2018 Benefits Summary - Community Based Care - 2021 Employee Benefits Guide
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Community Based Care
2018 Benefits Summary
2021 Employee Benefits Guide
Insurance Contacts
Refer to this list when you need to contact one of your benefit vendors. For general information,
contact Human Resources.
Benefit Provider Phone Website
Medical and Pharmacy BCBS 877-258-3334 www.bluecrossnc.com
Health Savings
Health Equity 877-713-7682 www.healthequity.com
Account
www.bluecrossnc.com/members/dental-
Dental BCBS 888-471-2738
blue-members
Vision BCBS / EyeMed 855-400-3641 www.eyemedvisioncare.com/bcbsnc
TELADOC Teladoc 800-TELADOC www.teladoc.com
Life and Disability Mutual of Omaha 800-877-5176 www.mutualofomaha.com
Accident Guardian 800-600-1600 www.GuardianAnytime.com
Critical Illness Guardian 800-600-1600 www.GuardianAnytime.com
Hospital Indemnity Guardian 800-600-1600 www.GuardianAnytime.com
Employee Assistance
Mutual of Omaha 800-316-2796 www.mutualofomaha.com/eap
Program
MARSH & MCLENNAN AGENCY
Marsh & McLennan Agency is our consulting partner for benefits. If you have any questions or issues regarding the
benefit plans offered to you, please contact:
Your dedicated benefits advocate:
Marsh & McLennan Agency
Employee Benefits Services
855.313.1075
ebservices@marshmma.com
2|Page
WHO IS ELIGIBLE?
You are eligible to enroll in the benefits described in this guide if you are an employee working 30 or more hours per week.
New hires become eligible for benefits on the first of the month following 60 days of employment. Eligible dependents include
your spouse or domestic partner, dependent children up to age 26 and unmarried children over age 26 who are incapable of
self-support.
HOW TO ENROLL
Each person must login to Plansource to confirm their Open Enrollment or new hire elections. Go to
https://benefits.plansource.com. You will need to login. Your user name is the first initial of your first name, up to the first
six characters of your last name, and the last four digits of your social security number. Your password is your birthdate in
the YYYYMMDD format. During open enrollment, your password has been reset to this YYYYMMDD format for simplicity.
Once you have logged in, click the “Enroll-Annual” link or “New Hire – Enroll” if you are a new hire. You will then be
prompted to go through each step of the enrollment process. See Instructions on Page 11.
WHEN TO ENROLL
The open enrollment period runs from November 9, 2020 through November 20, 2020. All employees must log in to confirm
your 2021 elections, even if you are waiving coverage or not making changes. Your current elections will not carry forward
unless you log in to confirm. The benefits you elect during open enrollment will be effective from January 1, 2021 through
December 31, 2021. If you are enrolling as a new hire, outside of the open enrollment period, benefits are effective first of
the month following 60 days of employment.
WHEN CAN YOU MAKE CHANGES
Unless you have a qualified change in status, you cannot make changes to the benefits you elect until the next open
enrollment period. Qualified changes in status include, for example: marriage, divorce, legal separation, birth or adoption of
a child, change in child’s dependent status, death of spouse, child or other qualified dependent, change in residence,
commencement or termination of adoption proceedings, change in employment status or change in coverage under another
employer-sponsored plan.
iBENEFITS
Available for IOS and Android mobile devices, the iBenefits app makes checking your benefits information easier than ever!
Once you download the free app, enter the company code: CBC2021 to get started. You can view Community Based
Care’s benefit plans 24/7, quickly contact carriers and attach copies of your benefits ID cards.
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Medical and Prescription Drugs BCBS
Option A – HDHP Plan Option B – PPO Plan
Services
You Pay: You Pay:
Deductible (Plan Year)
$5,000 $5,000
- Individual
$10,000 $10,000
- Family
Embedded* Embedded*
Coinsurance Deductible, then 50% Deductible, then 30%
Out-of-Pocket Max
$7,000 $8,550
- Individual
$14,000 $17,100
- Family
Embedded** Embedded**
Preventive Care 100% covered 100% covered
Primary Care Visit Deductible, then 50% $25 copay
Specialist Visit Deductible, then 50% $50 copay
Lab and X-Ray
In Office Deductible, then 50% $25 / $50 copay
Out of Office Deductible, then 50% Deductible, then 30%
MRI, CAT, PET Deductible, then 50% Deductible, then 30%
Emergency Room Deductible, then 50% $500 copay
Urgent Care Deductible, then 50% $50 copay
Out-of-Network
Deductible $10,000 Individual / $20,000 Family $10,000 Individual / $20,000 Family
Coinsurance Deductible, then 80% Deductible, then 60%
Out-of-Pocket Maximum $14,000 Individual / $28,000 Family $17,100 Individual / $34,200 Family
Prescription Drugs
- Tier 1 Deductible, then 50% $10 copay
- Tier 2 Deductible, then 50% $25 copay
- Tier 3 Deductible, then 50% $40 copay
- Tier 4 Deductible, then 50% $80 copay
- Tier 5 Deductible, then 50% 25% with minimum of $100 and
maximum of $200 per 30 day supply
*Embedded Deductible: All individual deductible amounts will count towards meeting the family deductible, but an
individual will not have to pay more than the individual deductible amount.
**Embedded Out-of-Pocket Maximum: All individual out-of-pocket limit amounts will count towards meeting the family out-
of-pocket limit, but an individual will not have to pay more than the individual out-of-pocket limit amount.
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Health Savings Accounts (HSA) Health Equity
Employees participating in Option A, the high deductible health plan, are eligible to defer pre-tax dollars into a Health
Savings Account (HSA) in order to pay for eligible medical, dental, and vision expenses. In order to be eligible for an HSA
you cannot be enrolled under another medical plan which provides copayments, enrolled in Medicare or military benefits,
or have access to a medical FSA (for example, your spouse has an FSA through their employer).
In 2021, you may contribute up to $3,600 if electing individual coverage or up to $7,200 if electing family coverage.
If you are age 55 or older, you are eligible to make an annual catch-up contribution of up to $1,000.
Community Based Care will contribute $10 per month to your HSA account. Please note that both the employer and the
employee contributions count towards the IRS maximum.
Your HSA balance accumulates tax-free and carries over from year to year. Contributions are made per pay period. For a
complete list of eligibility requirements and eligible expenses please visit www.irs.gov/publications/p969.
Teladoc
Paid for 100% by Community Based Care and provided at no cost to you. Teladoc provides members with on-demand, 24/7
phone/video/online access to US based, licensed physicians. You and your family members can connect instantly with their
network of physicians for information, advice, and treatment including prescription medication when appropriate. For more
information, please contact Teladoc at 800-835-2362 or go to www.teladoc.com.
This benefit is available to all employees enrolled in either of the company sponsored medical plans. Dependents
of employees who are enrolled in the medical plan will receive Teladoc coverage regardless of whether the
dependent is enrolled in the medical plan. Your dependents get telemedicine access even if you do not cover them
under the medical plan.
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Dental BCBS
Benefits LOW Plan HIGH Plan
Preventive Services
Covered at 100% Covered at 100%
Exams, cleanings, x-rays
Deductible (Calendar Year)
$50 Individual / $150 Family $50 Individual / $150 Family
Applies to basic and major services only
Basic Services
Emergency Pain Treatment, Fillings, Simple Covered at 80% Covered at 80%
Extractions
Major Services
Crowns, Inlays, Onlays, Bridges, Dentures, Not Covered Covered at 50%
Repairs and Adjustments
Annual Maximum (Calendar Year) $1,000 annual maximum $1,000 annual maximum
Late Entrant Waiting Period
(Late Entrant means you are enrolling
12 Months Basic 12 Months Basic & Major
outside of being eligible as a new hire
without a qualifying event)
Please refer to your plan document for frequency and limitations.
Vision BCBS / EyeMed
The chart below provides information related to the vision plan available. Please refer to your plan document for
information regarding out of network benefits. Note that this coverage is provided through BCBS’s Blue 20/20 plan, which
utilizes EyeMed’s national network. Your vision provider may be more familiar with the EyeMed name.
Benefits In Network
Exam $10 copay
Standard Frames Up to $130 allowance, then member pays 80% of balance
Contact Lenses
Conventional Up to $130 allowance, then member pays 85% or 100% (disposable) of balance
Medical Necessary Covered at 100%
Single Vision Lenses $25 copay
Bifocal Lenses $25 copay
Trifocal Lenses $25 copay
6|PageBasic Life Insurance Mutual of Omaha
Community Based Care provides employees with group life and accidental death and dismemberment (AD&D) insurance
in the amount of $20,000 and pays the full cost of this benefit. Benefits begin reducing at age 65. Please be sure to update
your beneficiary information in Plansource.
Voluntary Life Insurance Mutual of Omaha
In addition to the basic life insurance, employees may elect to purchase additional life insurance on themselves or their
dependents through the convenience of payroll deduction. During open enrollment for 2021, you can elect up to
$100,000 in life insurance on yourself and $50,000 on your spouse; no medical questions asked! For future annual
enrollments, you can elect or increase coverage on yourself by two increments, or $20,000, not to exceed the Guaranteed
Issue amount, without answering health questions. Rates for both employee and spouse are based on employee’s age.
Guaranteed Issue (available when Employee: $200,000
first eligible as a new employee Spouse: $50,000
without medical questions) Dependent Child: $10,000
You may elect coverage in $10,000 increments up to a maximum of 5 times your salary or
Employee Coverage
$500,000 whichever is less.
You may elect coverage for your spouse in $5,000 increments up to a maximum of 100%
Spouse Coverage
of the employee elected amount or $250,000, whichever is less.
Child Coverage You may elect coverage for your dependent child(ren) in the amount of $10,000
Disability Income Benefits Mutual of Omaha
If you experience an illness or injury (non-work related for Short Term Disability) that prevents you from working, disability
coverage acts as income replacement to protect important assets and help you continue with some level of earnings.
Medical Underwriting (health questions) will be required for the LTD plan if you do not enroll when first eligible or
during the 2021 open enrollment. Medical Underwriting (health questions) is not required when enrolling into the
short-term disability plan. Pre-existing conditions may be excluded from receiving benefits. Rates are shown in
Plansource.
Short Term Disability Long Term Disability
Benefits Begin 15th day illness/hospitalization 91st day
Benefits Duration Up to 11 weeks Up to 5 years
Option 1: 40% of weekly income
Percentage of Income Replaced 60% of Monthly income
Option 2: 60% of weekly income
Maximum Benefit $1,500 weekly $5,000 Monthly
If you are treated or diagnosed with a If you are treated or diagnosed with a
condition within 3 months of your effective condition within 12 months of your effective
Pre-Existing Condition Limitation
date, that condition will not be covered until date, that condition will not be covered until
you have been enrolled for 6 months. you have been enrolled for 12 months
7|PageSupplemental Health Benefits Guardian
Community Based Care knows that employees value the opportunity to customize their insurance coverage to best fit
their individual needs. We are pleased to offer eligible employees the ability to add-on any of the following supplemental
health programs from Guardian to complement your medical plan coverage. These programs were carefully selected and
tailored to fit the Community Based Care medical plan options this year.
Accident Insurance
Accident insurance can help protect you, your spouse, or your children from the unexpected expense of an accident.
Some of the common reasons for claims under this plan include fractures, burns, and sports related injuries – including
kids organized sports. This plan includes a $50 wellness benefit per covered member per calendar year.
EMPLOYEE BI-WEEKLY / PER PAYCHECK DEDUCTIONS
Employee Only Employee & Spouse Employee & Children Employee & Family
$6.18 $9.77 $10.19 $13.78
*See schedule of benefits for full list of covered injuries and expenses.
Critical Illness
Critical Illness insurance helps guard against financial hardship if you or a dependent is diagnosed with a covered
condition. Some of the expenses this benefit can help pay include initial diagnosis, treatment, and follow-up care. You can
choose up to a maximum of $20,000 in coverage for yourself and up to $10,000 for your spouse.
Children receive a benefit maximum of 25% of the employee benefit at no additional cost.
Covered Illnesses include, but are not limited to: invasive cancer, heart attack, stroke, major organ failure or transplant.
Pre-Existing conditions may apply as follows- If you are treated or diagnosed with a condition within 3 months of your
effective date, that condition will not be covered until you have been enrolled for 12 months.
See full benefit summary in Plansource for all covered conditions. This plan also features a $50 wellness benefit per
covered member per calendar year.
Premium varies by age and benefit amount. Employee and spouse are charged separately based on individual ages.
Rates according to your age and elected benefit amount are calculated in Plansource.
Hospital Indemnity
The Hospital Indemnity plan provides a benefit for hospital admission and confinement for an illness or injury. This benefit
is paid directly to you and can be used however you need. The plan includes a $1,000 benefit for initial admission,
intensive care stays, and hospital confinement, including maternity stays. The plan also provides a $200 to $400 per day
benefit while you are in the hospital.
EMPLOYEE BI-WEEKLY / PER PAYCHECK DEDUCTIONS
Employee Only Employee & Spouse Employee & Children Employee & Family
$9.63 $18.11 $15.00 $23.48
* Please refer to the full schedule of benefits for detailed benefits and plan limitations
8|PageEmployee Assistance Program Mutual of Omaha
Mutual of Omaha’s Employee Assistance Program assists employees and their eligible dependents with personal and job-
related concerns including emotional well-being, family and relationships, legal and financial, healthy lifestyles and work
and life transitions. All consultations are completely confidential.
As an employee or eligible dependent of Community Based Care, your EAP benefits include:
• Access to a professional, 24/7
• Robust network of licensed and/or certified mental health professionals
• Three face-to-face sessions with a counselor
• Legal and financial resources and more!
9|PageYour Contribution
Medical BCBS
EMPLOYEE BI-WEEKLY / PER PAYCHECK DEDUCTIONS
Employee Only Employee & Spouse Employee & Children Employee & Family
Option A –
$46.98 $295.95 $224.79 $487.92
HDHP Plan
Option B –
$79.80 $361.59 $314.19 $723.12
PPO Plan
Dental BCBS
EMPLOYEE BI-WEEKLY / PER PAYCHECK DEDUCTIONS
Employee Only Employee & Spouse Employee & Children Employee & Family
Low Plan $7.08 $14.16 $17.31 $26.51
High Plan $16.93 $33.85 $41.37 $63.37
Vision BCBS / EyeMed
EMPLOYEE BI-WEEKLY / PER PAYCHECK DEDUCTIONS
Employee Only Employee & Spouse Employee & Children Employee & Family
$3.62 $6.89 $7.25 $10.65
Pre-Tax Advantage: Section 125 Plan
Your share of medical, dental, and vision payroll deductions are taken on a pre-tax basis through an IRS Section 125 Plan. However,
due to Section 125 Plan rules, you may only make changes in these coverage levels and elections at the annual Open Enrollment or at
the time of a Qualifying Event such as marriage, divorce, birth of a child, loss of insurance, or court order. Any Qualifying Event must be
reported to Human Resources within 30 days of the event. If there has not been a Qualifying Event, you may not make any changes to
your elections until the next Open Enrollment period. These are Internal Revenue Service rules and there can be no exceptions.
Contact Human Resources for more information.
The information in this Benefits Summary is presented for illustrative purposes and is based on information provided by the employer. The text
contained in this Summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately
report your benefits, discrepancies, or errors are always possible. In case of discrepancy between the Benefits Summary and the actual plan
documents the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act
of 1996. If you have any questions about this summary, contact Human Resources .
10 | P a g ePlansource Enrollment Instructions
To enroll in benefits, go to: www.plansource.com/login
During open enrollment, you must log in to confirm your elections, even if you are not making changes.
To access your benefit elections and make any changes online, please use the login instructions below.
1. LOGIN
https://benefits.plansource.com
USERNAME: Your user name is the following: the first initial of your first name, up to the first six characters of
your last name and the last four of your SSN.
For example: If your name is Jane Anderson and the last four of your SSN is 1234, your user name would
be janders1234.
Password: Your birth date in YYYYMMDD format. During open enrollment, your password has been reset to this
format.
For example: If you birth date is August 14, 1962, your password
would be 19620814. At initial login, you will be prompted to change your password.
2. LAUNCH ENROLLMENT
Click on “Update My Benefits” to begin. If you are a new hire or during Open Enrollment –this link will say
“Get Started”.
3. ENROLL
Follow the enrollment through each step of the enrollment process from top to bottom
In making your elections, choose the plan option of
choice by clicking on “View Plan”, then choose “Update Cart” or “Enrolled”, or select the “Decline
Coverage” option. Once you select your plan, the system will take you through to the next benefit.
To view additional content about your plan, click on “View More” on the top section of your screen.
If you want to make a change to who is covered under your plan, click on “Edit Family Covered” and you
can uncheck any family members that should not be covered. Otherwise, all dependents will
automatically be covered.
4. CONFIRM ENROLLMENT SELECTIONS
Once you complete all coverage elections, you will land on the Confirmation Statement. Click the “Review and
Checkout” button at the bottom of the page to complete your enrollment process. This button will not be available
until all benefits have an election made. Review the benefits elected and when ready, click the “Checkout” button at
the bottom of the page to complete your enrollment process. If your email address is in the system, you will
automatically receive an email confirmation statement. If not, you can print out your confirmation statement.
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