Benefit Summary and Usage Report.pdf

Dental Plan

New Standard/5P676/U90

Annual Deductible Applies to Orthodontic Services Orthodontic Eligibility Requirement CMM-Annual Roll-Over

50% 50%

100% 100%

50% 50%

50% 50%

50% 50%

50% 50%

50% 50%

Split Class Split Class See Exclusions and Limitations section for benefit guidelines.

80% 80%

Split Class Split Class

80% 80%

80% 80%

80% 80%

80% 80%

80% 80%

80% 80%

80% 80%

80% 80%

80% 80%

Split Class Split Class See Exclusions and Limitations section for benefit guidelines.

100% 100%

Split Class Split Class

100%

100% 100% See Exclusions and Limitations section for benefit guidelines.

100% 100%

See Exclusions and Limitations section for benefit guidelines.

Split Class Split Class

100% 100%

100%

Yes

NETWORK PLAN PAYS**

NON-NETWORK PLAN

PAYS***

BENEFIT GUIDELINES

None

No (In Network) No (Out Network)

No

Adult & Child

Annual deductible applies to preventive and diagnostic services

$0 $0

$1,250 per person per Calendar Year

$1,250 per person per Calendar Year

$1,000 per person per Lifetime

$1,000 per person per Lifetime

NON-ORTHODONTICS ORTHODONTICS

NETWORK NON-NETWORK NETWORK NON-NETWORK

$50 $50

Diagnose or correct misalignment of the teeth or bite

# This plan includes a roll-over maximum benefit. Some of the unused portion of your annual maximum may be available in future periods.

* Your dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement on the least costly treatment alternative. If you and your dentist agreed on a treatment which is more costly than the treatment on which the plan benefit is based, you will be responsible for the difference between the fee for service rendered and the fee covered by the plan. In addition, a pre-treatment estimate is recommended for any service estimated to cost over $500; please consult your dentist.

**The network percentage of benefits is based on the discounted fees negotiated with the provider.

***The non-network percentage of benefits is based on the usual and customary fees in the geographic areas in which the expenses are incurred.

Veneers are only covered when a filling cannot restore a tooth. For a complete description and coverage levels for Veneers, please refer to your Certificate of Coverage. Cone Beams are limited to combined captured and interpretation treatment codes only. For a complete description and coverage levels for Cone Beams, please refer to your Certificate of Coverage.In accordance with the Illinois state requirement, a partner in a Civil Union is included in the definition of Dependent. For a complete description of Dependent Coverage, please refer to your Certificate of Coverage.

The Prenatal Dental Care (not available in WA) and Oral Cancer Screening programs are covered under this plan.

The material contained in the above table is for informational purposes only and is not an offer of coverage. Please note that the above table provides only a brief, general description of coverage and does not constitute a contract. For a complete listing of your coverage, including exclusions and limitations relating to your coverage, please refer to your Certificate of Coverage or contact your benefits administrator. If differences exist between this Summary of Benefits and your Certificate of Coverage/benefits administrator, the certificate/benefits administrator will govern. All terms and conditions of coverage are subject to applicable state and federal laws. State mandates regarding benefit levels and age limitations may supersede plan design features.

Inlays/Onlays/Crowns

Dentures and Removable Prosthetics

Fixed Partial Dentures (Bridges)

Implants

ORTHODONTIC SERVICES

Periodontics - Surgical

Periodontics

MAJOR SERVICES

Periodontics - Non-Surgical

Endodontics

Oral Surgery (incl. surgical extractions)

Periodontics

Emergency Treatment/General Services

Simple Extractions

XRays - Other

Restorations (Amalgams or Composite)

Sealants

Space Maintainers

BASIC SERVICES

Radiographs

Periodontics

Periodontics - Maintenance

Prophylaxis (Cleaning)

Fluoride Treatment (Preventive)

Radiographs

XRays - Bitewing

Lab and Other Diagnostic Tests

PREVENTIVE SERVICES

DIAGNOSTIC SERVICES

Periodic Oral Evaluation 100% 100%

Individual Annual Deductible

Family Annual Deductible

Maximum (the sum of all Network and Non-Network benefits will not exceed Annual maximum)

New enrollee's waiting period

COVERED SERVICES *

$0 $0

$100 $100

UnitedHealthcare Insurance Company (30100)® Voluntary Options PPO 30 / covered dental services

UnitedHealthcare/Dental Exclusions and Limitations Dental Services described in this section are covered when such services are:

A. Necessary;

B. Provided by or under the direction of a Dentist or other appropriate provider as specifically described;

C. The least costly, clinically accepted treatment, and D. Not excluded as described in the Section entitled. General Exclusions.

GENERAL LIMITATIONS

OSSEOUS GRAFTS Limited to 1 per quadrant or site per consecutive 36 months.

PERIODONTAL SURGERY Hard tissue and soft tissue periodontal surgery are limited to 1 quadrant or site per consecutive 36 months per surgical area.

REPLACEMENT OF COMPLETE DENTURES, FIXED OR REMOVABLE PARTIAL DENTURES, CROWNS, INLAYS OR ONLAYS Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances.

CONE BEAM Limited to 1 time per consecutive 60 months.

RELINING AND REBASING DENTURES Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 12 months.

REPAIRS TO FULL DENTURES, PARTIAL DENTURES, BRIDGES Limited to repairs or adjustments performed more than 12 months after the initial insertion.

Limited to 1 per consecutive 6 months.

PALLIATIVE TREATMENT Covered as a separate benefit only if no other service, other than the exam and radiographs, were performed on the same tooth during the visit.

OCCLUSAL GUARDS Limited to 1 guard every consecutive 36 months and only covered if prescribed to control habitual grinding.

FULL MOUTH DEBRIDEMENT Limited to 1 time every consecutive 36 months.

GENERAL ANESTHESIA Covered only when clinically necessary.

SEDATIVE FILLINGS Covered as a separate benefit only if no other service, other than x-rays and exam, were performed on the same tooth during the visit.

SCALING AND ROOT PLANING Limited to 1 time per quadrant per consecutive 24 months.

ROOT CANAL THERAPY Limited to 1 time per tooth per lifetime.

PERIODONTAL MAINTENANCE Limited to 2 times per consecutive 12 months following active or adjunctive periodontal therapy, exclusive of gross debridement.

FULL DENTURES Limited to 1 time every consecutive 60 months. No additional allowances for precision or semi-precision attachments.

PARTIAL DENTURES Limited to 1 time every consecutive 60 months. No additional allowances for precision or semi-precision attachments.

SEALANTS Limited to covered persons under the age of 16 years, and once per first or second permanent molar every consecutive 36 months.

RESTORATIONS (Amalgam or Composite) Multiple restorations on one surface will be treated as a single filling.

PIN RETENTION Limited to 2 pins per tooth; not covered in addition to cast restoration.

INLAYS, ONLAYS, AND VENEERS Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.

CROWNS Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.

POST AND CORES Covered only for teeth that have had root canal therapy.

COMPLETE SERIES OR PANOREX RADIOGRAPHS Limited to 1 time per consecutive 36 months.

BITEWING RADIOGRAPHS Limited to 1 series of films per calendar year.

EXTRAORAL RADIOGRAPHS Limited to 2 films per calendar year.

DENTAL PROPHYLAXIS Limited to 2 times per calendar year..

FLUORIDE TREATMENTS Limited to covered persons under the age of 16 years, and limited to 2 times per consecutive 12 months.

SPACE MAINTAINERS Limited to covered persons under the age of 16 years, limited to 1 per consecutive 60 months. Benefit includes all adjustments within 6 months of installation.

PERIODIC ORAL EVALUATION Limited to 2 times per consecutive 12 months.

42642172-05 - 9/28/2021

GENERAL EXCLUSIONS

The following are not covered:

Dental Services otherwise Covered under the Policy, but rendered after the date individual Coverage under the Policy terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Policy terminates.

Acupuncture; acupressure and other forms of alternative treatment, whether or not used as anesthesia.

Orthodontic service Coverage does not include the installation of a space maintainer, any treatment related to treatment of the temporomandibular joint, or a surgical procedure to correct a malocclusion, replacement of retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances previously submitted for payment under the plan.

Foreign Services are not Covered unless required as an Emergency.

Dental Services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country.

by any municipality, county, or other political subdivision. Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.

Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.

Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.

Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).

Occlusal guards used as safety items or to affect performance primarily in sports-related activities.

Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.

Services rendered by a provider with the same legal residence as a Covered Person or who is a member of a Covered Person's family, including spouse, brother, sister, parent or child. This exclusion does not apply for groups sitused in the state of Arizona, in order to comply with state regulations.

Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.

Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision.

Replacement of complete dentures, fixed and removable partial dentures or crowns if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement.

Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.

Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.

Expenses for Dental Procedures begun prior to the Covered Person becoming enrolled under the Policy.

Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)

Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, injury, or Congenital Anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body.

Any Dental Procedure not directly associated with dental disease.

Any Dental Procedure not performed in a dental setting.

Procedures that are considered to be Experimental, Investigational or Unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition.

Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.

Dental Services that are not Necessary.

Hospitalization or other facility charges.

New Standard/5P675/MAC

Annual Deductible Applies to Orthodontic Services Orthodontic Eligibility Requirement CMM-Annual Roll-Over

50% 50%

100% 100%

50% 50%

50% 50%

50% 50%

50% 50%

50% 50%

Split Class Split Class See Exclusions and Limitations section for benefit guidelines.

80% 80%

Split Class Split Class

80% 80%

80% 80%

80% 80%

80% 80%

80% 80%

80% 80%

80% 80%

80% 80%

80% 80%

Split Class Split Class See Exclusions and Limitations section for benefit guidelines.

100% 100%

Split Class Split Class

100%

100% 100% See Exclusions and Limitations section for benefit guidelines.

100% 100%

See Exclusions and Limitations section for benefit guidelines.

Split Class Split Class

100% 100%

100%

Yes

NETWORK PLAN PAYS**

NON-NETWORK PLAN

PAYS***

BENEFIT GUIDELINES

None

No (In Network) No (Out Network)

No

Adult & Child

Annual deductible applies to preventive and diagnostic services

$0 $0

$1,000 per person per Calendar Year

$1,000 per person per Calendar Year

$1,000 per person per Lifetime

$1,000 per person per Lifetime

NON-ORTHODONTICS ORTHODONTICS

NETWORK NON-NETWORK NETWORK NON-NETWORK

$50 $50

The Prenatal Dental Care (not available in WA) and Oral Cancer Screening programs are covered under this plan.

The material contained in the above table is for informational purposes only and is not an offer of coverage. Please note that the above table provides only a brief, general description of coverage and does not constitute a contract. For a complete listing of your coverage, including exclusions and limitations relating to your coverage, please refer to your Certificate of Coverage or contact your benefits administrator. If differences exist between this Summary of Benefits and your Certificate of Coverage/benefits administrator, the certificate/benefits administrator will govern. All terms and conditions of coverage are subject to applicable state and federal laws. State mandates regarding benefit levels and age limitations may supersede plan design features.

* Your dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement on the least costly treatment alternative. If you and your dentist agreed on a treatment which is more costly than the treatment on which the plan benefit is based, you will be responsible for the difference between the fee for service rendered and the fee covered by the plan. In addition, a pre-treatment estimate is recommended for any service estimated to cost over $500; please consult your dentist.

**The network percentage of benefits is based on the discounted fees negotiated with the provider.

***The non-network percentage of benefits is based on the allowable amount applicable for the same service that would have been rendered by a network provider. For a complete list of amounts, please refer to your Certificate of Coverage.

Veneers are only covered when a filling cannot restore a tooth. For a complete description and coverage levels for Veneers, please refer to your Certificate of Coverage.

Cone Beams are limited to combined captured and interpretation treatment codes only. For a complete description and coverage levels for Cone Beams, please refer to your Certificate of Coverage.

In accordance with the Illinois state requirement, a partner in a Civil Union is included in the definition of Dependent. For a complete description of Dependent Coverage, please refer to your Certificate of Coverage.

Diagnose or correct misalignment of the teeth or bite

# This plan includes a roll-over maximum benefit. Some of the unused portion of your annual maximum may be available in future periods.

Inlays/Onlays/Crowns

Dentures and Removable Prosthetics

Fixed Partial Dentures (Bridges)

Implants

ORTHODONTIC SERVICES

Periodontics - Surgical

Periodontics

MAJOR SERVICES

Periodontics - Non-Surgical

Endodontics

Oral Surgery (incl. surgical extractions)

Periodontics

Emergency Treatment/General Services

Simple Extractions

XRays - Other

Restorations (Amalgams or Composite)

Sealants

Space Maintainers

BASIC SERVICES

Radiographs

Periodontics

Periodontics - Maintenance

Prophylaxis (Cleaning)

Fluoride Treatment (Preventive)

Radiographs

XRays - Bitewing

Lab and Other Diagnostic Tests

PREVENTIVE SERVICES

DIAGNOSTIC SERVICES

Periodic Oral Evaluation 100% 100%

Individual Annual Deductible

Family Annual Deductible

Maximum (the sum of all Network and Non-Network benefits will not exceed Annual maximum)

New enrollee's waiting period

COVERED SERVICES *

$0 $0

$100 $100

UnitedHealthcare Insurance Company (30100)® Voluntary Options PPO 20 / covered dental services

A. Necessary;

B. Provided by or under the direction of a Dentist or other appropriate provider as specifically described;

C. The least costly, clinically accepted treatment, and D. Not excluded as described in the Section entitled. General Exclusions.

GENERAL LIMITATIONS

OSSEOUS GRAFTS Limited to 1 per quadrant or site per consecutive 36 months.

PERIODONTAL SURGERY Hard tissue and soft tissue periodontal surgery are limited to 1 quadrant or site per consecutive 36 months per surgical area.

REPLACEMENT OF COMPLETE DENTURES, FIXED OR REMOVABLE PARTIAL DENTURES, CROWNS, INLAYS OR ONLAYS Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances.

CONE BEAM Limited to 1 time per consecutive 60 months.

RELINING AND REBASING DENTURES Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 12 months.

REPAIRS TO FULL DENTURES, PARTIAL DENTURES, BRIDGES Limited to repairs or adjustments performed more than 12 months after the initial insertion.

Limited to 1 per consecutive 6 months.

PALLIATIVE TREATMENT Covered as a separate benefit only if no other service, other than the exam and radiographs, were performed on the same tooth during the visit.

OCCLUSAL GUARDS Limited to 1 guard every consecutive 36 months and only covered if prescribed to control habitual grinding.

FULL MOUTH DEBRIDEMENT Limited to 1 time every consecutive 36 months.

GENERAL ANESTHESIA Covered only when clinically necessary.

SEDATIVE FILLINGS Covered as a separate benefit only if no other service, other than x-rays and exam, were performed on the same tooth during the visit.

SCALING AND ROOT PLANING Limited to 1 time per quadrant per consecutive 24 months.

ROOT CANAL THERAPY Limited to 1 time per tooth per lifetime.

PERIODONTAL MAINTENANCE Limited to 2 times per consecutive 12 months following active or adjunctive periodontal therapy, exclusive of gross debridement.

FULL DENTURES Limited to 1 time every consecutive 60 months. No additional allowances for precision or semi-precision attachments.

PARTIAL DENTURES Limited to 1 time every consecutive 60 months. No additional allowances for precision or semi-precision attachments.

SEALANTS Limited to covered persons under the age of 16 years, and once per first or second permanent molar every consecutive 36 months.

RESTORATIONS (Amalgam or Composite) Multiple restorations on one surface will be treated as a single filling.

PIN RETENTION Limited to 2 pins per tooth; not covered in addition to cast restoration.

INLAYS, ONLAYS, AND VENEERS Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.

CROWNS Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.

POST AND CORES Covered only for teeth that have had root canal therapy.

COMPLETE SERIES OR PANOREX RADIOGRAPHS Limited to 1 time per consecutive 36 months.

BITEWING RADIOGRAPHS Limited to 1 series of films per calendar year.

EXTRAORAL RADIOGRAPHS Limited to 2 films per calendar year.

DENTAL PROPHYLAXIS Limited to 2 times per calendar year.

FLUORIDE TREATMENTS Limited to covered persons under the age of 16 years, and limited to 2 times per consecutive 12 months.

SPACE MAINTAINERS Limited to covered persons under the age of 16 years, limited to 1 per consecutive 60 months. Benefit includes all adjustments within 6 months of installation.

Dental Services otherwise Covered under the Policy, but rendered after the date individual Coverage under the Policy terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Policy terminates.

Acupuncture; acupressure and other forms of alternative treatment, whether or not used as anesthesia.

Orthodontic service Coverage does not include the installation of a space maintainer, any treatment related to treatment of the temporomandibular joint, or a surgical procedure to correct a malocclusion, replacement of retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances previously submitted for payment under the plan.

Foreign Services are not Covered unless required as an Emergency.

Dental Services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country.

by any municipality, county, or other political subdivision. Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.

Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.

Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.

Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).

Occlusal guards used as safety items or to affect performance primarily in sports-related activities.

Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.

Services rendered by a provider with the same legal residence as a Covered Person or who is a member of a Covered Person's family, including spouse, brother, sister, parent or child. This exclusion does not apply for groups sitused in the state of Arizona, in order to comply with state regulations.

Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.

Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision.

Replacement of complete dentures, fixed and removable partial dentures or crowns if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement.

Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.

Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.

Expenses for Dental Procedures begun prior to the Covered Person becoming enrolled under the Policy.

Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)

Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, injury, or Congenital Anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body.

Any Dental Procedure not directly associated with dental disease.

Any Dental Procedure not performed in a dental setting.

Procedures that are considered to be Experimental, Investigational or Unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition.

Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.

Dental Services that are not Necessary.

Santa Rosa County School Board (FL)

Summary of Benefits: Short-Term Disability Plan Effective Date: 01/01/2023

Help prepare for the unexpected with income protection through UnitedHealthcare.

Your ability to earn an income is your biggest asset. Short-Term Disability Insurance pays you a benefit while you are temporarily unable to work due to a sickness or injury. It provides income protection so you can focus on your health rather than worrying about paying your bills and expenses.

Your Short-Term Disability plan highlights:

Eligibility: All Active Full Time Employees working a minimum of 18.75 Hours per week.

Coverage amount is a percentage of your weekly earnings just prior to becoming disabled.

60.00% of your weekly earnings to a maximum of $1,500 per week.

Maximum Benefit Period is the total length of time you can receive disability benefits under this plan; provided you continue to meet the definition of disability as defined by your policy.

11 weeks of benefits

Benefits begin after you complete the Elimination Period.

This is a period of time you must be disabled before benefits are payable. This timeframe may be the same or different for accident and for sickness.

Short Term Disability Insurance benefit begins on day 15 after your accident or on day 15 of sickness.

Pre-Existing Condition is a disease or physical condition for which treatment has been received within a defined period of time immediately prior to becoming covered under the plan.

If your plan includes a Pre-Existing Condition provision it is displayed as two time periods. (e.g. 3/12)

• Look Back Period: Number of months prior to the effective date where we look for received treatment or a diagnosis by a physician.

• Exclusion Period: Number of months following the effective date where if you become disabled due to a pre-existing condition, then benefits for the disability are excluded.

Look Back period: 3 months

Exclusion period: 12 months

Lump Sum Survivor Benefit is an additional benefit payable to your family if you die while you are disabled and receiving benefits under this plan.

3 weeks of the gross disability payment not to exceed $3,000

Minimum Weekly Benefit is the minimum weekly benefit amount payable for a qualifying disability, regardless of other sources of income.

$25

The benefit summary is an overview of your insurance. Once a group policy is issued to your employer, a certificate of coverage will be available to explain your benefits in detail.

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Evidence of Insurability Requirements EOI No Longer Required during Annual Enrollment Period

Plan Effective Date: 01/01/2023

Frequently Asked Questions about your Short-Term Disability

Am I eligible for coverage? You are eligible if you are working a minimum of

18.75 Hours per week and considered benefit

eligible by your employer.

Who pays for my coverage? Your employer has made this coverage available to all eligible employees on a voluntary basis which means you pay your premiums if you elect the coverage.

When can I enroll in coverage? If you are required to contribute to your coverage you may enroll during your open enrollment period which is defined by your employer.

You have 31 days from the date you become eligible for the coverage to enroll. Contact your company HR representative to confirm.

What does it mean to be Disabled under this Short-Term Disability plan?

You are considered Disabled or have a Disability when we determine that you are:

· not Actively at Work and you are unable to perform some or all of the Material and Substantial Duties of your regular job due to a Sickness or Injury; and

· you have a loss in your weekly earnings (20% or more) due to your Sickness or Injury; and

· you are under the Regular Care of a Physician

Can I keep my Short-Term Disability coverage if I leave my employer?

No, your Short-Term Disability coverage is not portable. You cannot take the coverage with you if you leave your employer.

Does my coverage reduce as I get older? No, your Short-Term Disability benefits are calculated based on a portion of your earnings not your age.

When does my coverage go into effect? You must be Actively at Work with your employer on the date your coverage is scheduled to take effect.

Otherwise, your coverage takes effect when you return to Active Work.

Other Important Details:

The benefit summary is an overview of your insurance. Once a group policy is issued to your employer, a certificate of coverage will be available to explain your benefits in detail.

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Plan Effective Date: 01/01/2023

This Summary of Benefits sheet is an overview of the coverage being offered and is provided for illustrative purposes only. This is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the Summary of Benefits sheet and the insurance policy, the terms of the insurance policy apply.

If you need to file a claim:

· Notify your employer of your absence from work.

· Complete, sign and date the necessary forms.

· Send the completed forms via fax or mail to the contact details listed on the claim form. You may also email the completed forms to our unsecured email address fpcustomersupport@uhc.com®

Exclusions:

You cannot receive Short-Term Disability Insurance benefit payments for disabilities that are caused or contributed by:

• War or act of war (declared or not)

• The commission of, or attempt to commit a felony

• An intentionally self-inflicted injury

• Any case where your being engaged in an illegal occupation was a contributing cause to your disability

• Sickness or injury which Workers' Compensation benefits are paid, or may be paid, if duly claimed

• Any injury sustained as a result of doing work for pay or profit for another employer

*You must be under the regular care of a physician to receive benefits.

Your benefit payments will be reduced by other income you receive or are eligible to receive due to your disability, including but not limited to:

• Social Security Disability Insurance

• Workers' Compensation

• Other employer-based insurance coverage you may have

• Unemployment benefits

• Settlements or judgments for income loss

• Retirement benefits that your employer fully or partially pays for (such as pension plan)

• Employer's sick leave or salary continuation plan

• Loss of time or lost wages from no-fault motor vehicle insurance plan

*Some state variations may apply

Short-Term Disability Cost Summary (Current Monthly Rates)

Who is eligible for coverage? All Active Full Time Employees working a minimum of 18.75 Hours per week.

Coverage Type: Voluntary Age-banded per $10 of Total Covered Weekly Benefit

The benefit summary is an overview of your insurance. Once a group policy is issued to your employer, a certificate of coverage will be available to explain your

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Plan Effective Date: 01/01/2023

Age Range Rate

Age less than 25

Ages 25-29

Ages 30-34

Ages 35-39

Ages 40-44

Ages 45-49

Ages 50-54

Ages 55-59

Ages 60-64

Ages 65 +

$0.587

$0.632

$0.547

$0.464

$0.433

$0.393

$0.467

$0.523

$0.583

$0.714

Premium Calculation Example:

Voluntary Short-Term Disability

Annual Earnings

Weekly Earnings

/ = X

Benefit %

Weekly Covered Benefit

Weekly Covered Benefit Rate

X =

Subtotal

Cost Per Month

/ 10

To calculate the cost of coverage, use the formula below:

UnitedHealthcare Life and Disability products are provided by UnitedHealthcare Insurance Company and certain products in California by Unimerica Life Insurance Company. Life and Disability products are provided on policy forms LASD-POL (05/03) et al. and UHCLD-POL 2/2008 et al., in Texas on forms LASD-POL-TX (05/03) and UHCLD-POL 2/2008-TX and in Virginia on LASD-POL (05/03) and UHCLD-POL 2/2008. The policies have exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company.

Some products are not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT and Unimerica Life Insurance Company is located in Milwaukee, WI.

The benefit summary is an overview of your insurance. Once a group policy is issued to your employer, a certificate of coverage will be available to explain your

NCA-18; v3.0 Page 4 of 4 0011400001wWveBAAS (STDF4364) 50002343-2-1

SANTA ROSA COUNTY SCHOOL BOARD

VOLUNTARY LTD

BENEFIT

UNITS

UP TO 25 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60+

$100 $0.120 $0.120 $0.168 $0.240 $0.336 $0.612 $0.810 $1.128 $0.912

$200 $0.240 $0.240 $0.336 $0.480 $0.672 $1.224 $1.620 $2.256 $1.824

$300 $0.360 $0.360 $0.504 $0.720 $1.008 $1.836 $2.430 $3.384 $2.736

$400 $0.480 $0.480 $0.672 $0.960 $1.344 $2.448 $3.240 $4.512 $3.648

$500 $0.600 $0.600 $0.840 $1.200 $1.680 $3.060 $4.050 $5.640 $4.560

$600 $0.720 $0.720 $1.008 $1.440 $2.016 $3.672 $4.860 $6.768 $5.472

$700 $0.840 $0.840 $1.176 $1.680 $2.352 $4.284 $5.670 $7.896 $6.384

$800 $0.960 $0.960 $1.344 $1.920 $2.688 $4.896 $6.480 $9.024 $7.296

$900 $1.080 $1.080 $1.512 $2.160 $3.024 $5.508 $7.290 $10.152 $8.208

$1,000 $1.200 $1.200 $1.680 $2.400 $3.360 $6.120 $8.100 $11.280 $9.120

$1,100 $1.320 $1.320 $1.848 $2.640 $3.696 $6.732 $8.910 $12.408 $10.032

$1,200 $1.440 $1.440 $2.016 $2.880 $4.032 $7.344 $9.720 $13.536 $10.944

$1,300 $1.560 $1.560 $2.184 $3.120 $4.368 $7.956 $10.530 $14.664 $11.856

$1,400 $1.680 $1.680 $2.352 $3.360 $4.704 $8.568 $11.340 $15.792 $12.768

$1,500 $1.800 $1.800 $2.520 $3.600 $5.040 $9.180 $12.150 $16.920 $13.680

$1,600 $1.920 $1.920 $2.688 $3.840 $5.376 $9.792 $12.960 $18.048 $14.592

$1,700 $2.040 $2.040 $2.856 $4.080 $5.712 $10.404 $13.770 $19.176 $15.504

$1,800 $2.160 $2.160 $3.024 $4.320 $6.048 $11.016 $14.580 $20.304 $16.416

$1,900 $2.280 $2.280 $3.192 $4.560 $6.384 $11.628 $15.390 $21.432 $17.328

$2,000 $2.400 $2.400 $3.360 $4.800 $6.720 $12.240 $16.200 $22.560 $18.240

$2,100 $2.520 $2.520 $3.528 $5.040 $7.056 $12.852 $17.010 $23.688 $19.152

$2,200 $2.640 $2.640 $3.696 $5.280 $7.392 $13.464 $17.820 $24.816 $20.064

$2,300 $2.760 $2.760 $3.864 $5.520 $7.728 $14.076 $18.630 $25.944 $20.976

$2,400 $2.880 $2.880 $4.032 $5.760 $8.064 $14.688 $19.440 $27.072 $21.888

$2,500 $3.000 $3.000 $4.200 $6.000 $8.400 $15.300 $20.250 $28.200 $22.800

$2,600 $3.120 $3.120 $4.368 $6.240 $8.736 $15.912 $21.060 $29.328 $23.712

$2,700 $3.240 $3.240 $4.536 $6.480 $9.072 $16.524 $21.870 $30.456 $24.624

$2,800 $3.360 $3.360 $4.704 $6.720 $9.408 $17.136 $22.680 $31.584 $25.536

$4,000.00 - $5,999.99

UP TO $3,999.99

$14,000.00 - $15,999.99

$12,000.00 - $13,999.99

$10,000.00 - $11,999.99

$8,000.00 - $9,999.99

$6,000.00 - $7,999.99

$24,000.00 - $25,999.99

$22,000.00 - $23,999.99

$20,000.00 - $21,999.99

$18,000.00 - $19,999.99

$16,000.00 - $17,999.99

$34,000.00 - $35,999.99

$32,000.00 - $33,999.99

$30,000.00 - $31,999.99

$28,000.00 - $29,999.99

$26,000.00 - $27,999.99

$44,000.00 - $45,999.99

$42,000.00 - $43,999.99

$40,000.00 - $41,999.99

$38,000.00 - $39,999.99

$36,000.00 - $37,999.99

$54,000.00 - $55,999.99

$52,000.00 - $53,999.99

$50,000.00 - $51,999.99

$48,000.00 - $49,999.99

$46,000.00 - $47,999.99

$56,000.00 - $57,999.99

PREMIUMS BASED ON 12 PAYROLL DEDUCTIONS PER YEAR

Note: Employee may select any monthly benefit, in $100 increments, up to 60% of employee's monthly earnings.

ANNUAL EARNINGS

VOLUNTARY LTD

$2,900 $3.480 $3.480 $4.872 $6.960 $9.744 $17.748 $23.490 $32.712 $26.448

$3,000 $3.600 $3.600 $5.040 $7.200 $10.080 $18.360 $24.300 $33.840 $27.360

$3,100 $3.720 $3.720 $5.208 $7.440 $10.416 $18.972 $25.110 $34.968 $28.272

$3,200 $3.840 $3.840 $5.376 $7.680 $10.752 $19.584 $25.920 $36.096 $29.184

$3,300 $3.960 $3.960 $5.544 $7.920 $11.088 $20.196 $26.730 $37.224 $30.096

$3,400 $4.080 $4.080 $5.712 $8.160 $11.424 $20.808 $27.540 $38.352 $31.008

$3,500 $4.200 $4.200 $5.880 $8.400 $11.760 $21.420 $28.350 $39.480 $31.920

$3,600 $4.320 $4.320 $6.048 $8.640 $12.096 $22.032 $29.160 $40.608 $32.832

$3,700 $4.440 $4.440 $6.216 $8.880 $12.432 $22.644 $29.970 $41.736 $33.744

$3,800 $4.560 $4.560 $6.384 $9.120 $12.768 $23.256 $30.780 $42.864 $34.656

$3,900 $4.680 $4.680 $6.552 $9.360 $13.104 $23.868 $31.590 $43.992 $35.568

$4,000 $4.800 $4.800 $6.720 $9.600 $13.440 $24.480 $32.400 $45.120 $36.480

$4,100 $4.920 $4.920 $6.888 $9.840 $13.776 $25.092 $33.210 $46.248 $37.392

$4,200 $5.040 $5.040 $7.056 $10.080 $14.112 $25.704 $34.020 $47.376 $38.304

$4,300 $5.160 $5.160 $7.224 $10.320 $14.448 $26.316 $34.830 $48.504 $39.216

$4,400 $5.280 $5.280 $7.392 $10.560 $14.784 $26.928 $35.640 $49.632 $40.128

$4,500 $5.400 $5.400 $7.560 $10.800 $15.120 $27.540 $36.450 $50.760 $41.040

$4,600 $5.520 $5.520 $7.728 $11.040 $15.456 $28.152 $37.260 $51.888 $41.952

$4,700 $5.640 $5.640 $7.896 $11.280 $15.792 $28.764 $38.070 $53.016 $42.864

$4,800 $5.760 $5.760 $8.064 $11.520 $16.128 $29.376 $38.880 $54.144 $43.776

$4,900 $5.880 $5.880 $8.232 $11.760 $16.464 $29.988 $39.690 $55.272 $44.688

$5,000 $6.000 $6.000 $8.400 $12.000 $16.800 $30.600 $40.500 $56.400 $45.600

Important Note: The above rates are subject to change. The rates shown here are meant as an illustration for you to determine the approximate deduction you may expect to see each paycheck. Due to the rounding of rates, these deductions will vary, though differences should be slight. This is not part of an insurance policy and only the actual provisions of an issued policy control. USAble Life’s policies set forth the rights and obligations of covered persons and USAble Life. Please be aware that certain limitations and exclusions apply and that benefits may reduce or terminate. If you enroll for coverage, you will be provided with a certificate of insurance. Please read your certificate carefully.

$64,000.00 - $65,999.99

$62,000.00 - $63,999.99

$60,000.00 - $61,999.99

$58,000.00 - $59,999.99

$74,000.00 - $75,999.99

$72,000.00 - $73,999.99

$70,000.00 - $71,999.99

$68,000.00 - $69,999.99

$66,000.00 - $67,999.99

$100,000.00 & OVER

$98,000.00 - $99,999.99

$96,000.00 - $97,999.99

$94,000.00 - $95,999.99

$92,000.00 - $93,999.99

$90,000.00 - $91,999.99

$88,000.00 - $89,999.99

$86,000.00 - $87,999.99

$84,000.00 - $85,999.99

$82,000.00 - $83,999.99

$80,000.00 - $81,999.99

$78,000.00 - $79,999.99

$76,000.00 - $77,999.99

Voluntary Hospital Indemnity Protection Plan Santa Rosa County School Board

Summary of Benefits Effective: 1.1.2023

1 You must be Actively at Work with your employer on the day you apply for coverage and the date your coverage takes effect.

THIS IS A LIMITED BENEFIT POLICY. This policy does not meet the definition of minimum essential coverage and therefore should not be used as a substitute for major medical insurance.

This is a summary of benefits only and does not include all plan provisions, exclusions, and limitations relating to your coverage.

Please refer to your Certificate of Coverage. If differences exist between this summary and your Certificate of Coverage, the Certificate of Coverage will govern.

8.14.20 MBH - 2022 doc

Am I eligible? All Active Full-Time Employees working a minimum 18.75 hours per week.

What is Voluntary Hospital Indemnity Insurance?

The Hospital Indemnity Protection Plan is an insurance plan that pays cash directly to you. It can be used to help pay costs from a hospital stay and related treatment, your health plan deductible and other out-of-pocket costs.

What does the Voluntary Hospital Indemnity Protection Plan cover?

- Base Plan Benefits

- Hospital admission

- Hospital confinement

- Intensive care unit (ICU) confinement

- Base + Enhanced Plan Benefits

- Hospital admission

- Hospital confinement

- Intensive care unit (ICU) admission

- ICU confinement

- Emergency room

- Lodging

- Transportation

How much Voluntary Hospital Indemnity Insurance coverage can I buy?

You may buy the Hospital Indemnity Insurance Base Plan or Base + Enhanced Plan benefits for yourself [and your Spouse/Domestic Partner and Child(ren).

If you buy coverage for yourself, you may also buy coverage for your dependents.

Children are eligible up to age 26.

What benefits are available with the Voluntary Hospital Indemnity Protection Plan?

This chart shows the benefits provided with the Plan and provides the benefit amounts associated with each coverage option available. Please review to decide which plan coverage option best fits your needs.

Base Plan Covered Benefits and Daily Benefit Amounts

Benefits

Hospital admission 1 day per plan year per insured

$1,500

Hospital confinement Up to 364 days per plan year per insured

$200

ICU confinement Up to 364 days per plan year per insured

$200

Summary of Benefits Effective: 1.1.2023

This is a summary of benefits only and does not include all plan provisions, exclusions, and limitations relating to your coverage. Please refer to your Certificate of Coverage. If differences exist between this summary and your Certificate of Coverage, the Certificate of Coverage will govern.

Base + Enhanced Plan Covered Benefits and Daily Benefit Amounts

Benefits Hospital admission

1 day per plan year per insured $1,500 Hospital confinement

Up to 364 days per plan year per insured $200 ICU admission

1 day per plan year per insured $200 ICU confinement

Up to 364 days per plan year per insured $1,500

Emergency care treatment Up to 4 days per plan year per insured $100

Lodging benefit Up to 30 days per plan year for insured’s companion $200

Transportation benefit Up to 30 days per plan year per insured $250

Can I keep my Hospital Indemnity Insurance if I leave my employer?

The Portability feature allows you to continue your Hospital Indemnity Insurance coverage If you leave your employer. You must elect portability for your own coverage in order to elect portability for your dependents. To elect Portability, you must apply and pay the premium within 31 days of the termination of your Hospital Indemnity Insurance. Evidence of insurability will not be required.

Exclusions and Limitation Provisions

The Policy does not cover loss due to any injury or sickness that begins during the first 12 months after the covered person’s effective date of insurance if caused or contributed to by a pre-existing condition. This Policy also does not cover any loss caused by or resulting from (directly or indirectly): an act or accident of war, declared or undeclared, any substantial armed conflict between organized forces of a military nature; loss sustained while on active duty as a member of the armed forces of any nation; self-inflicted injury; active participation in a riot; committing or attempting to commit a felony; taking part in the commission of an assault or being engaged in an illegal activity;

use of alcohol or the non-medical use of narcotics, sedatives, stimulants, hallucinogens, or any other such substance, whether or not prescribed by a physician; cosmetic or elective surgery; treatment received outside the United States or its territories; the reversal of a tubal ligation or vasectomy; artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications or physician services, unless required by law; participation in any form of aeronautics (including parachuting and hang gliding); except as a fare-paying passenger in a licensed aircraft; newborn child’s routine nursing or routine well baby care during the initial confinement in a hospital; driving in any organized or scheduled race or speed test or while testing an automobile or any motorized vehicle on any racetrack or speedway; childbirth occurring within the first 12 months of the effective date of insurance; normal pregnancy; mental and nervous disorders; dental or plastic surgery for cosmetic purposes; practicing for or participating in any semi-professional or professional competitive athletic contests.

Summary of Benefits Effective: 1.1.2023

This is a summary of benefits only and does not include all plan provisions, exclusions, and limitations relating to your coverage. Please refer to your Certificate of Coverage. If differences exist between this summary and your Certificate of Coverage, the Certificate of Coverage will govern.

This list may not include all exclusions and limitations applicable to your coverage and may vary as a result of state specific requirements. Please refer to your Certificate of Coverage

Coverage continues, upon timely payment of premium, unless terminated because the person is no longer actively at work for the group or no longer meets the specific eligibility requirements stated in the Policy; or benefits have been fully paid for qualifying conditions or the Policy terminates. The Policy is renewable at the option of the company. See the Policy for terms and periods related to continuation during approved leaves.

HOSPITAL INDEMNITY PROTECTION PLAN

BASE + ENHANCED PLAN

CURRENT MONTHLY RATES

Base Base + Enhanced

Employee only $20.02 $22.51

Employee + Spouse $37.24 $42.08

Employee + Child(ren) $37.03 $42.70 Employee + Spouse + Child(ren) $58.42 $67.20

UnitedHealthcare Hospital Indemnity product is provided by UnitedHealthcare Insurance Company on policy forms UHIHIP-POL- TX, et al. and UHIHIP-CERT-TX, et al. in Texas and UHIHIP-POL-VA, et al. and UHIHIP-CERT-VA, et al. in Virginia. The product provides a limited benefit for certain hospital indemnity plan benefits. Please note: HOSPITAL INDEMNITY coverage is NOT considered “minimum essential coverage” under the Affordable Care Act and therefore does NOT satisfy the mandate to have health insurance coverage. Failure to have other health insurance coverage may be subject to a tax penalty. Please consult a tax advisor. The policy has exclusions, limitations, reductions of benefits, and terms under which the policy may be continued in force or discontinued.

For costs and complete details of the coverage, call or write your insurance agent or the company. This product is not available in all states. UnitedHealthcare Insurance Company is located in Hartford, CT.

Accident Protection Plan (APP)

Summary of Benefits Effective: 1.1.2023

This is a summary of benefits only and does not include all plan provisions, exclusions, and limitations relating to your coverage. Please refer to your Certificate of Coverage. If differences exist between this summary and your Certificate of Coverage, the Certificate of Coverage will govern.

Gold Plan

Am I eligible? All Active, Full-Time Employees working a minimum of 18.75 hours per week.

What is Accident Insurance?

Pays the benefit to you upon your own or covered dependent’s injuries* due to a covered accident. Benefits are paid per covered accident unless otherwise stated. You may use the money for any expense while you recuperate.

* Subject to all plan limitations and exclusions.

Why do I need Accident Insurance?

You can never anticipate an accident but you can financially protect yourself when you experience one. Whether you use it to pay for medical out-of-pocket expenses, lost income or other household needs, additional cash can make a big difference.

Is accident coverage for accidents that happen at any time?

Coverage is for accidents that happen on and off the job (24 hours).

How much Voluntary Accident Insurance may I purchase?

Your employer offers Accident coverage for yourself and your eligible dependents, as outlined in the chart on the last page. You may choose to purchase Base Benefits only or Base + Enhanced Benefits , whichever coverage you see as the best option for you or your family’s needs.

Are there other limitations to enrollment?

You must be Actively at Work with your employer on the day your coverage takes effect.

There are Limitations outlined in this summary.

Do I still pay my Accident Insurance premiums if I become disabled?

If you become totally disabled as a result of a Covered Accident and you remain totally disabled for at least 30 consecutive days, your Employee Accident Insurance premium may be waived up to 6 months.

Can I keep my Accident coverage if I leave my employer?

Portability (sometimes called Continuation) may be an option available if you leave your employer and your coverage. Please see your plan documents to determine if you meet all conditions to be eligible for portability.