power costs, inc. benefit guide

Power Costs, Inc.

2012 Benefit Guide

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Power Costs, Inc. Benefit Partner Contact Information

Health Plan Customer Service:

1(800) 842-8000

Provider Directory: www.myuhc.com

Network: UnitedHealthcare

Dental Plan Customer Service:

1 (888) 222-3660

Provider Directory:www.sunlifedentalbenefits.com

Supplemental

Life & AD&D,

EAP and Short

Term and Long

Term Disability.

Customer Service:

Life Claims: 1 (800) 775-8805

Disability Claims: 1 (800) 877-5176

Ancillary products

Accident, Heart,

Stoke and Cancer

Insurance.

J.D. Bostic

Office: 1(888) 238-3801

Fax: 405-238-6559

Cell: 405-444-0128

Email: [email protected]

Benefit Broker for

Employer’s Medical,

Dental, EAP,

Supplemental Life

and AD&D, Disability

plans, Flex Plan and

COBRA

Caba, Inc. Contacts:

Flex Plan Dept.:

Telephone Number: 1 (888) 840-8924

Fax: (405) 858-7343

Email: [email protected]

Customer Service Contact:

Telephone Number: 1 (888) 840-8924

Local: (405) 840-3033 x 109

Fax: (405) 858-7361

http://www.aflac.com/

http://www.bcbsok.com/

http://www.sunlifedentalbenefits.com/

mailto:[email protected]

Index

Health Plan Section I

Dental Plan Section II

Supplemental Life Section III

Disability Insurance Section IV

Flexible Benefit Plan Section V

Employee Assistance Program Section VI

Benergy Section VII

Forms Section VIII

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Section I

Health Plan

This section includes information about

about the Power Costs, Inc. health plan option:

Benefit Summary

Premium Cost

Eligibility and Requirements

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The employer’s Health Plan provides comprehensive coverage for full-time employees and their eligible dependents. The cost of the coverage is shared between the employer and the employee. Employee contributions are made on a pre-tax basis.

Who is eligible? Full-time employees working 32 or more hours per week are eligible. Dependent children are eligible to the end of the month they turn 26.

When can participation begin? First of the month following date of hire.

What is the cost for the coverage?

How can I find a provider ? Please visit the UnitedHealthcare website for the provider directory. The website is located at www.myuhc.com. You will need to select Unitedhealthcare Choice Plus as the plan and follow the prompts to verify if your provider is in network. Under this plan you have a choice to access any provider, but if you see a provider in your network you will have the lowest out-of-pocket expenses. You may also access your health claims through the UnitedHealthcare website.

Health Plan UnitedHealthcare

Coverage Per Pay Period Costs to Employee

Employee Only $71.56

Employee Plus Spouse $463.55

Employee Plus Children $283.42

Employee Plus Family $664.76

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http://www.myuhc.com/

Health Plan Highlights:

Please see the Health Plan Benefit Summary on the next page for more information about this Plan

Health Plan Cont.

UnitedHealthcare

General Provisions In-Network Benefits Out-of-Network Benefits

Deductible $5,000 Individual *

$15,000 Family

*refer to reimbursement

information on next page.

$10,000 Individual *

$30,000 Family

*refer to reimbursement

information on next page.

Out-of-Pocket Maximum $5,000 plus deductible per

Individual

$15,000 plus deductible per

Family for most in-network

services.


Individual


Family for most out-of-network

services.

Lifetime Benefit

Maximum

Unlimited Unlimited

Physician’s Office Visits /

Specialist’s Office Visits

$30 co-payment for most

physician’s office visits using a

UnitedHealthcare Doctor.

$60 co-payment for most

specialist’s office visits using a

UnitedHealthcare Doctor.

Plan pays 50% of allowable

amount after deductible for

out-of-network Physician’s

office visits and Specialist’s

office visits.

Inpatient Hospital Plan pays 80% of allowable

amount after deductible for in-

network services.


amount after deductible for

out-of-network services.

Outpatient Hospital Plan pays 80% of allowable

amount after deductible for in-

network services.


amounts after deductible for

out-of-network services.

Prescription Drug

Coverage

Tier 1 / Specialty: $15 Copay / $15 Copay

Tier 2 / Specialty: $35 Copay / 20% Copay

Tier 3 / Specialty: $60 Copay / 25% Copay

Individual Out-of Pocket Max $3,000

Family Out-of-Pocket Max $9,000

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5,000.00$ Actual Annual UHC Deductible 5,000.00$ Actual Annual UHC Deductible

3,100.00$ Amount of Charges on EOB for

In-Network Services

3,100.00$ Amount of Charges on EOB for

Out-of-Network Services

1,500.00$ Insured's Deductible 1,500.00$ Insured's Deductible

1,600.00$ Amount Over Insured's $1,500

Deductible

1,600.00$ Amount Over Insured's $1,500

Deductible

X 80% 80% Coinsurance X 60% 60% Coinsurance

$1,280.00 Reimbursement to Insured for this

Claim

$960.00 Reimbursement to Insured for this

Claim

$320.00 is the 20% Co-insurance the Insured

is responsible for on this claim

$640.00 is the 40% Co-insurance the Insured

is responsible for on this claim

Power Costs, Inc.

Deductible Reimbursement Program IllustrationA Deductible Reimbursement Program is a way for your employer to share in the cost of your

deductible while helping you keep your premium costs low.

The insured will cover the first $1,500 of charges of the $5,000 annual deductible on the

Medical Plan. Once this amount has been met, the insured will send the Deductible

Reimbursement Form and a copy of the Explanation of Benefits (EOB) from United

HealthCare to Caba each time an expense is incurred that will apply to the annual

deductible from $1,501 to $5,000. If the charges are eligible, Caba will process the

reimbursement at 80% for services provided by an In-Network Provider or 60% if the services

are provided by an Out-Of-Network Provider.

Example 1

In-Network Provider

Example 2

Out-of-Network Provider

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POWER COSTS, INC. DEDUCTIBLE REIMBURSEMENT FORM

Effective January 1, 2012 the insured will cover the first $1,500 of charges of the $5,000

annual deductible on the Medical Plan. Once the insured has $1,500 in charges applied

to their annual deductible, the insured will complete a Deductible Reimbursement Form

and submit the form to Caba along with copies of all of their Explanation of Benefits

(EOBs) from United Healthcare showing charges being applied to their deductible. If the

charges are eligible, Caba will process the reimbursement at 80% for services provided by

an In-Network Provider or 50% if the services are provided by an Out-Of-Network Provider.

The maximum reimbursement amount is $2,800 per insured.

Please Print:

Employee Name:

Employee Social Security Number:

Employee Date of Birth:

Phone Number: (In case we need to contact you)

Employee Mailing Address:

If reimbursement is not for the Employee, please also include:

Dependent Name:

Dependent Social Security Number:

Dependent Date of Birth:

Caba, Inc. Mailing Address:

2601 N. W. Expressway, Suite 1000W

Oklahoma City, OK 73112

Fax Number:

405-858-7343

Toll Free Telephone Number:

1-888-840-8924

Section II

Dental Plan


About the Power Costs, Inc. dental plan option:

Benefit Summary

Premium Cost


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The employer’s Dental Plan covers preventive, basic and major services for full-time employees and their eligible dependents. The cost of the coverage is shared between the employer and the employee. Employee contributions are made on a pre-tax basis.

Who is eligible? Full-time employees working 32 or more hours per week are eligible. Dependent children are eligible to age 19 (or age 23 if a full-time student). Dependent children are covered until the first of the month following their 19th birthday unless they are a full-time student and then they are covered until the first of the month following their 23rd birthday.


What is the cost for the coverage?

How can I find a provider ? Please visit the SunLife Dental Financial website for the provider directory. The website is located at www.sunlifedentalbenefits.com. Under this plan you have a

choice to access any provider, but if you see a provider in your network you will have the lowest out-of-pocket expenses. SunLife Financial also offers online access to your dental claim information through login access from their website.

Dental Plan

Sun Life Financial

Coverage Per Pay Period Costs to Employee

Employee $6.99

Employee Plus Spouse $37.28

Employee Plus Children $28.58

Employee Plus Family $70.83

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http://www.sunlifedentalbenefits.com/

Dental Plan Highlights:

Please see the Dental Plan Benefit Summary on the next page for more information about this Plan

Dental Plan Cont.

SunLife Financial

General Provisions In-Network Benefits Out-of-Network Benefits

Benefit Year Deductible $50 individual/$150 Family $50 individual/$150 Family

Preventive Services The deductible is waived for

preventive services

Plan pays 100%

Play pays 100% of Usual & Customary Charges - can be balance billed for costs above Usual & Customary

Basic Services Plan pays 80% after deductible

Plan pays 80% of Usual & Customary charges after deductible - can be balance billed for costs above Usual & Customary

Major Services Plan pays 50% after deductible

Plan pays 50% of Usual & Customary charges after deductible – can be balance billed for costs above Usual & Customary

Benefit Year Maximum The maximum benefit payable for preventive, basic and major dental services rendered to an eligible person during the benefit year shall be $1,500. The maximum is combined for in- and out-of-network services.

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Section III

Supplemental Life and AD&D


about Power Costs, Inc. supplemental life and AD&D option:

Benefit Summary

Premium Cost


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Eligible employees have the option to purchase supplemental Life and Accidental Death and Dismemberment Insurance coverage for themselves and their eligible dependents.

Who is eligible? Full-time employees working 32 or more hours per week are eligible. The eligible employee’s spouse and dependent children are also eligible.


What is the cost for the coverage? Please see the rate table following the Voluntary Life and AD&D Insurance Benefit Summary.

Voluntary Life and AD&D Plan Highlights:

Please see the Voluntary Life and AD&D Insurance Benefit Summary on the next page for more information about this plan.

Supplemental Life and

AD&D Insurance Mutual of Omaha

General Provisions Benefits

Voluntary Employee Life Insurance Voluntary employee life insurance is available in

increments of $10,000. The minimum amount an

employee can purchase is $10,000. The maximum

amount an employee can purchase is 5 times the

employee’s annual salary up to $300,000.

The Guaranteed Issue Amount is 5 times the

employee’s annual salary up to $100,000.

Voluntary Spouse Life Insurance Voluntary spouse coverage is available in increments

of $5,000. The minimum amount is $5,000. The

maximum amount is 50% of the employee’s benefit

up to $50,000.

The Guaranteed Issue Amount is 100% of the

employee’s benefit up to $30,000.

Voluntary Child(ren) Life Insurance Voluntary child(ren) coverage is available in

increments of $2,000. The minimum amount is $2,000.

The maximum amount is 50% of the employee’s

benefit up to $10,000.

The Guaranteed Issue amount is 50% of employee’s

benefit, up to $10,000.

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Section IV

Disability Insurance


about Power Costs, Inc. disability insurance offering:

Benefit Summary

Premium Cost


37

The employer’s Short Term Disability (STD) Plan provides full-time employees with a weekly income if they are disabled due to illness, injury or pregnancy.

Who is eligible? Full-time employees working 32 or more hours per week are eligible.


What is the cost for the coverage? The cost of this coverage is paid by the employer.

Short Term Disability Plan Highlights:

Please see the Short Term Disability Benefit Summary on the next page for more information about this plan.

Short Term Disability

Insurance Mutual of Omaha


Elimination Period If you become disabled, there is an elimination period before

benefits are payable.

Your benefits begin:

-On the 15th day of your disabling illness or injury.

Weekly Benefit -Your benefit would be equivalent to 60% of your before-tax

weekly earnings, not to exceed the plan’s maximum weekly

benefit amount, less other income sources.

Maximum Weekly Benefit $2000.00

Maximum Benefit Period Short Term Disability benefits are available for up to 11 weeks.

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The employer’s Long Term Disability (LTD) Plan is designed to replace a portion of your income should you become disabled due to illness or injury.



What is the cost for the coverage? The cost of this coverage is paid by the employer.

Long Term Disability Plan Highlights:

Please see the Long Term Disability Benefit Summary on the next page for more information about this plan.

Long Term Disability

Insurance Mutual of Omaha


Elimination Period If you become disabled, there is an elimination period before benefits are payable. Your benefits begin 90 days after the onset of your disabling illness or injury.

Monthly Benefit Your benefit is equivalent to 60% of your before-tax monthly earnings, not to exceed the plan’s maximum monthly benefit amount, less other income sources.

Maximum Benefit Period If you become disabled prior to age 62, benefits are payable to age 65 or your Social Security Normal Retirement Age. At age 62 (and older), the benefit period will be based on a reduced duration schedule.

Maximum Monthly Benefit

$7,500

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Section V

Flexible Benefit Plan


about the Power Costs, Inc. flexible benefit plan:

Benefit Summary

Please refer to separate hand out for more details.

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The Flexible Benefits Plan allows you the opportunity to enhance your present benefit package. The Plan allows you, through the use of current tax laws, to use tax-free dollars to help cover eligible payroll deducted insurance premiums, costs of certain health care expenses such as deductibles and co-insurance and dependent care expenses. In effect you can save from 25% to 35% on the dollars you pay for these services because they come out of your pay before Federal, State and Social Security (FICA) taxes are deducted.

Participation in the Flexible Benefits Plan will effectively provide you the

opportunity to increase your take home pay.


When can participation begin? First of the month following date of hire of employment.

What is the cost for participation in the Plan? The cost of this Plan is paid by the employer.

Your Flexible Benefit Plan allows for participation in the Pre-Tax Premiums, Medical Reimbursement Account and Dependent Care Reimbursement Account. Reimbursement account participants will receive a Visa debit card so they may pay for services at the point the service was provided rather than having to wait for reimbursement.

The maximum for Dependent Care is $5,000 and Medical Reimbursement is $3,000 per year.

See the Flexible Benefit Plan packet attached to this presentation for more information.

Flexible Benefit Plan

Caba, Inc.

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Section VI

Employee Assistance Services

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Employee Assistance Program Mutual of Omaha

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You will receive 5 visits with this service

5 visits with this service

Section VII

Benergy

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Section VIII

Forms This section includes all forms necessary to enroll in the Power Costs, Inc. benefit plans. Please

make sure to return your forms to your Human Resources Department to ensure enrollment.

For questions on specific forms or about your benefits, please contact Rebecca Perot-Tripp at 405.801.3481

To make changes to existing coverage, or start new coverage on medical or dental plans:

Use Group Enrollment Application – UnitedHealthcare

Use Eligibility / Enrollment – SunLife Financial

To enroll in supplemental life insurance or to change beneficiary:

Use Group Enrollment Form – Mutual Of Omaha

If you were eligible prior to 1/1/2012, you will need to complete an Evidence of Insurability form as well. If this is your first opportunity to enroll, and you are applying for more than $100,000 for yourself or $30,000 for spouse, use Evidence of Insurability form – Mutual of Omaha as well as the enrollment form.

To turn in claims for the Benny card or a manual claim for medical or dependent care:

Use the Benny Card Submittal of Receipts – Benny Card reimbursement

Caba Flexible Spending Form – manual claims and dependent care.

*Authorization for Direct Deposit Form – to allow Caba to direct deposit your reimbursements. * (Please make sure that you turn in a new form should your banking information change)

To submit a claim for the Deductible Reimbursement:

Use the Power Costs, Inc. Deductible Reimbursement Form from Caba.

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POWER COSTS, INC. DEDUCTIBLE REIMBURSEMENT FORM

Effective January 1, 2012 the insured will cover the first $1,500 of charges of the $5,000

annual deductible on the Medical Plan. Once the insured has $1,500 in charges applied

to their annual deductible, the insured will complete a Deductible Reimbursement Form

and submit the form to Caba along with copies of all of their Explanation of Benefits

(EOBs) from United Healthcare showing charges being applied to their deductible. If the

charges are eligible, Caba will process the reimbursement at 80% for services provided by

an In-Network Provider or 50% if the services are provided by an Out-Of-Network Provider.

The maximum reimbursement amount is $2,800 per insured.

Please Print:

Employee Name:

Employee Social Security Number:

Employee Date of Birth:

Phone Number: (In case we need to contact you)

Employee Mailing Address:

If reimbursement is not for the Employee, please also include:

Dependent Name:

Dependent Social Security Number:

Dependent Date of Birth:

Caba, Inc. Mailing Address:

2601 N. W. Expressway, Suite 1000W

Oklahoma City, OK 73112

Fax Number:

405-858-7343

Toll Free Telephone Number:

1-888-840-8924

power costs, inc. benefit guide

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