Employee Assistance Program 7 Employer Paid Term Life ... · Dependent Care FSAs help pay for eligible child and adult care services, such as preschool, before or after school programs,

Table of ContentsWelcome 2Medical Insurance 3Employee Assistance Program 7Dental Insurance 8Vision Insurance 12Employer Paid Term Life Insurance 14Employer Paid Long-Term Disability Insurance 15

Short-Term Disability Insurance 16Accident Insurance 17Critical Illness Insurance 20Hospital Indemnity Insurance 21Lifetime Benefit Term Life Insurance 22Voluntary Term Life Insurance 24FSA 25Rates 26

Regular Employees

Dear New Employee:

Welcome to the Diocese of Jefferson City! We believe it is important to provide you with a competitive and comprehensive benefits package. In doing so, we continually adapt and look for benefits that support our employees and their families.

Please take the time to review the benefit statement as it includes everything you need to know regarding our insurance offerings. You have important decisions to make and we are committed to providing you the resources you need to understand your options.

To complete your benefits enrollment, please contact the BenManage enrollment center by calling 877-338-6311, Monday through Friday from 8:00 AM to 5:00 PM. Your enrollment must be completed within 15 days of your hire date. Even if you wish to waive insurance coverage, you will need to go through the enrollment process to assign a beneficiary(ies) to the employer-paid life insurance.

Sincerely,

Cheryl Hertfelder Gala WolfmeierDirector of Human Resources Benefits Coordinator

Diocese of Jefferson City2020 Benefit Enrollment GuideMedical Insurance

3

Medical Insurance

In-network Out-of-network

Deductible (Single/Family) $500/$1,000 $750/$2,100

Out-of-Pocket Limit (Single/Family) $1,500/$3,000 $3,500/$7,000

Services You May Need In-network Provider Out-of-network Provider Limitations & Exceptions

Health care provider’s office or clinic visitPrimary care visit to treat an injury or illness

$25 Copay per visitdeductible does not apply 40% Coinsurance / visit E-visits (via video or phone) $25 Copayment

/ visit; deductible does not apply.

Specialist visit $25 Copayment / visit; deductible does not apply 40% Coinsurance / visit

E-visits (via video or phone) $25 Copayment / visit; deductible does not apply.

In-Network Allergy injections $10 Copayment / visit; deductible does not apply.

Preventive care/screening/ immunization No charge

Primary Care - 40% Coinsurance / visit

Free Standing Clinic –40% Coinsurance

You may have to pay for services that aren’t preventive. Ask your provider if the services

needed are preventive. Then check what your plan will pay for.

Lab Tests

Diagnostic test (x-ray, blood work)Lab Work – No Charge;

deductible does not apply Radiology – 10% Coinsurance

40% CoinsuranceLimited to services performed outside

physician’s office. Payment may differ based on place of service.

Imaging (CT/PET scans, MRIs) 10% Coinsurance 40% Coinsurance

Limited to services performed outside physician’s office. Payment may differ based

on place of service. Precertification is required. A 25% penalty up to $300 may apply. Penalty

does not apply to out-of-pocket limit.

Perscription Drugs

Generic drugs$10 / prescription (retail); $25

/ prescription (mail);deductible does not apply

Same as In-Network +20% coinsurance penalty

Deductible does not apply.

Covers up to 30-day supply at retail; 90-day supply mail order or Smart90 prescription.

Retail maintenance prescriptions are limited to an initial fill and two refills. If you continue to use retail, outside of the Smart

90 program, you will pay the mail order copayment for a 30-day supply.

You may fill a 90-day supply at Walgreens owned retail pharmacies through the

Smart90 program.

If a generic equivalent is available and a brand-name medication is dispensed for any

reason, you will pay the difference in cost plus the brand copayment.

Preferred brand drugs$25 / prescription (retail); $60

/ prescription (mail);deductible does not apply


Non-preferred brand drugs$40 / prescription (retail); $100 / prescription (mail);deductible does not apply


Specialty drugs

Generic 10% up to a maximum of $150Preferred 20% up to a maximum of $150Non-Preferred 20% up to a maximum of $250

Certain specialty pharmacy drugs are considered non-essential health benefits and copayments may be set to the maximum of above or any available manufacturer-funded copay assistance.For a complete list of non-essential specialty medications, see

mycbs.org/health/SaveonSP

More information about prescription drug coverage is available at www.myCBS.org/health Log in and click on My Prescription Drugs or call Express Scripts at 800-718-6601.More information about the Smart 90, Generics Member Pays The Difference, Formulary, Retail Refill Allowance and SaveonSP programs is available at: www.myCBS.org/Rx

Benefit EligibilityIn order to be eligible for benefits through the Diocese of Jefferson City an employee who is employed on or before December 31, 2019 will be required to work 20 hours per week or an employee who is employed on or after January 1, 2020 will be required to work 30 hours per week.

Employees are eligible for benefits the first of the month following the date of hire.


4


Outpatient SurgeryFacility fee (e.g. ambulatory surgery center, hospital)

10% Coinsurance 40% CoinsuranceLimited to services performed outside

physician’s office. You may be billed amounts in excess of prevailing charges for Out-of-

Network Providers. Precertification is required. A 25% penalty up to $300 may apply. Penalty

does not apply to out-of-pocket limit.Physician/surgeon fees 10% Coinsurance 40% Coinsurance

Immediate Medical Attention

Emergency room care – Facility fee10% Coinsurance after $150 Copayment; deductible does

not apply

10% Coinsurance after $150 Copayment; deductible does

not applyCopayment is waived if admitted.

Emergency room care – Physician/surgeon fees 10% Coinsurance 10% Coinsurance

Emergency room care may include tests and services described elsewhere in the SBC (i.e. Diagnostic tests or Imaging). You may be billed amounts in excess of prevailing

charges for Out-of-Network Providers.

Emergency medical transportation 10% Coinsurance

For transportation service charges exceeding $5,000 by ground and/or air,

payment will not exceed 150% of Medicare allowance for such incurred expenses.

Charges include transportation and medical supplies used during transport.

Urgent care

Primary Care – $25 Copayment;

deductible does not applyFree Standing Clinic –

10% CoinsuranceEmergency Room –

10% Coinsurance after $150 Copayment;

deductible does not apply

Primary Care – 40% Coinsurance

Free Standing Clinic – 40% Coinsurance

Emergency Room – 10% Coinsurance after

$150 Copayment; deductible does not apply

Payment may differ based on place of service.

Deductible and coinsurance applies to urgent care services billed via the emergency room or outpatient clinic.

Hospital StayFacility fee (e.g., hospital room) 10% Coinsurance 40% Coinsurance Precertification is required.

Physician/surgeon fee 10% Coinsurance 40% Coinsurance None

Mental Health, Behavioral Health, Or Substance Abuse NeedsOutpatient services 10% Coinsurance 40% Coinsurance None

Inpatient services 10% Coinsurance 40% Coinsurance Precertification is required.

Pregnancy

Office visits $25 Copayment / visit; deductible does not apply 40% Coinsurance

Copayment applies to initial prenatal visit only (per pregnancy). Cost sharing does not

apply to preventive services.

Childbirth/delivery professional services 10% Coinsurance 40% Coinsurance

Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC

(i.e. ultrasound).

Childbirth/delivery facility services 10% Coinsurance 40% Coinsurance None

Recovery or Other Special Health NeedsHome health care 10% Coinsurance 40% Coinsurance Limited to 100 visits per year maximum

Rehabilitation services 10% Coinsurance / visit 40% Coinsurance / visit

Services for all State Licensed Practitioners, including Acupuncturist & Massage therapist visits, are limited to combined 12 visits per

year.

Habilitation services

Specialist - $25 Copayment / visit; deductible does not appl

Outpatient Facility – 10% Coinsurance

40% Coinsurance

Payment may differ based on place of service. Limited to a combined 20 visits

per year for all providers, including, but not limited to, physical, occupational and speech

therapy. Visit limits apply to Habilitation services only.


5


Recovery or Other Special Health Needs

Skilled nursing care 10% Coinsurance 40% CoinsuranceLimited to 120 day maximum for all confine-ments resulting from the same or a related

illness or injury.

Durable medical equipment 10% Coinsurance 40% Coinsurance Check your plan document for limitations.Orthotics – Limited to $500 lifetime

Hospice service 10% Coinsurance 40% Coinsurance Limited to 180 day per year maximum

Dental or Eye CareChildren’s Eye exam No charge 40% Coinsurance Covered up to age 5.

Children’s Glasses Not covered Unless covered by your vision plan.

Children’s Dental check-up Not covered Unless covered by your dental plan.

Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Contraceptives• Cosmetic surgery• Dental care (Adult)• Eye exam over age 5

• Hearing aids and related charges• Infertility treatment (except initial diagnosis)• Long-term care• Private-duty nursing

• Routine eye care (Adult)• Routine foot care• Sterilization or Abortion• Weight loss programs

Other Covered Services(Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Bariatric surgery• Chiropractic care (payable per medical necessity as specialist MD).• Habilitation services (payable per medical necessity).• Non-emergency care when traveling outside the U.S. (only when on assignment by ER).• Services provided by State Licensed Practitioners within the scope of license not specifically covered under any other provisions of the medical plan,

including Acupuncture, Massage Therapy, and Nutritional Counseling – Limited to 12 combined visits per year for all services.


6

A Quick and Easy Way to Find a DoctorSelecting a doctor that’s right for you is important. �e Provider Finder® Online Directory is a reliable and convenient tool to locate doctors in your network. Filter search results by provider type, specialty, network type, ZIP code, language and gender. You can even get directions from Google Maps®. �e Provider Finder® Online Directory is available 24 hours a day, 7 days a week, and is fast and easy to use.

For All States except Wisconsin, your ID# starts with PSC followed by 9 digits. Your Group Number is P35936. Your Network/Plan is Participating Provider Organization.

If you are in Wisconsin, your ID # starts with JYB followed by 9 digits. Your group Number is PG3001. Your Network/Plan is Blue Preferred POS.

To �nd a doctor or hospital with Provider Finder®, simply visit mycbs.org/ppo-hcsc.

1) On the “Find a Doctor or Hospital” page, under the “Find an In-Network Provider” heading, either click on “Search In-Network Providers” or search for Providers by Name or Location.

2) If you click the “Search In-Network Providers” link, click on the arrow next to “How do you get insurance?” and select “�rough my employer or my spouse’s employer.”

3) Click on the arrow next to “Are you a member or are you shopping for an insurance plan?” and select “I am a member.”

4) Click on the arrow next to “Select the type of care you are looking for” and select “Medical.”

5) Click on the arrow next to “Where do you live?” and select your state of residency. Click on the arrow next to “Select Plan/Network.” If you reside in any state other than Wisconsin, select “Preferred (or Participating) Provider Organization [PPO].”

6) If you live in Wisconsin, click on the arrow next to “Where do you live?” and select “Wisconsin.” Click on the arrow next to “Select Plan/Network” and select “Blue Preferred POS.

7) You are required to enter either a zip code, city or address in the “Located near” line. You can narrow your search further by entering a doctor, facility or clinic name, distance, provider type or specialty. You can also narrow your search by checking additional boxes below.

8) Click on the “Find a Doctor or Hospital” banner below the search parameters.

9) You will be presented with a list of health care professionals who match your criteria. On the le� hand side of the page, you can also narrow your results by entering criteria such as ZIP code, city, county, language, gender and extended hours. If you click on the provider’s name under results, you will see additional information about your selection, such as gender, languages spoken, hospital a�liation and educational background.

NOTE: Be sure to verify your search results! �e BlueCross/BlueShield Directory is a convenience we're pleased to provide to our members. Please remember that directory information is for reference only. Always con�rm with the provider that they are part of the BCBS network before scheduling your appointment or receiving services.

Step-by-Step Instructions

Provider Finder® Online Directory

PPO-8/2019

Christian Brothers Services

Health&BenefitsBlueCross/BlueShield of Illinois

7

Dear Catholic Diocese of Jefferson City Employee: Life can be a juggling act. It takes time and energy to balance your work, family and personal challenges. To help you manage life’s daily challenges, the Catholic Diocese of Jefferson City is pleased to announce the SupportLinc employee assistance program (EAP). SupportLinc offers confidential and professional support, including the following resources, at no cost to you or your family:

• SHORT-TERM COUNSELING Through SupportLinc, all employees and benefit-eligible family members may receive up to five (5) in-person counseling sessions with a licensed clinician to address issues such as depression, stress, relationship problems, grief, substance abuse, anxiety or other emotional health concerns.

• FREE LEGAL SERVICES The SupportLinc program provides free telephonic or (30-minute) face-to-face consultation with a local attorney.

• EXPERT REFERRALS SupportLinc’s knowledgeable specialists provide referrals to resources that help address a wide range of issues such as child or elder care, adoption, pet care, home repair, education and housing needs.

• FREE FINANCIAL SERVICES SupportLinc provides expert financial planning and consultation through our network of licensed financial counselors.

• WEB PORTAL The SupportLinc web portal provides access to thousands of articles, tip sheets and videos covering a wide array of health, well-being and work-life balance topics. The site also contains child and elder care search engines, reference libraries, legal and financial resources, self-improvement programs and educational training modules.

• MOBILE APP The SupportLinc eConnect® mobile app, which can be downloaded using the QR code below, allows you to talk or chat directly with a SupportLinc counselor or schedule a time for SupportLinc to call you.

All requests for information or assistance through the SupportLinc program are free of charge and completely confidential. You can contact SupportLinc anytime, around-the-clock, 365 days a year. To get started, call, chat or log in using the information below.

1-888-881-5462 (LINC)

www.supportlinc.com

[email protected] @supportlinc

Around-the-Clock Support and Guidance

Username: diojeffcity

Supportlinc mobile app Username: diojeffcity

8

Diocese of Jefferson City2020 Benefit Enrollment GuideDental Insurance

Dental InsuranceHigh Low

In-Network Out-of-Network In-Network Out-of-Network

Calendar year deductible Individual/Familydoes not apply to preventative care

$50/$150 $50/$150 $50/$150 $50/$150

Reimbursement Negotiated FeeSchedule

R&C90th Percentile

Negotiated FeeSchedule Schedule Amount

Annual Maximum Benefit $2000 $2000 $1000 $1000

Preventive CareBenefits are payable immediately from the start date of an individual’s eligibility

Examinations 2 times in 1 calendar year 100% 100% 100% 100%

Examinations – Problem FocusedCombined with Examinations Limit 100% 100% 100% 100%

Prophylaxis: Cleanings 2 times in 1 calendar year 100% 100% 100% 100%

Sealants1 per molar in 36 months for a child under age 16 100% 100% 100% 100%

Fluoride1 time in 1 calendar year for a dependent child under age 16 100% 100% 100% 100%

Full Mouth X-RaysOnce in 60 months 100% 100% 100% 100%

Bitewing X-RaysFor a child under 14: 1 time in 1 calendar yearAdult: 1 time in 1 calendar year

100% 100% 100% 100%

Basic CareBenefits are payable immediately from the start date of an individual’s eligibility

Space Maintainers1 per lifetime for a child under age 14 80% 60% 80% 60%

Amalgam Fillings1 replacement per surface in 24 Months 80% 60% 80% 60%

Root Canal1 per tooth per lifetime 80% 60% 50% 40%

Periodontal Maintenance4 perio. Treatments in 1 calendar year, includes 2 cleanings (total comb: 4)

80% 60% 50% 40%

Periodontal Surgery1 per quadrant in any 36 month period 80% 60% 50% 40%

Scaling & Root Planing1 per quadrant in any 24 month period 80% 60% 50% 40%

Prefabricated Crowns1 per tooth in 5 calendar years 80% 60% 80% 60%

Repairs 1 in 12 months 80% 60% 80% 60%

Recementations 1 in 12 months 80% 60% 80% 60%

Dentures – Rebases / Relines 1 in 36 months 80% 60% 80% 60%

Denture Adjustments 1 in 12 months 80% 60% 80% 60%

Tissue Conditioning 1 in 36 months 80% 60% 80% 60%

9

High Low

In-Network Out-of-Network In-Network Out-of-Network

Major CareBenefits are payable immediately from the start date of an individual’s eligibility

Consultations 1 in 12 months 50% 50% 50% 40%

Crown Buildups / Post Core 50% 50% 50% 40%1 per tooth in 5 calendar years 1 per tooth in 10 calendar years

Dentures 50% 50% 50% 40%1 in 5 calendar years 1 in 10 calendar years

Immediate Temporary Dentures – Complete / Partial1 replacement in 12 months 50% 50% 50% 40%

Fixed Bridges 50% 50% 50% 40%1 in 5 calendar years 1 in 10 calendar years

Inlays /Onlays /Crowns50% 50% 50% 40%

1 replacement per tooth in 5 calendar years

1 replacement per tooth in 10 calendar years

Implant Services 50% 50% 50% 40%1 per tooth position in 5 calendar years 1 per tooth position in 10 calendar years

Implant Repairs 50% 50% 50% 40%1 per tooth in 5 calendar years 1 per tooth in 10 calendar years

Implant Supported Prosthetic 50% 50% 50% 40%1 per tooth in 5 calendar years 1 per tooth in 10 calendar years

Occlusal Adjustments1 in 12 months 50% 50% 50% 40%


10

HIGH DENTAL PLAN In-Network (MetLife PDP Plus) Benefits are paid according to the Schedule of Benefits above with the employee, or dependent, paying the deductible and MetLife paying benefits based upon the agreed negotiated fee, up to $2,000 per covered member. Out-of-Network - 90th R&C (Reasonable & Customary)

Reimbursement for your out-of-network dental care is based on the 90th percentile of “reasonable and customary” charges. We look at what dentists in your area actually charge for services, and we calculate reimbursement based on the 90th percentile of those charges.

The way we determine allowable charges for the 90th R&C means your eligible benefit amount for out-of-network care is high relative to average dental charges in the community. This helps you pay less out of pocket.

Sometimes when you visit an out-of-network dentist you may have to pay part of the bill. This is called balance billing. But with a 90th percentile R&C plan, in most cases you won’t be balance billed above your typical out-of-pocket costs — your deductible, coinsurance amount and your plan maximum.

LOW DENTAL PLAN In-Network (MetLife PDP Plus) Benefits are paid according to the Schedule of Benefits above with the employee, or dependent, paying the deductible and MetLife paying benefits based upon the agreed negotiated fee, up to $1,000 per covered member. Out-of-Network - Maximum Allowable Charge (MAC)

Under a MAC plan, the reimbursement for services provided by an out-of-network dentist is capped at the Maximum Allowable Charge (MAC). For example, if you visit an out-of-network dentist who charges $150 for a cleaning (covered at 100%), but the MAC is set at $100, insurance will cover up to $100 and

you will be responsible for the remaining $50. In most cases you will be balance billed above the amount payable by the plan.

Let’s try to simplify it with an illustrative example: two fictional people who have dental insurance plans with MetLife, Kelly and Robyn. Say both of them need a crown and they decide to see the same dentist, Dr. Tooth, for the procedure. Dr. Tooth charges $1,284 for a crown. Unfortunately, Dr. Tooth is not a part of the MetLife PDP Plus network, so Kelly and Robyn are subject to out-of-network coverage. Let’s see what they’ll each owe. First up is Kelly’s appointment. Kelly is enrolled in the low MetLife MAC plan, and under Kelly’s MAC plan, crowns are covered at 50%. The MAC for crowns on her plan is set at $694, so MetLife will reimburse Kelly $347 (50% * $1,284) and Kelly will be responsible for paying Dr. Tooth the remaining $937. Later that day, Robyn has her appointment and is enrolled in the high MetLife PPO plan, which uses R&C to determine the OON reimbursement. The R&C percentile on her plan is set at the 90th, which comes out to a R&C value of $1,564 in her area. Dr. Tooth charges $1,284 for a crown, so MetLife will cover $642 (50% * $1,284) and Robyn will cover the remaining $642.

Kelly Robyn

Insurance Type MAC R&C

Procedure Crown (D2740) Crown (D2740)

Dr. Tooth’s charge $1,284 $1,284

MetLife PPO max amount $694 (PDP Fee) $1,284 (lesser of R&C and submitted charge)**

Service level coverage % 50% 50%

Insurance pays - OON $347 (50% * $694) $642 (50% * $1,284)

Member pays - OON $937 $642

Notes: *This is a hypothetical example that reviews a crown – porcelain/ceramic substrate (D2740) in the Houston area (Zip 77027). It assumes that the annual deductible has been met. ** 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.


11

PDP Plus NetworkMetLife Preferred Dentist Program

Dental Insurance

More choices for a healthier smileWith MetLife Dental insurance, you have a network that gives you access to thousands of participating dentists. More choices mean it’s easier than ever to get the dental care you need for a happy, healthy smile.

More ways to saveYou can choose to go to any dentist, but staying in-network is the best way to lower your costs1 and make the most of your dental plan. That’s because participating dentists have agreed to accept negotiated fees for covered services that are usually 30-45% less than average charges in the same community.2 This can mean more savings for you!

Find a dentistTo find a participating general dentist or specialist, visit metlife.com/dental to access our Find A Dentist online directory. Additionally, International Dental Travel Assistance is automatically available to you and your covered dependents.3

Manage your dental planWhen enrolled in MetLife Dental insurance, you may obtain your plan information online at metlife.com/mybenefits. At this site you can:

• Review your plan information, such as covered services & procedures• View claim history• Access the Oral Health Library for educational articles on dental care

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166L0819517344[exp0820][All States][DC,GU,MP,PR,VI] © 2019 MetLife Services and Solutions, LLC.

1. Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how often participants visit the dentist and the cost of services rendered.

2. Based on internal analysis by MetLife. Negotiated fees refer to the fees that in-network dentists have agreed to accept as payment in full for covered services, subject to any deductibles, copayments, cost sharing and benefits maximums. Negotiated fees are subject to change.

3. International travel assistance is provided by AXA Assistance USA, Inc. AXA Assistance provides dental referral services only. AXA Assistance is not affiliated with MetLife and the services and beneifts they provide are separate and apart from the insurance or services provided by MetLife. Referral services are not available in all locations.

Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions, limitations and terms for keeping them in force. Please contact MetLife or your plan administrator for complete details.

PDP Plus NetworkMetLife Preferred Dentist Program

Dental Insurance

More choices for a healthier smileWith MetLife Dental insurance, you have a network that gives you access to thousands of participating dentists. More choices mean it’s easier than ever to get the dental care you need for a happy, healthy smile.

More ways to saveYou can choose to go to any dentist, but staying in-network is the best way to lower your costs1 and make the most of your dental plan. That’s because participating dentists have agreed to accept negotiated fees for covered services that are usually 30-45% less than average charges in the same community.2 This can mean more savings for you!

Find a dentistTo find a participating general dentist or specialist, visit metlife.com/dental to access our Find A Dentist online directory. Additionally, International Dental Travel Assistance is automatically available to you and your covered dependents.3

Manage your dental planWhen enrolled in MetLife Dental insurance, you may obtain your plan information online at metlife.com/mybenefits. At this site you can:

• Review your plan information, such as covered services & procedures• View claim history• Access the Oral Health Library for educational articles on dental care

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166L0819517344[exp0820][All States][DC,GU,MP,PR,VI] © 2019 MetLife Services and Solutions, LLC.

1. Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how often participants visit the dentist and the cost of services rendered.

2. Based on internal analysis by MetLife. Negotiated fees refer to the fees that in-network dentists have agreed to accept as payment in full for covered services, subject to any deductibles, copayments, cost sharing and benefits maximums. Negotiated fees are subject to change.

3. International travel assistance is provided by AXA Assistance USA, Inc. AXA Assistance provides dental referral services only. AXA Assistance is not affiliated with MetLife and the services and beneifts they provide are separate and apart from the insurance or services provided by MetLife. Referral services are not available in all locations.

Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions, limitations and terms for keeping them in force. Please contact MetLife or your plan administrator for complete details.

When choosing your network, please choose the PDP Plus Network to find the correct providers for our plan.

12

Diocese of Jefferson City2020 Benefit Enrollment GuideVision Insurance

Vision care services In-Network Coverage(Using a Network Provider)

Out-of-Network Reimbursement(Using a Non-Network Provider)

Comprehensive exam of visualfunctions and prescription of corrective eyewear

$10 copay $45 allowance

Retinal ImagingThis screening is used to take pictures ofthe inside of the eye particularly the retinato look for possible changes.

Up to $39 copay Applied to the exam allowance

Standard Corrective LensesSingle VisionLined BifocalLined TrifocalLenticular

$25 Copay$25 Copay$25 Copay$25 Copay

$30 allowance$50 allowance$65 allowance

$100 allowance

Standard Lens EnhancementUltraviolet coatingPolycarbonate (child up to age 18)

Additional Lens Enhancements1

Progressive StandardProgressive Premium/Custom

Polycarbonate (adult)

Scratch-resistant coating (variable by type)Tints (variable by type)

Anti-reflective coating (variable by type)

Photochromic (variable by type)

Covered in FullCovered in Full

Covered in FullPremium: Up to $95-$105 copayCustom: Up to $150-$175 copaySingle Vision: Up to $31 copay

Multifocal: Up to $35 copayUp to $17 - $33 copay

Single Vision: Up to $17 - $34 copayMultifocal: Up to $17 - $44 copay

Up to $41 - $85 copay Up to $47 - $82 copay

Applied to the allowance for the applicable corrective lens Applied to the allowance for the applicable corrective lens

$50 allowance

$50 allowance

Applied to the allowance for the applicable corrective lens



Applied to the allowance for the applicable corrective lens Applied to the allowance for the applicable corrective lens

Frame Allowance(You will receive an additional 20% off any amount that you pay over your allowance.This offer is available from all participatinglocations except Costco, Walmart and Sam’s Club.)

CostcoCostco

Walmart and Sam’s ClubWalmart and Sam’s Club

$150 allowance

$85 allowance

$70 allowance

Contact LensesElectiveNecessary Contact Fitting and Evaluation

$150 allowance Covered in full after eyewear copay

Standard or Premium fit:Covered in full with a maximum copay of $60

$105 allowance $210 allowance

Applied to the contact lens allowance

Value Added FeaturesAdditional Savings on Glasses andSunglasses1

Get 20% off the cost for additional pairs of prescription glasses and non-prescription sunglasses, including lens enhancements. At times, other promotional offers may also be available.

Laser Vision correction2 Savings averaging 15% off the regular price or 5% off a promotional offer for laser surgery including PRK, LASIK and Custom LASIK. Offer is only available at MetLife participating locations.

FrequencyExaminationsStandard Corrective LensesFramesContact Lenses

Once every 12 monthsOnce every 12 monthsOnce every 24 monthsOnce every 12 months

Vision Insurance

1Member costs for listed lens enhancements will be limited to copays that MetLife has negotiated with participating providers. These copays can be viewed by members after enrollment at www.metlife.com/mybenefits. All lens enhancements are available at participating private practices. Maximum copays and pricing are subject to change without notice. Please check with your provider for details and copays applicable to your lens choice. Please contact your local Costco, Walmart and Sam’s Club to confirm the availability of lens enhancements and pricing prior to receiving services. Additional discounts may not be available in certain states.2 Custom LASIK coverage only available using wavefront technology with the microkeratome surgical device. Other LASIK procedures may be performed at an additional cost to the member. Laser vision care discounts are only available from participating locations.

13

Vision benefits are underwritten by Metropolitan Life Insurance Company (MetLife), New York, NY. Certain claims and network administration services are provided through Vision Service Plan (VSP), Rancho Cordova, CA. VSP is not affiliated with MetLife or its affiliates. Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods, and terms for keeping them in force. Please contact MetLife or your plan administrator for costs and complete details.

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166 L1019518773[exp0421][All States] © 2019 MetLife Services and Solutions, LLC

Find a vision providerWith MetLife Vision, you can choose from thousands of ophthalmologists, optometrists and opticians at private practices or at popular retail locations like Costco® Optical, Visionworks and more. You can find the names, addresses, and phone numbers of providers by searching our online Find a Vision Provider directory.

Vision Insurance

Step 1:Go to metlife.com

Step 2:Select “I want to find a MetLife:”

Click “Vision Provider” and enter your ZIP Code, and select your network.

Step 3:Refine Your Search (optional)

Use the Refine Your Search option to locate a provider by frame brand, language spoken or a specific service.

Please select the MetLife Vision PPO Network

14

Life and Accidental Death and Dismemberment Benefit Summary

Plan Features

Class Description: All Eligible Full-Time Employees1

Amount of Life Insurance: 1.5 times employee’s annual base salary w/$10,000.00 minimum and $200,000.00 maximum.

Rounding Rule: Life Amount is determined based on function of employee’s annual base salary, then rounded to the next $1,000.

Amount of AD&D Insurance: Matches Life AmountGuaranteed Issue Amount: $200,000Reduction Schedule

Coverage will reduce upon reaching certain ages as follows:

Waiver of Premium Benefit: Age 60 w/ 6 month waiting period, terminates at age 65

Employer Contribution Percentage: 100%Benefit Features Offered for Group Term Life and AD&D Insurance:Accelerated Life BenefitIndividual Reinstatement - 30 DaysContinuation of Insurance OptionsConversion PrivilegeSeat Belt BenefitAir Bag BenefitRepatriation BenefitParalysis/Loss of Use BenefitChild Higher Education BenefitChild Care BenefitDisappearance/Exposure BenefitSevere Burns

Employee’s age when reduction occurs 70

Percent of Life Amount Remaining 50%

Employer-Paid Term Life Insurance

Diocese of Jefferson City2020 Benefit Enrollment GuideEmployer Paid Life

1 Use of the term “Employee” includes employees, owners, members, partners, shareholders, or participants eligible to apply for coverage under American United Life Insurance Company® (AUL) contract.

15

Diocese of Jefferson City2020 Benefit Enrollment GuideLong-Term Disability Insurance

Employer Paid Long-Term Disability InsurancePlan Details

Class Description All Eligible Full-Time Employees1

Benefit Percentage 60%Maximum Monthly Benefit $8,000Minimum Monthly Benefit The greater of 15% of the Gross Monthly Benefit or $50Elimination Period 90 DaysMaximum Benefit Duration SSFRAPre-Existing Condition Exclusion 3/12Partial Disability Benefit Proportionate LossResidual Benefit YesEmployer Contribution Percentage 100%

Benefit Features

• Continuation of Personal Insurance under Family Medical Leave Act (FMLA)• Continuation of Personal Insurance during Leave Of Absence• Continuation of Personal Insurance during a Temporary Lay Off• Continuation of Personal Insurance during Leave of Absence for Active Military Service• 2 Year Regular Occupation Period• Gainful Occupation - 80% if working / 60% if not working• Recurrent Disability Provision - 6 months• Return to Work Benefit - 12 months• Social Security Integration Method - Family Integration• Accidental Dismemberment & Loss of Sight Benefit• Accumulation of Elimination Period - 2 times the elimination period• Individual Reinstatement - 30 days• Mandatory Rehabilitation Program• Normal pregnancy and certain complications included in definition of sickness• Survivor Income Benefit - 3 months• Waiver of Premium• Workplace Modification Benefit• Tax Reporting Services - pertaining to Employee FICA, Employer FICA, IRS Form W2 & 941

An eligible employee is a full-time employee authorized to work and reside in the United States. Eligible employees must work the required minimum number of hours and cannot be considered part-time, temporary or seasonal employee. If any eligible employee is not actively at work on the contract effective date date, group insurance coverage for that employee will not exist until he/she returns to full-time active work.

I Use of the term “employee” includes employees, owners, proprietor, partners, members, corporate officers, or participants eligibleto apply for coverage under American United Life Insurance Company® (AUL) contract.

16

Diocese of Jefferson City2020 Benefit Enrollment GuideShort-Term Disability Insurance

Voluntary Short-Term Disability InsurancePlan Details

Class Description All Eligible Full-Time Employees1

Features STDInjury Elimination Period: 14 DaysSickness Elimination Period: 14 DaysMaximum Benefit Duration: 13 Weeks

Weekly Benefit Amount:Increments of $100 with a minimumWeekly Benefit Amount: of $200 and a maximum of $1,750not to exceed 60% of Covered Weekly Earnings

Pre-Existing Condition Exclusion 3/12Total Disability Definition Regular JobPartial Disability Benefit Proportionate LossResidual Benefit YesBenefit Features

• Continuation of Personal Insurance under Family Medical Leave Act (FMLA)• Continuation of Personal Insurance during Leave of Absence, including Active Military Service and a Temporary Layoff• Continuity of Coverage - Franchise• Coverage Type - Non-Occupational• Individual Reinstatement - 30 days• Minimum Weekly Benefit - $25• Normal pregnancy and certain complications included in definition of Sickness• Portability Privilege• Recurrent Disability - 30 days• Social Security Integration Method - Family• Tax Reporting Services - pertaining to Employee FICA & W2• Waiver of Premium• Workplace Modification Benefit

An eligible employee is a full-time employee authorized to work and reside in the United States, Eligible employees must work the required minimum number of hours and cannot be considered a part-time, temporary or seasonal employee, If any eligible employee is not actively at work on the contract effective date, group insurance coverage for that employee will not exist until he/she returns to full-time active work.

I Use of the term “employee” includes employees, owners, shareholders, partners, members, or participants eligibleto apply for coverage under American United Life Insurance Company® (AUL) contract.

17

Diocese of Jefferson City2020 Benefit Enrollment GuideAccident Insurance Accident Insurance

IV (3/16)AG80075L R2

Aflac Group Hospital Indemnity INSURANCE

Even a small trip to the hospital can have a major impact on your finances.

Here’s a way to help make your visit a little more affordable.

Features and Plan ProvisionsCovered Insureds All Eligible Full-Time Employees

Available for all family membersSpouses-only and Child-only coverage is not available

Complete Fractures Open

ReductionClosed

ReductionA fracture is a break in a bone that can be seen by X-ray. If a bone is fractured in a covered accident, and it is diagnosed and treated by a doctor within 90 days after the accident, we will pay the appropriate amount shown.

Multiple fractures refer to more than one fracture requiring either open or closed reduction. If multiple fractures occur in any one covered accident, we will pay the appropriate amounts shown for each fracture. However, we will pay no more than double the benefit amount for the fractured bone which has the highest dollar amount.

Chip fracture refers to a piece of bone that is completely broken off near a joint. If a doctor diagnoses the fracture as a chip fracture, we will pay 25% of the amount shown for the affected bone.

The maximum amount payable for the Fracture Benefit per covered accident is double the benefit amount for the fractured bone that has the higher dollar amount.

Hip/Thigh $6,000 $3,000

Vertebrae $5,400 $2,700

Pelvis $4,800 $2,400Skull (depressed) $4,500 $2,250Leg $3,600 $1,800Forearm/Hand/Wrist $3,000 $1,500Foot/Ankle/Knee Cap $3,000 $1,500Shoulder Blade/Collar Bone $2,400 $1,200Lower Jaw (Mandible) $2,400 $1,200Skull (Simple) $2,100 $1,050Upper Arm/Upper Jaw $2,100 $1,050

Facial Bones (Except teeth) $1,800 $900Vertebral Processes $1,200 $600Coccyx/Rib/Finger/Toe $480 $240Complete Dislocations

Open Reduction

Closed Reduction

Dislocation refers to a completely separated joint. If a joint is dislocated in a covered accident, and it is diagnosed and treated by a doctor within 90 days after the accident, we will pay the amount shown.We will pay benefits only for the first dislocation of a joint. We will not pay for recurring dislocations of the same joint. If the insured dislocated a joint before the effective date of the certificate and then dislocates the same joint again, it will not be covered by this plan.Multiple dislocations refer to more than one dislocation requiring either open or closed reduction in any one covered accident. For each covered dislocation, we will pay the amounts shown. However, we will pay no more than double the benefit amount for the dislocated joint that has the higher dollar amount.Partial dislocation is one in which the joint is not completely separated. If a doctor diagnoses and treats the accidental injury as a partial dislocation, we will pay 25% of the amount shown in the benefit schedule for the affected joint.The maximum amount payable for the Dislocation Benefit per covered accident is double the benefit amount for the dislocated joint that has the higher dollar amount.If you have both fracture and dislocation in the same covered accident, we will pay for both. However, we will pay no more than double the benefit amount for the fractured bone or dislocated joint that has the higher dollar amount.

Hip $5,000 $2,500Knee (not kneecap) $3,250 $1,625Shoulder $2,500 $1,250Foot/Ankle $2,000 $1,000Hand $1,750 $875Lower Jaw $1,500 $750Wrist $1,250 $625Elbow $1,000 $500Finger/Toe $400 $200

ParalysisQuadriplegia $7,500 Paralysis means the permanent loss of movement of two or more limbs. We will pay the appropriate amount shown if, because of a

covered accident:• The insured is injured,• The injury causes paralysis which lasts more than 90 days, and• The paralysis is diagnosed by a doctor within 90 days after the accident.The amount paid will be based on the number of limbs paralyzed.If this benefit is paid and the insured later dies as a result of the same covered accident, we will pay the appropriate Death Benefit, less any amounts paid under the Paralysis Benefit.

Paraplegia $3,750

LacerationsUp to 2” long2” to 6” longMore than 6” long

$38$150 $300

The laceration must be repaired with stitches by a doctor within 72 hours after the accident. The amount paid will be based on the length of the laceration.If an insured suffers multiple lacerations in a covered accident, and the lacerations are repaired with stitches by a doctor within 72 hours after the accident, we will pay this benefit based on the largest single laceration which requires stitches.

Lacerations not requiring stitches $18.75Injuries Requiring SurgeryEye Injuries (treatment and surgery within 90 days) $175 Removal of foreign body from eye (requiring no surgery) $35 Tendons/Ligaments (treatment within 60 days, surgical repair within 90 days)

SingleMultiple

If the insured fractures a bone or dislocates a joint, and tears, severs, or ruptures a tendon or ligament in the same accident, we will pay one benefit. We will pay the largest of the scheduled benefit amounts for fractures, dislocations, or tendons and ligaments.

$300 $450

Ruptured Disc (treatment within 60 days, surgical repair within one year)Injury occurs during first certificate yearInjury occurs after first certificate year

$100$400

Torn Knee Cartilage (treatment within 60 days, surgical repair within one year)Injury occurs during first certificate yearInjury occurs after first certificate year

$100$400

18

Diocese of Jefferson City2020 Benefit Enrollment GuideAccident InsuranceBurns (treatment within 72 hours, first degree burns not covered)Second Degree

Less than 10% of body surface covered At least 10%, but not more than 25% of body surface covered At least 25%, but not more than 35% of body surface covered More than 35% of body surface covered

$100$200$500

$1,000Third Degree Burns

Less than 10% of body surface coveredAt least 10%, but not more than 25% of body surface coveredAt least 25%, but not more than 35% of body surface coveredMore than 35% of body surface covered

$1,000$5,000

$10,000$20,000

Concussion (A concussion or Mild Traumatic Brain Injury (MTBI) is defined as a disruption of brain function resulting from a traumatic blow to the head.)(Note: Concussion and MTBI are used interchangeably. The concussion must be diagnosed by a doctor.)

$150

Coma (state of profound unconsciousness lasting 30 days or more) $7,500Internal Injuries (resulting in open abdominal or thoracic surgery) $750Exploratory Surgery (without repair, i.e., arthroscopy) $175Emergency Dental Work (injury to sound, natural teeth)

Repaired with crownResulting in extraction

$100$33

Medical Fees (for each accident)

Employee or Spouse $75

We will pay the amount shown for X-rays or doctor services.

For benefits to be payable, because of a covered accident, the insured must be injured and receive initial treatment from a doctor within 72 hours after the accident.

We will pay the Medical Fees Benefit:

• For treatment received due to injuries from a covered accident and• For each covered accident up to one year after the accident date.

Child(ren) $50

Accident BenefitsEmergency Room TreatmentIn a hospital emergency room and within 72 hours after the covered accident.

Once per 24-hour period and once per covered accident.

We will not pay the Accident Emergency Room Treatment Benefit and the Medical Fees Benefit for the same covered accident. We will pay the highest eligible benefit amount.

$125

Emergency Room Observation Benefit For injuries received in a covered accident if the insured:

• Receives treatment in a hospital emergency room, and• Is held in a hospital for observation for at least 24 hours, and• Receives initial treatment within 72 hours after the accident.

This benefit is payable only once per 24-hour period and only once per covered accident. This benefit would be paid in addition to Accident Emergency Room Treatment Benefit.

$75

Major Diagnostic TestingPaid if, because of injuries sustained in a covered accident, you require one of the following exams, and a charge is incurred:

• Computerized tomography (CT scan).• Computerized axial tomography (CAT).• Magnetic resonance imaging (MRI).• Electroencephalography (EEG).

These exams must be performed in a hospital or a doctor’s office. This benefit is limited to one payment per covered accident.

$150

Post Traumatic Stress Disorder Diagnosis Post-traumatic Stress Disorder (PTSD) is a mental health condition triggered by a covered accident. We will pay the amount shown if the insured is diagnosed with Post-traumatic Stress Disorder. The insured must meet the diagnostic criteria for PTSD, stipulated in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV-TR), and be under the active care of either a psychiatrist or Ph.D.-level psychologist.

This benefit is payable only once per covered accident.

$150

Accident Follow-Up Treatment Up to six treatments per covered accident, per covered person. The insured must have received initial treatment within 72 hours of the accident, and the follow-up treatment must begin within 30 days of the covered accident or discharge from the hospital.

$20

Physical Therapyup to six treatments (one per day) per covered accident, per covered person for treatment from a physical therapist. A physician must prescribe the physical therapy. The insured must have received initial treatment within 72 hours of the accident, and physical therapy must begin within 30 days of the covered accident or discharge from the hospital. Treatment must take place within six months after the accident. This benefit is not payable for the same visit that the Accident Follow-up Treatment benefit is paid.

$20

Ambulance within 90 days of the accidentGroundAir

$150$750

Transportation (within 90 days) If hospital treatment or diagnostic study is recommended by your physician and is not available in the insured’s city of residence, we will pay the amount shown. The distance to the location of the hospital must be more than 50 miles from the insured’s residence.

Train or PlaneBus

$200$100

Blood/Plasma - within 90 days of the accident $75Prosthesis - Hearing aids, wigs, or dental aids—including false teeth—are not covered. $350Appliance - Payable for crutches, wheelchairs, leg braces, back braces, and walkers. $75

IV (3/16)AG80075L R2




19

Diocese of Jefferson City2020 Benefit Enrollment GuideAccident InsuranceAccident Benefits (continued)Family Lodging Benefit (per night) If an insured is required to travel more than 100 miles for inpatient treatment of injuries received in a covered accident, we will pay the amount shown for an immediate family member’s lodging. Benefits are payable up to 30 days per accident and only while the insured is confined to the hospital.

$75

WellnessThis benefit is payable after premiums have been paid for 12 months and while coverage is in force. This benefit is only payable for Wellness Tests performed as the result of preventive care, including tests and diagnostic procedures ordered in connection with routine examinations. We will pay the amount shown once each 12-month period for each covered person for the following:

$25• Annual physical exams.• Mammograms.• Pap smears.• PSA tests.• Ultrasounds.

• Blood screenings.• Eye examinations.• Immunizations.• Flexible sigmoidoscopies.

Hospital AdmissionWe will pay the amount shown, when because of a covered accident, the insured:

• Is injured,• Requires hospital confinement, and• Is confined to a hospital for at least 24 hours within 6 months after the accident date.

We will pay this benefit once per calendar year. We will not pay this benefit for confinement to an observation unit. We will not pay this benefit for emergency room treatment or outpatient surgery or treatment.

$750

Hospital Confinement (per day) We will pay the amount shown when, because of a covered accident, the insured:

• Is injured, and• Those injuries cause confinement to a hospital for at least 24 hours within 90 days after the accident date.

The maximum period for which you can collect the Hospital Confinement Benefit for the same injury is 365 days.This benefit is payable once per hospital confinement even if the confinement is caused by more than one accidental injury.We will not pay this benefit for confinement to an observation unit. We will not pay this benefit for emergency room treatment or outpatient surgery or treatment.

$150

Hospital Intensive Care (per day) We will pay the amount shown when, because of a covered accident, the insured:

• Is injured, and• Those injuries cause confinement to a hospital intensive care unit.

The maximum period for which an insured can collect the Hospital Intensive Care Benefit for the same Injury is 30 days.This benefit is payable in addition to the Hospital Confinement Benefit.

$300

Rehabilitation Unit Benefit (per day) We will pay the amount shown for injuries received in a covered accident if the insured:

• Is admitted for a hospital confinement,• Is transferred to a bed in a rehabilitation unit of a hospital for treatment, and• Incurs a charge.

This benefit is limited to 30 days per period of hospital confinement. This benefit is also limited to a calendar year maximum of 60 days. We will not pay the Rehabilitation Unit Benefit for the same days that the Accident Hospital Confinement Benefit is paid. We will pay the highest eligible benefit.

$50

Accidental Death & Dismemberment (within 90 days) Employee Spouse ChildrenAccidental Death $40,000 $20,000 $5,000 Accidental Common Carrier Death $80,000 $40,000 $10,000 Single Dismemberment $6,250 $2,500 $1,250 Double Dismemberment $12,500 $5,000 $2,500 Loss of One or More Fingers or Toes $625 $250 $125 Partial Amputation of Finger(s) or Toe(s) (including at least one joint) $50 $50 $50 Dismemberment means:

• Loss of a hand – The hand is cut off at or above the wrist joint; or• Loss of a foot – The foot is cut off at or above the ankle; or• Loss of sight – At least 80% of the vision in one eye is lost. Such loss of sight must be permanent and irrecoverable; or• Loss of a finger/toe – The finger or toe is cut off at or above the joint where it is attached to the hand or foot.

If the employee does not qualify for the Dismemberment Benefit but loses at least one joint of a finger or toe, we will pay the Partial Dismemberment Benefit shown. If this benefit is paid and the employee later dies as a result of the same covered accident, we will pay the appropriate death benefit, less any amounts paid under this benefit.Accidental Death – If the employee is injured in a covered accident and the injury causes him/her to die within 90 days after the accident, we will pay the Accidental Death Benefit shown.Accidental Common Carrier Death – If the employee is injured in a covered accident and the injury causes him/her to die within 90 days after the accident, we will pay the Accidental Common Carrier Death Benefit in the amount shown if the injury is the result of traveling as a fare-paying passenger on a common carrier, as defined below. This benefit is paid in addition to the Accidental Death Benefit.

Common carrier means:• An airline carrier which is licensed by the United States Federal Aviation Administration and operated by a licensed pilot on a regular schedule between established airports; or• A railroad train which is licensed and operated for passenger service only; or• A boat or ship that is licensed for passenger service and operated on a regular schedule between established ports.

Optional Catastrophic Accident Benefit Employee Spouse or ChildTo be eligible for the optional Catastrophic Accident Benefit, an employee must be covered under the base Accident Plus plan. Employees must elect coverage for this optional benefit in order for spouse and children to be covered. The Optional Catastrophic Accident Benefit does not require any insured to answer questions.We will pay the amount shown due to a covered accidental injury that results in a catastrophic loss. This benefit reduces by 50% at age 65. This benefit is payable after a 365 day elimination period.

$50,000 $25,000

IV (3/16)AG80075L R2




20

Diocese of Jefferson City2020 Benefit Enrollment GuideCritical Illness Insurance

Critical Illness InsuranceIV (3/16)AG80075L R2




Features and Plan Provisions(specific benefit provisions may vary by state)

Spouse Coverage Up to 50% of the face amount elected by the employee

Child Coverage Up to 50% of the face amount elected by the employee

Guaranteed Issue Amounts Employee: Up to $30,000Spouse: Up to $15,000

Base BenefitsHeart Attack (Myocardial Infarction) 100%

Sudden Cardiac Arrest 100%

Coronary Artery Bypass Surgery 25%

Major Organ Transplant 100%

Bone Marrow Transplant (Stem Cell Transplant) 100%

Kidney Failure (End-Stage Renal Failure) 100%

Stroke (Ischemic or Hemorrhagic) 100%

Cancer BenefitsCancer (Internal or Invasive) 100%

Non-Invasive Cancer 25%

Skin Cancer $250 per calendar year

Health Screening BenefitsHealth Screening (payable for employee and spouse only) $50 per calendar year

Additional BenefitsComa 100%

Severe Burns 100%

Paralysis 100%

Loss of Sight 100%

Loss of Speech 100%

Loss of Hearing 100%

Optional Benefits RiderAdvanced Alzheimer’s Disease 25%

Advanced Parkison’s Disease 25%

Benign Brain Tumor 100%

Childhood Conditions RiderCystic Fibrosis, Cerebral Palsy, Cleft Lip or Cleft Palate, Down Syndrome,Phenylalanine Hydroxylase Deficiency Disease (PKU), Spina Bifida , Type I Diabetes 50% of employee benefit

Plan DescriptionThe Aflac Group Critical Illness Plan provides cash benefits when an insured person is diagnosed with a covered critical illness-and these benefits are paid directly to you (unless otherwise assigned). The plan provides a lump-sum benefit to help with out-of-pocket medical expenses and the living expenses that can accompany a covered critical illness. It is also H.S.A.-compatible.

21

Diocese of Jefferson City2020 Benefit Enrollment GuideHospital Indemnity Insurance

Hospitalization Benefits Benefit Amount

Hospital Admission (per confinement)Once per covered sickness or accident per calendar year

Payable when an insured is admitted to a hospital and confined as an inpatient because of a covered accidental injury or because of a covered sickness. Not payable for confinement to an observation unit, or for emergency room treatment or outpatient treatment.

$1,000

Hospital Confinement (per day)Maximum confinement period: 31 days per covered sickness or covered accident

Payable for each day that an insured is confined to a hospital as an inpatient as the result of a covered accidental injury or because of a covered sickness.If we pay benefits for confinement and the insured becomes confined again within six months because of the same or related condition, we will treat this confinement as the same period of confinement. This benefit is payable for only one hospitalconfinement at a time even if caused by more than one covered accidental injury, more than one covered sickness, or a covered accidental injury and a covered sickness.

$150

Hospital Intensive Care (per day)Maximum confinement period: 10 days per covered sickness or covered accident

Payable for each day that an insured is confined in a hospital intensive care unit because of a covered accidental injury or because of a covered sickness. We will pay benefits for only one confinement in a hospital’s intensive care unit at a time, even if it is caused by more than one covered accidental injury, more than one covered sickness or a covered accidental injury and a covered sickness. If we paybenefits for confinement in a hospital’s intensive care unit and an insured becomes confined to a hospital’s intensive care unit again within six months because of the same or related condition, we will treat this confinement as the same period of confinement.

This benefit is payable in addition to the Hospital Confinement Benefit.

$150

Intermediate Intensive Care Step-Down Unit (per day)Maximum confinement period: 10 days per covered sickness or covered accident

Payable for each day that an insured is confined in an intermediate intensive care step-down unit because of a covered accidental injury or because of a covered sickness.We will pay benefits for only one confinement in an intermediate intensive care step-down unit at a time, even if it is caused by more than one covered accidental injury, more than one covered sickness or a covered accidentalinjury and a covered sickness. If we pay benefits for confinement in a hospital’s intermediate intensive care step-down unit and an insured becomes confined to a hospital’s intermediate intensive care step-down unit again within six months because of the same or related condition, we will treat this confinement as the same period of confinement.

This benefit is payable in addition to the Hospital Confinement Benefit.The insured must be admitted to a hospital within six months of the date of the covered accident for benefits to be payable.

$75

Hospital Indemnity InsuranceIV (3/16)AG80075L R2




Plan DescriptionThe Aflac Group Hospital Indemnity Plan provides cash benefits directly to you that help pay for some of the costs – medical and nonmedical – associated with a covered hospital stay due to a sickness or accidental injury.

22

Diocese of Jefferson City2020 Benefit Enrollment GuideLife Insurance

Lifetime Benefit Term Life InsuranceProduct Features• Valuable life insurance protection through age 120!• LifeTime Benefit Term life insurance up to $225,000 for eligible actively at work employees.• Life base insurance premiums are guaranteed never to increase through age100.• No medical exams required. Issuance of coverage depends upon answers to a few health questions.• Provides paid-up death benefit values after only ten years, so if you decide to stop paying premiums at some time in the future, you are guaranteed

paid-up coverage of a reduced amount.• Flexible! You have the option to: Continue your coverage at the same premium; or Elect paid-up insurance coverage of a reduced amount after 10

years with no further premium payments—Guaranteed!• Fully portable – you own it and take it with you when you leave your employment.• Spouse and child coverage is available.• Based on current interest rate assumptions the death benefit is designed to remain level through age 120 and fully paid up at age 100. In the event

of a long term decline in interest rates, your coverage does contain a guarantee ensuring that the initial death benefit will last for the longer of 25 years or to age 70 and thereafter can never be less than 50% of your initial death benefit

Issue LimitsGuaranteed Issue Eligibility- Defined Benefit**

Employee Coverage: Issue Ages 19 – 70; Maximum amount allowed is $100,000

Child Term Rider Coverage: Issue ages 15 days to 25 years; 25 units

Child Certificate Coverage: Issue ages 15 days to 18 years: $25,000Issue ages 19 years to 25 years: Whatever $3/wk will purchase

Conditional Guaranteed Issue Eligibility- Defined Benefit**Employee Coverage: Issue Ages 19 – 70; Maximum amount allowed is $150,000

Spouse Coverage: Issue Ages 19 – 70; Maximum amount allowed is $75,000

Simplified Eligibility - Defined BenefitEmployee Coverage: Issue Ages 19 – 70; Maximum amount allowed is $225,000

Spouse Coverage: Issue Ages 19 – 70; Maximum amount allowed is $112,500

Employee Coverage: Issue Ages 71 - 80; Maximum amount allowed is $50,000

The maximum amount of coverage for any one life is limited to the SI maximum limits above even when multiple products are made available.

EOB: This offer includes the Accelerated Death Benefit for Long Term Care with Extension of Benefits. The maximum amount payable for LBT with Long Term Care and Extension of Benefits is $450,000.

EOB: Employees with Issue Ages 71 – 80 are eligible for Accelerated Death Benefit for Long Term Care only and are NOT eligible for Extension of Benefits.

Dependent Child Coverage and EligibilityEmployees may apply for coverage on a Dependent Child in one of the following two ways, but not both:

Dependent Child Optional Benefit Rider:o Available on a Guarantee Issue basis.o Exception: when a child rider is added to an existing employee or spouse LBT contract and the child is not newly eligible, the child is added on a Simplified Issue basis – see below*.

Dependent Child Individual LBT Certificate:o Available on a Guarantee Issue basis only at the Employee’s initial eligibility period.o Employees applying for coverage on a child AFTER their initial eligibility period, may apply for coverage on a Simplified Issue basis – see below*.o Exception: when an Employee adds a newborn child (new step child or newly adopted child) after their initial eligibility period, they may apply for coverage on a Guarantee Issue basis.

*The Employee must answer all the required health questions on the child proposed for coverage on page one and two of the enrollment form whichChubb’s Administrative Office will review to determine if the coverage applied for can be issued.

Overview of Included Benefit RiderAccelerated Death Benefit Rider for Terminal Illness: Automatically included at no cost. Allows an accelerated payment of 50% of the death benefit not to exceed $100,000 if the insured’s death is diagnosed to occur within a 12 month period.

**Applies to employee enrollment only during initial eligibility for this coverage

23

Diocese of Jefferson City2020 Benefit Enrollment GuideLife Insurance

Overview of Optional Benefit Riders(Not all riders are available in all states. See certificate for full explanation and description of terms and benefits.)

Dependent Children Term Rider: Issue ages from 15 days to age 25. One premium covers all eligible children – natural, step, adopted or any under legal guardianship. Coverage lasts to age 26 and may be converted up to 5 times the term amount. Maximum initial term amount is $25,000.Employees may apply for coverage on a Dependent Child in one of the following two ways, but not both: Dependent Child Optional Benefit Rider OR Dependent Child Individual LBT Certificate

Waiver of Premium Rider: Available only to employees. Issue ages from 20–55. Waives the base premium and all rider premiums after the 6th month of disability if the insured becomes totally disabled prior to age 60.

Payor Waiver of Premium Rider: Operates on the same basis as the Waiver of Premium, but waives premiums for any individual certificate of coverage on a spouse or child contract if the payor becomes totally disabled.

Accelerated Death Benefit for Long Term Care (LTC) Rider:This rider may be added only to employee or spouse contracts. Issue ages are 19–80 for employees and 19-70 for spouses. The insured must be certified as being chronically ill (unable to perform 2 out of 6 activities of daily living or be cognitively impaired) and be confined to a nursing home or assisted living facility, or be receiving home health care or adult day care. The accelerated LTC benefit is 4% of the current death benefit amount payable each month for up to 25 months. If death occurs prior to the end of the 25 month period, the remaining amount is paid as a death benefit.

Restoration of Your Death BenefitOrdinarily, accelerating your life coverage for Long Term Care benefits can reduce your death benefit to $0. While inforce, this rider restores your life coverage to not less than 50% of the death benefit, up to a maximum of $50,000, on which your LTC benefits were based. This rider assures there will be a death benefit available for your beneficiary up to your insured’s age 121.

24

Plan Features

Class Description: Eligible Employee1 Spouse* Child

Maximum Amount of Life Insurance:

$200,000, not to exceed 5 times employee’s annual base salary

in increments of $1,000.$50,000 $10,000

Minimum Amount of Life Insurance: $25,000 $25,000 $10,000

Amount of AD&D Insurance: Matches Life Amount Matches Life Amount Matches Life AmountGuaranteed Issue Amount: $200,000 $50,000 $10,000Reduction Schedule

Coverage will reduce upon reaching certain ages as follows:

Waiver of Premium Benefit: Age 60 w/ 6 month waiting period, terminates at age 65

Benefit Features Offered for Group Voluntary Term Life and AD&D InsuranceAccelerated Life BenefitSuicide Limitation – Two Years2

Individual Reinstatement - 30 DaysContinuation of Insurance OptionsSeat Belt BenefitAir Bag BenefitRepatriation BenefitParalysis/Loss of Use BenefitChild Higher Education BenefitChild Care BenefitDisappearance/Exposure BenefitSevere Burns

Employee’s age when reduction occurs 70

Percent of Life Amount Remaining 50%

Voluntary Term Life Insurance

Diocese of Jefferson City2020 Benefit Enrollment GuideVoluntary Term Life

*Spouse coverage cannot exceed 50% of employee’s life amount.

1 Use of the term “Employee” includes employees, owners, members, partners, shareholders, or participants eligible to apply for coverage under American United Life Insurance Company® (AUL) contract.2 This limitation may vary by state.

25

Healthcare FSAs provide reimbursement for out-of-pocket medical, dental, and vision care expenses, such as deductibles, prescriptions, check-ups, and more.

Dependent Care FSAs help pay for eligible child and adult care services, such as preschool, before or after school programs, daycare, summer camps (not overnight camps), and more. Eligibility includes:-a child under the age of 13, or-a child, spouse, or other dependent who is physically or mentally incapable of self-care and resides with you for more than half the year and regularly spends at least 8 hours a day in your home .

Leftover Funds- Rollover OptionYour plan includes a $500 carryover option. The $500 carryover allows you to rollover up to $500 of unused medical/limited FSA funds at the end of the plan year. Refer to your Summary Plan Description (SPD) for detailed information regarding your plan.FSA Funding LimitsEach year, the IRS places a limit on the maximum that can be contributed to FSA accounts. For 2020, the contributions are limited to the following:

Healthcare FSA/Limited Use FSA $2,700

Dependant Care FSA

$5,000(married filing joint or as single/head of household)

$2,500(married filing separate)

The IRS requires a “use it or lose it requirement” for funds remaining in your cafeteria account at the end of the year. There is now a grace period to use the cafeteria money, which is March 15th of the following year. However, the expenses submitted during the grace period must be for the previous calendar year.

How do you get reimbursed for qualified expenses?Use your Benefit Card, if applicable or submit claims online in the Employee Portal or Mobile App. Manual claims may be submitted with a claim form via fax, secure email, or mail.

Do you have to wait for the money to be deposited in your account in order to make a claim for reimbursement?The annual amount allocated for the Medical/Limited Flexible Spending Account is available to you at any time throughout the plan year. The amount available to you from your Dependent Care Account is the amount you have contributed to date.

FSA

Diocese of Jefferson City2020 Benefit Enrollment GuideFSA

26

Diocese of Jefferson City2020 Benefit Enrollment Guide

EMPLOYEE HEALTH INSURANCE MONTHLY PREMIUM SCHEDULEEffective January 1, 2020

Medical Insurance Premiums Only (for Dental and Vision Premiums See Below)EMPLOYEE

SHAREEMPLOYEE or CLERGY $70.00

RELIGIOUS WOMEN & MEN* $-

EMPLOYEE AND SPOUSE $494.00

EMPLOYEE AND DEPENDENTS $416.00

FAMILY $840.00

FAMILY (both spouses)** $242.00

**When both spouses work for diocese/parish; amount charged equally to each employer.*The employer pays the entire premium for religious.

Optional Dental Insurance PremiumsEMPLOYEE SHARE EMPLOYEE SHARE

Low Dental High DentalEMPLOYEE or CLERGY $28.05 $46.38

RELIGIOUS WOMEN & MEN* $- N/A

EMPLOYEE AND SPOUSE $56.06 $92.76

EMPLOYEE AND DEPENDENTS $51.18 $84.69

FAMILY $79.22 $131.06

*Low Dental provides a max of $1,000 in claim payments per year/High Dental provides a max of $2,000 in claim payments per year

Optional Vision Insurance PremiumsEMPLOYEE

SHAREEMPLOYEE or CLERGY $7.35

RELIGIOUS WOMEN & MEN* $-

EMPLOYEE AND SPOUSE $14.72

EMPLOYEE AND DEPENDENTS $12.47

FAMILY $20.56

Coverage After Retiring From The Diocese of Jefferson CityRetired Diocesan employees may purchase retiree health benefits, subject to the following conditions:

1. Employee must be age 55 or older.2. Employee must currently be enrolled in the diocesan health plan for at least five consecutive years.3. Employee must be receiving some type of retiree income benefit, either diocesan retirement plan or Social Security.

Prior to Medicare eligibility, (age 65) the diocesan plan will be primary. Once the employee is eligible for Medicare, the diocesan plan willbecome secondary. It is assumed that the employee is enrolled in Medicare Parts A and B.

Monthly premiums for retiree coverage are as follows:RETIRED EMPLOYEE Medicare A&B CBEBT Premium Spouse PremiumAge 55-64 not eligible Primary $679.88 $861.34

Age 65 + Primary Secondary $412.36 $412.36

Dental and Vision Insurance may be purchased by the retiree (and their spouse) per the charts above.

27

Optional Short-Term Disability Insurance Premiums

Age of EmployeeEMPLOYEE SHARE - Short-Term Disability Monthly Premium Rate

per $10 of Weekly Benefit.0-19 $1.190

20-24 $1.190

25-29 $1.343

30-34 $1.145

35-39 $0.710

40-44 $0.460

45-49 $0.459

50-54 $0.536

55-59 $0.660

60-64 $0.761

65-69 $0.835

70+ $0.887

Optional Group Critical Illness Insurance Premiums

Age of Employee EMPLOYEE SHARE - Cost Per 1,000 of Benefit. NON-TOBACCO

EMPLOYEE SHARE - Cost Per 1,000 of Benefit. TOBACCO

18-29 $0.433 $0.594

30-39 $0.684 $1.046

40-49 $1.302 $2.024

50-59 $2.502 $4.012

60+ $4.752 $7.393

Optional Permanent Life Insurance With Long Term Care Insurance Premium Examples

Age$10 PER WEEK (Assumes Non-Smoker)

will purcahse the face value listed below per age band

$15 PER WEEK (Assumes Non-Smoker) will purcahse the face value listed below per age band

$20 PER WEEK (Assumes Non-Smoker) will purcahse the face value listed below per age band

25 $88,347.00 $132,565.00 N/A

35 $59,301.00 $88,982.00 $118,662.00

45 $34,517.00 $51,793.00 $69,068.00

55 $17,919.00 $26,888.00 $35,856.00

65 $9,126.00 $13,694.00 $18,262.00

Optional Group Accident Insurance PremiumsEMPLOYEE

SHAREEmployee Only $11.70

Employee and Spouse $18.84

Employee and Dependents $22.62

Family $29.76

Optional Group Hospital Indemnity Insurance PremiumsEMPLOYEE

SHAREEmployee Only $22.10

Employee and Spouse $40.32

Employee and Dependents $32.86

Family $51.08

*These are example age bands and face values but due to the complex rating factors involved with this product but all age bands and price points will be avalable during enrollment

Optional Term Life and AD&D Insurance PremiumsAge of Employee (***Spouse rate is based on the Employee's age)

EMPLOYEE SHARE - Voluntary Life and AD&D Rate per $1000 of Benefit Amount

0-29 $0.085

30-34 $0.105

35-39 $0.115

40-44 $0.138

45-49 $0.275

50-54 $0.425

55-59 $0.715

60-64 $1.105

65-69 $1.675

70-74 $2.085

75+ $2.085

*Child Life and AD&D Coverage is available at a cost of $2.53 per month

Employee Assistance Program 7 Employer Paid Term Life ... · Dependent Care FSAs help pay for eligible child and adult care services, such as preschool, before or after school programs,

Documents