-xxxx
www.myMERITAIN.com
28
24-Hour Automated Customer Service:
800-xxx-xxxx or www.myMERITAIN.com
■ You can call for information on a doctor or specialist who is close to you and serves your specific needs.
SCHEDULE YOUR
BIOMETRIC SCREENING
Lock in your discounted premium!
In early January and February of 2015, many participated in the Biometric Screenings conducted by Meritain and Interactive Health. The purpose of the screenings were to bring attention on the need for health and wellness and to identify potential health issues. Many health issues don’t start as “The Major Event”. Usually it is “The Major Event” which calls attention to the warnings signs that may have been present all along. What if we could have prevented “The Major Event” before it happened? What would that cost? How much would it save? These screening are a ways to identify “risks or warning signs” which as we get older, only increase. With technology today, no longer are we satisfied to be “Reactive” to our health needs, but be “Proactive” instead. Those who participated in the Biometric Screenings took that first step in being “Proactive”. Knowing the “Risks or Warning Signs” helps us to stay on the path to great health. All who participated have been able to secure the discounted rates advertised in this brochure. If you have not scheduled your screening yet, it is not too late. With the opening of the District’s Health & Wellness Centers through CareHere in early fall, you may schedule your screening before January 2016, in order to lock in your discounted rates too. Take the first step to good health, by scheduling your screening in early Fall. 29
COMING SOON
HEALTH & WELLNESS CLINICS
We are excited to announce for the coming school year, the opening of two Health & Wellness Clinics, to be administered by CareHere. Please look for the official announcement in early fall 2015. These clinics, will be open to all employees of Arlington Community Schools, Bartlett City Schools, City of Bartlett, Collierville Schools, Town of Collierville, Lakeland School System, City of Lakeland and Millington Municipal Schools, who are participating in the district’s health plan through Meritain/Aetna. Listed below are just a few of the benefits this clinic model will provide for insured employees and their dependents: 1. No office copay
2. Dispensing of prescription medicine at the time of
service with no copay
3. Dispensing of prescription maintenance drugs with
no copay
4. Conduct all employee Biometric Screenings in
order to maintain discounted premiums
5. Online Appointment Scheduler
6. No waiting office appointments
7. Smartphone application
8. 24/7 call center
9. Nutritional Counseling/Pre‐Diabetes Management
10. Tobacco Cessation
Two opportunities to save TODAY for TOMORROW
Great West
My Money · My Future · My Tennessee
40 l (k) Deferred Compensation Program
About the 401(k) plan
VALIC
Explore the Different Types of Retirement Plans
by VALIC
403(b) Plan - Open to public education employers.
Funded by the employee through elective, tax-deferred
contributions. Total contributions are limited to the same
contributions limits as the 401k
A 401(k) plan is a retirement
savings plan designed to
allow eligible employees to
supplement any existing
retirement and pension
benefits by saving and
investing before-tax dollars
through a voluntary salary
contribution. Contributions
and any earnings on
contributions are tax-deferred until money is withdrawn.
403(b) Roth –Has the same withdrawal rules and
contribution limit as a 403(b), but contributions are made
after-tax so that when distributions are made at retirement
that only the growth is taxable. One cannot exceed the
maximum limit set for the combined annual limit of a
403(b) and 403(b) Roth.
What is a Roth 401(k) contribution?
457 (b) Deferred Compensation Plan – Open to
A Roth 401(k) contribution is an option under the 401(k)
plan that allows eligible employees to supplement any
existing retirement and pension benefits by saving and
investing after-tax dollars through voluntary salary
deferral.
Distributions and any potential earnings are tax-free upon
reaching the age of 59½ if taken after the required five-year
holding period. You have the flexibility to designate all or
a portion of your 401(k) elective deferrals as Roth
contributions.
Can employees contribute to multiple plans?
Yes; however, if an employee contributes to another plan,
such as a 403(b) plan, the combined total of all
contributions cannot exceed the maximum limit of
$18,000 in 2015, or $24,000 if age 50 or older.
Governmental 457(b) plans have separate deferral limits,
so employees who contribute to a 457 plan may be able to
contribute an additional $18,000 to that plan in 2015 (plus
any applicable catch-up contributions). For more
information about contribution limits for multiple plans,
visit www.irs.gov.
If you are eligible to participate in the Program, you can
enroll on a voluntary basis by: Enrolling online at
www.gwrs.com. Click on “Let’s Get Started!” You will
need your Social Security number and either a Personal
Identification Number (PIN) or personal identifying
information to enroll.
30
State and local government employers. The rules of
withdrawal benefit those individuals who might begin
drawing their pension at an earlier age. By combining a
403(b) with a 457 (b) employees can double the maximum
of up to $36,000 in 2015. If age 50 or older in 2015, you
may further increase that contribution to include the
“catch-up” provision.
What are the contribution limits for 401(k), 403(b), and
403(b) Roth & 457?
In 2015, the maximum contribution amount is $18,000. It may
be indexed for inflation in $500 increments after 2015. For a
401(k), 403(b) and 403(b) Roth, collectively you may not
exceed the annual contribution level. The 457 (b) allows you
to essentially double the annual contribution by allowing
you to contribute the same as the 401(k), 403(b) or 403(b)
Roth.
If you turn age 50 or older in 2015, you may contribute an
additional $6,000 for a maximum contribution of $24,000.
If interested in enrolling please contact your district’s agent
Bartlett City Schools, Germantown Municipal School District
Karen Shrader – 901-237-8977 (cell)
Collierville Schools, Arlington Community Schools
David Stratton – 662-812-7698 (cell)
Millington Municipal Schools, Bartlett City Schools, Lakeland
School System
Michael Seebeck – 901-825-8958
Spousal Healthcare Eligibility Affidavit
Employee Name
___________________________ Employee ID
____________
Spouse Name
___________________________ Last four of SSN (Spouse) ____________
School District
___________________________
Section A: Must complete to enroll your spouse in Group Health Plan Coverage.
Your Spouse is:
#1
Not employed or is Retired
#2
An employee of one of the Municipal School Districts or Cities listed below: (Please check one)
Arlington Community Schools
Bartlett City Schools
Collierville Schools
Lakeland School System
Millington Municipal Schools
City of Bartlett
Town of Collierville
City of Lakeland
#3
*Employed or Self-Employed WITHOUT access to coverage from his/her employer (MUST COMPLETE
SECTION B)
#4
*Employed WITH access to coverage from his/her employer but employer pays less than 50% of the cost
(MUST COMPLETE SECTION B)
NOTE:
*If none of the above applies then he or she is not eligible for the Group Health Plan. (He or she is
eligible for other benefits such as dental, vision, life.)
I hereby certify that the information provided above is correct. I understand that any misrepresentation in the information I have provided
above will permit my employer to terminate my spouse’s coverage and seek any other legal remedies available including possible
prosecution for insurance fraud. If applicable, I authorize the release of the health care plan coverage information requested below and
authorize its use in accepting the application for the Group Health Plan coverage.
Employee Signature
_________________________________
Date
______________________
Spouse Signature
________________________________
Date
______________________
Section B:
Must be completed by spouse’s employer or spouse if self-employed
Is the person named above as Spouse eligible for coverage with your company?
YES _____
NO _____
If yes, does the employee’s share, exceed 50% of the total cost of premiums for your cheapest individual coverage?
YES ____
NO ____
Employer Name:
__________________________________________________________
Employer Address:
__________________________________________________________
Employer Phone Number:
__________________________________________________________
Authorized Employer Name:
____________________________ Title: __________________________
Authorized Employer Signature
___________________________ Date:__________________________
31
Please return completed document to the Employee Benefits office Email: benefits@bartlettschools.org, Fax: (901)202‐0854 LEGAL NOTICES
Arlington Community Schools, Bartlett City Schools, Collierville Schools, Lakeland School
System and Millington Municipal School System (MSSC) EMPLOYEE BENEFIT PLAN
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
This notice will become effective on _04/08/2015___________.
At, MSSC we respect your privacy and will protect your health information responsibly and
professionally. This notice describes the privacy practices of the [medical][, dental,][vision] and
prescription drug programs (the “Health Plan”) included in the MSSC Employee Benefit Plan. This
notice does not apply to disability benefits, life insurance, or any non-health plans or benefits.
As you read this notice, you’ll see the term “Protected Health Information” or PHI. Protected health
information is health information that identifies you and relates to your medical history (i.e., the health
care you receive or the amounts paid for that care) that is created or obtained by the Health Plan in
connection with your eligibility for or receipt of benefits under the Health Plan.
Federal law requires that the Health Plan maintain the privacy of protected health information, give you
this notice of the Health Plan’s legal duties and privacy practices, and follow the terms of this notice as
currently in effect. These protections will remain in effect with regards to your protected health
information held by the Health Plan during your lifetime, and for at least 50 years following your death.
MSSC contracts with claims administrators and other third parties to provide Health Plan services. For
purposes of this notice, the “Health Plan” includes third parties when performing services for the Health
Plan, including persons or entities creating, receiving, maintaining or transmitting your protected health
information in connection with your health coverage (referred to in this notice as “business associates”).
Protected health information may be shared among the components of the Health Plan and the third
parties providing services for the components of the Health Plan in the course of payment, Health Plan
operations, and treatment. The current claims administrators are listed under Contact Information,
below. When their services involve the use of protected health information, the third parties and their
subcontractors will be required to perform their duties in a manner consistent with this notice.
How the Health Plan Uses and Shares PHI for Payment, Health Plan Operations, and Treatment
Below are some examples of ways that the Health Plan may use or share information about you for
treatment, payment, and Health Plan operations. For each category, a number of uses or disclosures
will be listed, along with an example. However, not every use or disclosure in a category will be listed.
The Health Plan may use or share your protected health information for:

Payment: The Health Plan will use and disclose your protected health information to determine and
pay for covered services. Payment activities include determining eligibility; conducting precertification, utilization, case management, and medical necessity reviews; coordinating care;
calculating cost sharing amounts; coordination of benefits; reimbursement and subrogation; and
responding to questions, complaints, and appeals. For example, the Health Plan may use your
medical history and other health information to decide whether a particular treatment is medically
necessary and what the payment should be. During that process, the Health Plan may disclose
information to your provider. Any request for information or use of such information involving
psychotherapy notes will only be done with your written authorization. The Health Plan will mail
Explanation of Benefits forms and other information to the employee at the address it has on record
for the employee.

Health Plan Operations: The Health Plan will use and disclose your protected health information for
Health Plan operations. Operational activities include quality assessment and improvement;
performance measurement and outcomes assessment; health services research; and preventive
health, disease management, case management, and care coordination. For example, the Health
Plan may use protected health information to provide disease management programs for participants
with specific conditions, such as diabetes, asthma, or heart failure. Other operational activities
requiring use and disclosure of protected health information include administration of stop loss
coverage, including underwriting of such coverage; legal, actuarial, and audit services; business
planning and cost management; detection and investigation of fraud; administration of
pharmaceutical programs and payments; and other general administrative activities, including data
and information systems management and customer service. We will not use or disclose any genetic
information involving you for underwriting purposes.

Treatment: The Health Plan may use or disclose your protected health information to facilitate
medical treatment or services by providers. The Health Plan may disclose protected health
information to doctors, dentists, pharmacies, hospitals, and other health care providers who take care
of you. For example, doctors may request medical information from the Health Plan to supplement
their own records. The Health Plan may also send certain information to doctors for patient safety or
other treatment-related reasons.
The Health Plan may also disclose protected health information to providers or other health plans for the
payment, treatment, and certain operational activities of the provider or other health plan.
How the Health Plan Uses and Shares PHI for Communications about Benefits
The Health Plan may use or disclose protected health information to send you treatment reminders
for services such as mammograms or prostate cancer screenings. Also, the Health Plan may use or
disclose your protected health information to give you information about alternative medical treatments
and programs or health-related products and services that may be of interest to you. For example, the
Health Plan might send you information about smoking cessation or weight-loss programs. Disclosures
involving the sale of your health information to another entity for marketing purposes, or for any purpose
not disclosed in this notice, will only be done with your written authorization.
Disclosures that the Health Plan May Make to Others Involved in Your Health Care
The Health Plan may disclose protected health information to a family member, a friend, or any other
person you identify, provided the information is directly relevant to that person’s involvement with your
health care or payment for that care. For example, if a family member or a caregiver calls the Health
Plan with prior knowledge of a claim, the Health Plan may confirm whether or not the claim has been
received and paid. You may instruct the claims administrator to stop or limit this kind of disclosure. We
will continue to permit such disclosure to these individuals following your death, unless doing so is
inconsistent with any prior expressed preference made by you that is known to us.
Disclosures You May Authorize the Health Plan to Make
The Health Plan will not use or disclose your protected health information for any reason other than
those listed in this notice unless you provide a written authorization.
-2-
You may give the Health Plan written authorization to use and/or disclose your protected health
information to anyone for any purpose. If you give the Health Plan an authorization, you may revoke it in
writing at any time. Your revocation will not affect any use or disclosure made pursuant to your
authorization while it was in effect.
Disclosures that the Health Plan May Make to MSSC
To determine if and when you and your family members are covered by the Health Plan, the Health
Plan will share enrollment information about you and your family members with MSSC.
The Health Plan will periodically disclose protected health information to MSSC Human Resources
Representatives so that the Human Resources Representatives can assist participants with benefits
questions and oversee the administration of the Health Plan. Also, the Health Plan will periodically
disclose protected health information to the Finance Department of MSSC so that the Finance
Department can perform financial planning and projections and monitor the performance of third parties.
In addition, the Finance Department is responsible for paying the claims covered by the Health Plan.
The Human Resources Representatives and the Finance Department will only use the protected health
information for the purposes for which it was disclosed or as required by law.1 Specifically, MSSC
certifies that it will:

Not use or disclose protected health information for employment-related actions and decisions or in
connection with any non-health benefits or another employee benefit plan sponsored by MSSC;

Not use or further disclose protected health information other than as permitted or required by this
notice or as required by law;
Ensure that any business associates (including a subcontractor) to whom MSSC provides protected
health information received from the Health Plan agree to the same restrictions and conditions that
apply to MSSC with respect to such information. If any of our business associates fails to take
adequate steps to safeguard and protect your health information, including controlling the activities of
any of their subcontractors, and to perform the activities necessary to fulfill their responsibilities in
regards to such information, including the corrective actions necessary due to a breach, we will
terminate our relationship with such entities, if feasible;

Provide training to our employees, including volunteers, trainees and others who are under are our
direct control with access to protected health information maintained by the Health Plan on their
responsibilities under the law, including the safeguarding and protection of the information. We will
also establish and enforce disciplinary measures against such employees for violations of such
responsibilities, and will require our business associates and their subcontractors to do the same;

Report to the Health Plan’s Privacy Officer any use or disclosure of protected health information that
is inconsistent with the uses or disclosures provided for of which MSSC becomes aware;

Provide notification to you within a reasonable time of our discovery of an impermissible use or
disclosures of your protected health information (breach), unless we reasonably determine that there
is a low probability that such information has been. Such notification will also be provided to the
media or the U.S. Secretary of Health and Human Services if required by law. We will also provide
you with notification of any such breaches committed by our business associates, unless we have
delegated the responsibility for such notifications to the business associate who is responsible for the
breach;
-3-

Confirm that the Health Plan makes your protected health information available to you for access,
amendment, and/or accounting, as described below;

Make internal practices, books, and records relating to the use and disclosure of protected health
information received from the Health Plan available to the Secretary of the U.S. Department of Health
and Human Services for purposes of determining compliance by the Health Plan with federal law;

Return protected health information to the Health Plan (when feasible), destroy protected health
information (when return is not feasible and retention is not required by law), or continue to maintain
the privacy of all protected health information (when return is not feasible and retention is required by
law);

Use its best efforts to request only the minimum necessary type and amount of protected health
information to carry out the functions for which the information is requested; and

Ensure adequate separation between the employees who are Human Resources Representatives or
in the Finance Department and all other employees of MSSC with access to Health Plan information
so that protected health information received by these individuals is not disclosed to other employees
of MSSC or other individuals in violation of this notice.
Other Uses and Disclosures of PHI
There are state and federal laws that may require or allow the Health Plan to release your health
information to others. The Health Plan may provide information for the following reasons:

Health Oversight Activities: The Health Plan may disclose your protected health information to a
government agency authorized to oversee the health care system or government programs, or its
contractors (e.g., state insurance department, U.S. Department of Labor) for activities authorized by
law, such as audits, examinations, investigations, inspections, and licensure activities.

Legal Proceedings: The Health Plan may disclose your protected health information in response to
a court or administrative order, subpoena, discovery request, or other lawful process, under certain
circumstances.

Law Enforcement: The Health Plan may disclose your protected health information to law
enforcement officials under limited circumstances. For example, in response to a warrant or
subpoena; for the purpose of identifying or locating a suspect, witness, or missing person; or to
provide information concerning victims of crimes.

For Public Health Activities: The Health Plan may disclose your protected health information to a
government agency that oversees the health care system or government programs for activities such
as preventing or controlling disease or activities related to the quality, safety, or effectiveness of an
FDA-regulated product or activity.

Required by Law: The Health Plan may disclose your protected health information when required to
do so by law.

Workers’ Compensation: The Health Plan may disclose your protected health information when
authorized by and to the extent necessary to comply with workers’ compensation laws and similar
programs.
-4-

Victims of Abuse, Neglect, or Domestic Violence: The Health Plan may disclose your protected
health information to appropriate authorities if the Health Plan reasonably believes that you’re a
possible victim of abuse, neglect, domestic violence, or other crimes.

Coroners, Funeral Directors, and Organ Donation: In certain instances, the Health Plan may
disclose your protected health information to coroners or funeral directors and in connection with
organ donation.

Research: The Health Plan may disclose your protected health information to researchers, if certain
established steps are taken to protect your privacy.

Threat to Health or Safety: The Health Plan may disclose your protected health information to the
extent necessary to prevent or lessen a serious and imminent threat to your health or safety or the
health or safety of others.

For Specialized Government Functions: The Health Plan may disclose your protected health
information in certain circumstances or situations to a correctional institution if you are an inmate in a
correctional facility, to an authorized federal official when it’s required for lawful intelligence or other
national security activities, or to an authorized authority of the Armed Forces.

For Cadaveric Organ, Eye, or Tissue Donation: The Health Plan may disclose your protected
health information for the purpose of facilitating organ, eye, or tissue donation and transplantation.
Your Rights
You have the following rights regarding the protected health information that the Health Plan
maintains about you.

You have the right to ask the Health Plan to restrict its use and disclosure of protected health
information for the purposes of treatment, payment, or health care operations. Your request must be
in writing and sent to the claims administrator. If the information you for which you are requesting the
restrictions involves health care services or supplies that were paid in full by you or on your behalf by
another person, we will honor such request. Otherwise, the Health Plan will consider your request,
but it is not required to agree to restrict the information.

You have the right to ask to receive confidential communications. If you believe that normal
communications would put you in danger, you may request that the Health Plan send
communications with protected health information (e.g., an Explanation of Benefits) to you by
alternative means or to an alternative location. Your request must be in writing and sent to the claims
administrator. Your request must include the alternative location (e.g., fax number, address, etc.) to
which you would like the Health Plan to send the information. Such requests, if reasonable, will be
accommodated when you state in the request that you believe that normal communications would
endanger you.

You have the right to inspect and obtain a copy of the protected health information that the Health
Plan maintains about you in a designated record set, including information maintained in paper or
electronic formats. A designated record set contains protected health information that the Health
Plan collects, maintains, or uses to administer or make decisions regarding your enrollment,
payment, claims adjudication, or case management. Your request must be in writing. If the request
pertains to records held by the claims administrator, you must complete an Access Request Form
-5-
and send it to the claims administrator. An Access Request Form can be obtained by contacting the
claims administrator or by downloading the form from the claims administrator’s website. The Health
Plan, or its designee, will respond within 30 days of the receipt of your request. The Health Plan may
charge a reasonable, cost-based fee to provide you with the information. If you request such
information be provided to you through unencrypted e-mail, you assume the risk on any unauthorized
access or such protected health information during its transmission to you, and are responsible for
safeguarding such information once it is delivered to you. There are exceptions as to what
information can be accessed. For example, information compiled for legal proceedings cannot be
accessed. If the Health Plan denies access to your information, in part or in whole, it will notify you in
writing. The denial will include the reason for the denial, your review rights (if applicable), and
information on how to file a complaint.

You have the right to ask the Health Plan to amend protected health information about you that is
contained in a designated record set (as described above) if you think that information is incorrect or
incomplete. Your request must be in writing. If the request pertains to records held by the claims
administrator, you must complete an Amendment Request Form and send it to the claims
administrator. An Amendment Request Form can be obtained by contacting the claims administrator
or by downloading the form from the claim administrator’s website. Your request must include the
reason for the request. The Health Plan, or its designee, may deny your request if you ask the
Health Plan to amend information that: is not part of the protected health information kept by or for
the Health Plan; was not created by the Health Plan, unless the person or entity that created the
information is no longer available to make the amendment; is not part of the information that you
would be permitted to inspect and copy; or is accurate and complete. If the Health Plan denies the
request, you may file a written statement of disagreement with the Health Plan.

You have the right to request an accounting of certain disclosures of protected health
information. Your request must be in writing and must specify the time period for which you are
requesting information. The period cannot start earlier than April 14, 2003, or go back more than six
years from the date of your request. Your request must be in writing. If the request pertains to
records held by the claims administrator, you must complete an Accounting Request Form and send
it to the claims administrator. An Accounting Request Form can be obtained by contacting the claims
administrator or by downloading the form from the claim administrator’s website. The accounting will
not include disclosures made to you or with your written authorization or in the course of treatment,
payment, or health care operations. If you request such an accounting more than once in a 12month period, the Health Plan will charge a reasonable fee.

You have the right to a copy of this notice upon request. Your request must be in writing and sent
to the Privacy Officer. A copy of the current notice will be sent to you.
For more information, or to begin the formal process connected with these rights, see Contact
Information, below.
Contact Information
If you want to exercise any of the rights described in this notice with respect to the records held, or
the disclosures made, by one of the Health Plan’s claims administrators, you may contact that claims
administrator. As of September 23, 2013, the claims administrators are:

For matters concerning [medical] [dental][vision] benefits:

For matters concerning prescription drug benefits:
-6-
Privacy Officer for MSSC
5650 Woodlawn, Bartlett, TN 38134
901-202-0855, Ext. 242
If you call a claims administrator, please tell the customer service representative that your call relates to
the privacy of your protected health information.
If you have questions regarding this notice, you may also contact the Health Plan’s Privacy Officer,
c/o the Benefits Shared Service, 5650 Woodlawn, Bartlett, TN 38134. You may also contact the Health
Plan’s Privacy Officer if you have any problems in exercising your rights.
Complaints
You have the right to file a written complaint with the Health Plan’s Privacy Officer if you think your
privacy rights have been violated. Include your name, address, and telephone number. You may also
file a complaint with the Secretary of the U.S. Department of Health and Human Services. You won’t be
retaliated against or denied any Health Plan benefit or service because you file a complaint.
The Health Plan’s Privacy Officer will investigate and address any issues of noncompliance with this
notice of which any one or more of these entities or persons is notified or becomes aware.
Revisions to the Notice
MSSC reserves the right to change the terms of this notice and to make the new notice effective for
all protected health information maintained by the Health Plan. MSSC will promptly revise and distribute
this notice whenever there is a material change to the uses or disclosures, your rights, the Health Plan’s
duties, or other practices stated in this notice. Except when required by law, a material change to this
notice will not be implemented before the effective date of the new notice in which the material change is
reflected.
-7-
Important Notice from the Arlington Community Schools, Bartlett City
Schools, Collierville Schools, Lakeland School System, Millington
Municipal Schools (MSSC) About
Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has
information about your current prescription drug coverage with the (MSSC) and
about your options under Medicare’s prescription drug coverage. This information
can help you decide whether or not you want to join a Medicare drug plan. If you are
considering joining, you should compare your current coverage, including which
drugs are covered at what cost, with the coverage and costs of the plans offering
Medicare prescription drug coverage in your area. Information about where you can
get help to make decisions about your prescription drug coverage is at the end of
this notice.
There are two important things you need to know about your current coverage and
Medicare’s prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with
Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan
or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription
drug coverage. All Medicare drug plans provide at least a standard level of
coverage set by Medicare. Some plans may also offer more coverage for a higher
monthly premium.
2. The (MSSC) has determined that the prescription drug coverage offered by the
Medical and Prescription Drug Plan Sponsored by the (MSSC) (all plan options) is,
on average for all plan participants, expected to pay out as much as standard
Medicare prescription drug coverage pays and is therefore considered Creditable
Coverage. Because your existing coverage is Creditable Coverage, you can keep
this coverage and not pay a higher premium (a penalty) if you later decide to join a
Medicare drug plan.
__________________________________________________________________________
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each
year from October 15th through December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of
your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join
a Medicare drug plan.
What Happens To Your Current Coverage If You Decide to Join A
Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current coverage with the (MSSC) may be
affected. If you do decide to join a Medicare drug plan and drop your current (MSSC)
coverage, be aware that you and your dependents may not be able to get this coverage back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug
Plan?
You should also know that if you drop or lose your current coverage with the (MSSC) and
don’t join a Medicare drug plan within 63 continuous days after your current coverage ends,
you may pay a higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your
monthly premium may go up by at least 1% of the Medicare base beneficiary premium per
month for every month that you did not have that coverage. For example, if you go nineteen
months without creditable coverage, your premium may consistently be at least 19% higher
than the Medicare base beneficiary premium. You may have to pay this higher premium (a
penalty) as long as you have Medicare prescription drug coverage. In addition, you may have
to wait until the following October to join.
For More Information About This Notice Or Your Current Prescription
Drug Coverage…
Contact the person listed below for further information. NOTE: You’ll get this notice each
year. You will also get it before the next period you can join a Medicare drug plan, and if this
coverage through the (MSSC) changes. You also may request a copy of this notice at any
time.
For More Information About Your Options Under Medicare Prescription
Drug Coverage…
More detailed information about Medicare plans that offer prescription drug coverage is in the
“Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from
Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
 Visit www.medicare.gov
 Call your State Health Insurance Assistance Program (see the inside back cover of
your copy of the “Medicare & You” handbook for their telephone number) for
personalized help
 Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug
coverage is available. For information about this extra help, visit Social Security on the web at
www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join
one of the Medicare drug plans, you may be required to provide a copy of
this notice when you join to show whether or not you have maintained
creditable coverage and, therefore, whether or not you are required to pay
a higher premium (a penalty).
Date:
Name of Entity/Sender:
Contact--Position/Office:
Address:
Phone Number:
04-08-2015
(MSSC)
Benefits, Shared Services
5650 Woodlawn, Bartlett, TN 38134
901-202-0855, Ext. 242
Women’s Health and Cancer Rights Act Enrollment Notice
The following is language that group health plans may use as a guide when crafting the
WHCRA enrollment notice:
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the
Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related
benefits, coverage will be provided in a manner determined in consultation with the attending physician
and the patient, for:




all stages of reconstruction of the breast on which the mastectomy was performed;
surgery and reconstruction of the other breast to produce a symmetrical appearance;
prostheses; and
treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other
medical and surgical benefits provided under this plan. Therefore, the following deductibles and
coinsurance apply:
EPO – Deductibles
Coinsurance
$500, $750, $1,000
100% after copay and deductible met
Basic - Deductibles
Coinsurance
$500, $750, $1,000
80% after copay and deductible met
HRA
$1,500, $2,250, $3,000
80% after deductible met
Deductibles
Coinsurance
If you would like more information on WHCRA benefits, call your Plan Administrator 901-202-0855, Ext.
242.
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32
Meritain Health
33

Municipal School Districts of Shelby County

Transcription

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