2021 EMPLOYEE BENEFITS SUMMARY BOOK - SOUTHERN UTE INDIAN TRIBE - Sky Ute ...
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SOUTHERN UTE INDIAN TRIBE
2021 EMPLOYEE BENEFITS
SUMMARY BOOK
Benefits Summarized in this Book include:
- Medical – Anthem BCBS
- Dental – Delta Dental of Colorado
- Vision – Vision Service Plan (VSP)
- Life/AD&D and Optional Life Insurance – The Hartford
- Long Term Disability– The Hartford
- Flexible Spending Accounts – Discovery Benefits
- Employee Assistance Program - ComPsych
- Retirement Savings Plan – Fidelity Investments
- Supplemental Benefits - Colonial
- Health Management Resources
This is a brief summary of benefits which is subject to change at any time and is not intended to be used as a certificate of coverage.
Please refer to your Summary Plan Descriptions or call your Benefit Representative for a more detailed explanation.
About this Summary
The information in this Summary is presented for illustrative purposes and is based on information
provided by the organization and insurance companies. 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 this Summary and the actual plan documents, actual plan documents will
prevail. All information is confidential, pursuant to the Health Insurance Portability and
Accountability Act of 1996.
Special Notes
If you (and/or your dependents) have Medicare or will become eligible for Medicare
in the next 12 months, a Federal Law gives you more choices about your prescription
drug coverage. Please see pages 31-32 for more details.
Please see important information about Health Care Reform (HCR) and the Patient
Protection and Affordable Care (PPACA) on page 32.
If you need assistance or have questions regarding your employee benefits, please contact the Benefits
Representative at your organization:
Sky Ute Casino Resort 970-563-1320 PO Box 340, Ignacio, CO 81137
Growth Fund 970-563-5065 PO Box 367, Ignacio, CO 81137
Permanent Fund 970-563-2426 PO Box 737, Ignacio, CO 81137
.
— Index and Carrier Contact Information —
OVERVIEW Page 1
Medical Insurance Page 4
Health Guide Member Services - 1-833-952-1553
www.anthem.com
Dental Insurance Page 11
Customer Service – 1-800-610-0201
www.deltadentalco.com
Vision Page 13
Customer Service – 1-800-877-7195
www.vsp.com
Life Insurance and AD&D Page 15
Optional Life Insurance Page 17
Long Term Disability Page 19
Life Claim Status – 1-888-563-1124
Long Term Disability Claim Status – 1-800-752-9713
www.thehartfordatwork.com
Flexible Spending Accounts Page 20
Member Services – 1-866-451-3399
www.customerservice@discoverybenefits.com
Employee Assistance Program Page 25
Member Services - 1-877-616-0508
www.guidanceresources.com
Retirement Savings Plan Page 26
Member Services – 1-800-835-5095
www.netbenefits.com
Supplemental Benefits Page 28
Colonial Service Center – 1-800-325-4368
Health Management Resources Page 29
Required Notices Page 31
Contact Reference Guide Page 38
— YOUR EMPLOYEE BENEFITS OVERVIEW —
Welcome to the Southern Ute Indian Tribe benefits program. This program has been
designed to provide comprehensive benefit coverage and includes benefit plans for
Medical, Dental, Vision, Basic Life, Optional Life, Long Term Disability, Flexible Spending
Accounts, the Employee Assistance Program (EAP), the Retirement Savings Plan, and
Supplemental Benefit Plans. You have the flexibility to choose the coverage that you feel is
important for you and your family members.
The Benefit Summary Book highlights the benefits available to you as an employee of the
Tribe. The benefits described in this Summary reflect several policy documents, including
insurance contracts. It does not constitute a summary plan description for purposes of
ERISA.
If a question arises about the nature and extent of your benefits under the plans and policies,
or if there is a conflict between the informal language of this Summary and the contracts,
the formal working documents will govern. Please note that benefits are subject to change
at any time and this Summary does not represent a contractual obligation on the part of the
Southern Ute Indian Tribe.
It’s time to enroll for benefit options for the 2021 plan year. This Summary gives you
the information you need to make decisions, including summaries about the plans.
Please read this Summary carefully, along with any supplemental materials you receive. If
you have questions, you may call your Benefit Representative or the respective insurance
company for additional information. Contact information is conveniently listed in the front
and back of this Summary Booklet.
1
Eligibility
For most benefits, you are eligible to participate if you are regularly scheduled to work a minimum
of 24 hours per week. Eligible dependents include:
Legally married spouse.
Common Law Spouse in a state or jurisdiction that recognizes common law marriage and,
during residence in that state, represent(ed) as husband and wife and otherwise meets the
applicable requirements for a common law marriage. A common law marriage is valid in the
same way as a ceremonial marriage for all purposes. A declaration form and an affidavit is
required at the time of enrollment and is available from your Benefit Representative.
Partner in a Civil Union (or Domestic Partnership) and, with partner, have a recorded Civil Union
Partnership license on file.
To remove a legally married or common-law spouse or domestic partner from coverage under
the Tribe’s health and welfare benefit plans, an employee will have to provide proof of the
spouse’s or partner’s death, or the dissolution of the legal or common-law marriage or of the
Civil Union Partnership.
You may cover dependents through the end of the month in which they turn age 26.
Dependents include, but are not limited to, the following:
o Children who are unable to support themselves because of mental or physical disability,
regardless of age.
o Legally adopted children.
o Step children.
o Children for whom you are the permanent legal guardian.
When Benefits Begin
Medical, Dental, Vision, Life, Flexible Spending Accounts (FSA), Optional Life and Long-Term
Disability coverage, as well as participation in the Retirement Savings Plan begin on the 91st day of
regular employment.
When Benefits End
Medical, Dental, and Vision coverage will end on the last day of the month in which:
You change your employment status from regular full-time or part-time and work less than 24
hours per week.
You discontinue coverage at the end of the calendar year.
You separate employment.
Basic Life, Optional Life and Long Term Disability coverage cease immediately upon termination.
You and your dependents have the option to continue coverage through COBRA for your Medical,
Dental, Vision and Health Care FSA after termination of employment. You may also have
conversion or portability options available on other benefit plans, such as the Life and Optional Life
plans and Supplemental (Colonial Life) policies. See page 31 for information about your Retirement
Savings Plan.
2
Qualified Status Change
For the Health Care Plan and the Flexible Spending Account, you may not change the benefits you
elect during the year unless you have a qualified status change as defined by federal law, which
includes:
Marriage Change in your, your spouse’s or dependent’s
Birth or adoption of a child employment status
Death of your spouse or child Open enrollment event for your spouse or
dependent
Legal separation or divorce
Change in eligibility for coverage under the
Attainment of limiting age for
Children’s Health Insurance Reauthorization Act
dependents (age 26)
of 2009 (CHIPRA) or Medicaid
If you have a qualified status change during the year, you must notify your Benefit Representative
within 31 days of the date of change. (You have 60 days to make changes under CHIPRA or Medicaid.)
Depending on the type of change, you may need to provide additional supporting documents. Any
changes you make to your benefits must be consistent with your qualified status change.
Employees and dependents who are eligible for health care coverage under the Southern Ute
Indian Tribe’s Employee Health Care Plan but are not enrolled will be permitted to enroll in the plan
if they lose eligibility for Medicaid or Children’s Health Insurance Program (CHIP) coverage or
become eligible for a premium assistance subsidy under Medicaid or CHIP.
Individuals must request coverage under the plan within 60 days of the loss of Medicaid or CHIP
coverage or the determination of eligibility for a premium assistance subsidy.
Tax Advantage with Before-Tax Contributions
Employee contributions to benefit premiums are automatically deducted from each paycheck. You
save by paying for some benefits with before-tax dollars. You make before-tax contributions for
these benefits:
Health Care Plans: Medical, Dental and Vision Plans
Flexible Spending Accounts: Health Care and Dependent Care Spending Accounts
Your contributions for these plans are deducted before you pay Social Security taxes, federal
income taxes, and most state and local income taxes. However, contributions for a Civil Union
Partner enrolled in any of the Tribe’s healthcare plans will be paid after-tax.
Before-tax deductions lower your taxable income, so you pay fewer taxes. Thus, your take-home
pay is higher than if you made after-tax contributions.
3
Medical Plan
Medical coverage may be the most important item included in your benefits. Not only does it encourage
wellness, but it also protects against financial strain should you or a family member need medical care.
The Southern Ute Indian Tribe offers medical coverage through Anthem Blue Cross and Blue Shield.
The Anthem Blue Cross and Blue Shield Preferred Provider Organization (PPO) network is utilized for the
medical plan. Anthem Blue Cross and Blue Shield has participating provider networks in many areas. Having
a Preferred Provider Organization (PPO) means that each time you need medical treatment, you have two
choices:
Visit an in-network provider – By accessing in-network providers, primary care physicians, specialists,
hospitals or other health care providers you can be assured of the highest benefits payable under the PPO
Plan. In-network providers have contracted with Anthem Blue Cross and Blue Shield and agree to accept
Anthem Blue Cross and Blue Shield’s maximum benefit allowance. Using an in-network provider keeps costs
down for both you and the Tribe because the coinsurance amount will be based upon the maximum benefit
allowance.
Use an out-of-network provider – You have the freedom to use primary care physicians, specialists,
hospitals, and other health care providers who do not participate in the Anthem Blue Cross and Blue Shield
network. However, care from out-of-network providers is provided at a higher cost to you and you are
responsible for filing claim forms. Your out-of-pocket cost will increase since out-of-network providers will
not accept Anthem Blue Cross and Blue Shield’s maximum benefit allowance.
Online Resources and Telemedicine
Anthem sponsors a comprehensive website to assist participants in using their medical benefits including a
$0 copay online doctor visit using the LiveHealthOnline Telemed service. On www.anthem.com you can also
compare procedure costs between different hospitals or facilities, view and download EOBs, ID cards, and
claim forms, locate in-network providers in your area and so much more!
Anthem Sydney App
Sydney Health makes it easy to find doctors near you, get important
information about benefits and claims, track your progress toward
health goals and more. You can even get your member ID card right
from Sydney. Download the Sydney Health app today in Google Play
or Apple App Store.”
4
Medical Plan Summary
Benefit Features In-Network Out-of-Network
Annual Deductible
A) Individual No Deductible $590
B) Family No Deductible $1,770 Aggregate
Annual Coinsurance
Out-of-Pocket Maximum
A) Individual $1,100 + Copays $3,500 + Deductible + Copays
Copays for office visits, inpatient and Copays for inpatient and outpatient
outpatient hospital admissions, hospital admissions and emergency care
emergency care, and prescription drugs do do not apply to this out-of-pocket
not apply to this out-of-pocket maximum. maximum.
B) Family
$3,300 aggregate + Copays $10,500 aggregate + Deductible +
Copays for office visits, inpatient and Copays
outpatient hospital admissions, Copays for inpatient and outpatient
emergency care, and prescription drugs do hospital admissions and emergency care
not apply to this out-of-pocket maximum. do not apply to this out-of-pocket
maximum.
Maximum Lifetime Benefit Paid by Unlimited Unlimited
the Plan for All Care
Other Plan Maximums Infertility services have a lifetime Infertility services have a lifetime
maximum of $2,000 per member in and maximum of $2,000 per member in and
out-of-network combined. out-of-network combined.
Bariatric surgery has a per occurrence Bariatric surgery has a per occurrence
maximum payment of $7,500 per maximum payment of $1,500 per
member from a facility that has been member from a facility that has not been
designated as a Center of Excellence. designated as a Center of Excellence
with a total per occurrence maximum
that shall not exceed $7,500 per member
in- and out-of-network combined.
Routine Office Visits including The covered person is responsible for a The covered person is responsible for 30%
Annual Physical Exams $25 per office visit copays + 10% after deductible.
coinsurance for all other services (e.g.
laboratory and x-ray services).
Preventive Care
A) Child services (up to age 13) $25 copay per visit. $50 copay per visit.
B) Adult services $25 copay per visit. However, $50 copay per visit; plus an additional $500
preventative mammograms, pap copay for covered colonoscopy facility
smears, prostate cancer screening, and services.
routine colorectal screening (including
routine colonoscopy) are covered at
100%. Note: For colonoscopies,
anesthesia is usually not a covered benefit.
5
Medical Plan Summary (continued)
Benefit Features In-Network Out-of-Network
Maternity
$25 copay for the first prenatal visit. The covered person is responsible for 30%
A) Prenatal care The covered person is responsible for after deductible.
10% of all other services (e.g.
ultrasound x-ray and laboratory).
The covered person is responsible for The covered person is responsible for 30%
B) Delivery & inpatient well baby care 10% after $295 per admission copay. after deductible and $885 per admission
copay for facility services.
Hospitalization The covered person is responsible for The covered person is responsible for 30%
A) Inpatient care 10% after $295 per admission copay. after deductible and $885 per admission
copay.
The covered person is responsible for
B) Outpatient care 10% after $295 per admission copay. The covered person is responsible for 30%
after deductible and $885 per admission
copay.
Laboratory and X-ray The covered person is responsible for The covered person is responsible for 30%
Outpatient care 10% coinsurance. after deductible.
Urgent, Non-Routine, After Hours Care The covered person is responsible for a The covered person is responsible for 30%
$25 per office visit copay + 10% after deductible.
coinsurance for all other services (e.g.
laboratory and x-ray services).
Emergency Care The covered person is responsible for The covered person is responsible for 10%
10% after $115 copay per emergency after $115 copay per emergency room
room visit; the copay is waived if visit; the copay is waived if admitted.
admitted.
Ambulance $235 copay per trip for ground $235 copay per trip for ground
ambulance. Covered person pays 10% ambulance. Covered person pays 10% per
per trip for air ambulance trip for air ambulance
Autism Spectrum Disorders (ASD) for Certain benefits are covered. Refer to your Anthem Health Plan Description Form or
covered dependent children the Summary Plan Description for more details.
Remember, you can set aside money on a before-tax basis through the Health Care Flexible Spending Account for out-of-
pocket medical expenses for you and your family.
Important Reminders:
You may not change the benefits you elect during the year unless you have a qualified status
change. Refer to pages 2 and 3 of this Benefits Summary Booklet for more on qualified changes.
You should become familiar with the benefits of the medical plan so when in need, you will know
what to do.
6Medical Plan Summary (continued)
Benefit Features In-Network Out-of-Network
Mental Health/Alcohol & Substance
Abuse Care
A) Inpatient care The covered person is responsible for The covered person is responsible for 30%
10% after $295 per admission copay. after $885 per admission copay.
The covered person is responsible for a The covered person is responsible for 30%
B) Outpatient care $25 copay per visit for outpatient facility after deductible.
services (refer to the Anthem Health
Plan Description Form [HPDF] for more
details).
Alternative Care
A) Chiropractic Care The covered person is responsible for a Not Covered.
$25 copay per visit + 10% for all other
services (e.g. laboratory and x-ray
services). Limited to 30 visits per
calendar year combined with massage
therapy and acupuncture.
B) Acupuncture Care The covered person is responsible for a Not Covered.
$25 copay per visit + 10% for all other
services (e.g. laboratory and x-ray
services). Limited to 30 visits per
calendar year combined with
chiropractic and massage therapy.
C) Massage Therapy The covered person is responsible for a Not Covered.
$25 copay per visit + 10% for all other
services (e.g. laboratory and x-ray
services). Limited to 30 visits per
calendar year combined with
chiropractic and acupuncture.
Physical, Occupational and Speech
Therapy
A) Inpatient care – limits are Included in the inpatient hospital Included in the inpatient hospital benefit.
combined for in-network and benefit. Limited to 30 non-acute Limited to 30 non-acute inpatient days
out-of-network services inpatient days per calendar year. per calendar.
B) Outpatient care – limits are The covered person is responsible for a The covered person is responsible for
combined for in-network and $25 copay per visit + 10% for all other 30% after deductible. Physical Therapy
out-of-network services services (e.g. laboratory and x-ray limited to 40 visits; Occupational and
services). Physical Therapy limited to Speech Therapy limited to 20 visits each;
40 visits; Occupational and Speech limits are per calendar year.
Therapy limited to 20 visits each; limits
are per calendar year.
7Medical Plan Summary (continued)
Benefit Features In-Network Out-of-Network
Prescription Drugs
A) Inpatient care Included with inpatient hospital Included with inpatient hospital benefit.
benefit.
B) Outpatient care Tier 1 – $20 copay Not Covered.
Up to a 30 day supply - please note, Tier 2 – $45 copay
some 90 day prescriptions can be filled Tier 3 – $70 copay
at your local pharmacy. Tier 4 – Self Injectables 30% up to a
$295 copay per prescription. All
specialty drugs must be purchased
from IngenioRx.
Not Covered.
Tier 1 – $20 copay
C) Prescription Home Delivery Service* Tier 2 – $90 copay
Up to a 90 day supply Tier 3 – $140 copay
Tier 4 – Self Injectables 30% up to a
$590 copay per 90-day prescription.
All specialty drugs must be purchased
*Not all prescription drugs are available from IngenioRx by either the member
through the Home Delivery Service. or the member’s doctor. Call customer
service for assistance with transitioning
your prescription from your current
specialty pharmacy to IngenioRx.
Specialty Drugs* Available through IngenioRx Not Covered.
*Not available at retail pharmacies or
through the Home Delivery Service.
Diabetic Drugs/Supplies 100% coverage for approved diabetic Not Covered.
supplies such as meters and testing
strips (insulin and other prescription
drugs for diabetes have a Tier 1
copay)
Your prescription plan includes coverage for smoking cessation prescription legend drugs if the member is enrolled in Anthem
Blue Cross and Blue Shield’s approved smoking cessation counseling program.
Prescription Contact Information:
Pre-Authorization: 1-866-310-3666
Rx Member Services and Home Delivery Service: 1-833-267-2133
Specialty Drugs (IngenioRx): 1-833-255-0645
8Prescription Drug Benefits
At your Doctor’s Office:
If your doctor decides that you need a prescription drug, you can request that your doctor prescribe a
medication on the Anthem Blue Cross and Blue Shield Preferred Drug List. Tier 1 (usually a generic drug)
will cost the least. When there is not a Tier 1 drug available, there may be more than one Tier 2 or Tier 3 drug
(usually brand-name drugs) to treat your condition.
Please note – not all prescription drugs are covered under the Anthem plan.
Home Delivery Drug Program:
Home Delivery Drug Program is available, if a pharmacy pick up is not an option. You have the opportunity
to get a 90 day fill for the price of two copays at your pharmacy.
Please note – not all prescription drugs are covered under the Anthem Home Delivery Service.
Prior Authorization:
Some medications, and some quantities of medications, require an authorization from Anthem before they
are eligible to be covered. This approval process is called prior authorization. Go to www.anthem.com, log
in to your account, and select Pharmacy for the most up-to-date information on which medications require
prior authorization.
Step Therapy:
Step Therapy is a program designed to encourage the use of therapeutically equivalent drugs before
“stepping up” to other drugs in the same class of drugs. The program is organized in a series of “steps”
directed by your doctor. The program is managed under the guidance and direction of licensed doctors,
pharmacists, and other medical experts.
What are the “steps”?
Doctors will prescribe drugs from the “step one” list of drugs. The member must try at least two of the “step
one” drugs. If the member demonstrates that the “step one” drugs were not effective, Anthem will authorize
the prescription drug that was originally requested.
First Step: The “step one” drugs have demonstrated the same clinical efficacy as the drug that was
originally prescribed by your doctor. Your copay is usually the lowest with the “step one” drug.
Second Step: If your treatment plan requires a different medication, then the program moves to the
second “step.” More expensive, newer brand name drugs are usually covered in the “second step” and
your costs are higher.
Access Your Pharmacy Benefits On-line
After you set up your Anthem account, use the Pharmacy
tab to:
Order Refills
Price a medication
Search Your Drug List
Get Information on Specialty Drugs
And more!
9Anthem’s Preventive Care Services List
Some preventive care services are based upon the member’s age.
Child Preventive Care (birth to 18 years)
Preventive physical exams. Behavioral counseling to promote a healthy diet
Screening tests include: Screening for sexually transmitted infection
Hearing screening Oral Health Assessment
Screening for lead exposure
Screening for anemia Immunizations:
Screening for tuberculosis Hepatitis A
Type 2 diabetes screening Hepatitis B
Pelvic exam and Pap test, including screening for Diphtheria, Tetanus, Pertussis (DtaP)
cervical and ovarian cancer Varicella (chicken pox)
Newborn screenings including sickle cell anemia Influenza (flu shot)
Developmental and behavioral assessments Pneumococcal Conjugate (pneumonia)
Cholesterol and lipid level screening Human Papilloma Virus (HPV)
Screening for depression Haemophilus influenza Type b (Hib)
Screening and counseling for obesity (BMI) Polio
Vision Screening Measles, Mumps, Rubella (MMR)
Hemoglobin Meningococcal Polysaccharide
Blood Pressure Rotavirus
Adult Preventive Care (19 years and older) Intervention services, to include counseling and
Preventive physical exams. Screening tests include: Education, including the following:
Screening and counseling for obesity
Hearing screening Counseling related to genetic testing for
Cholesterol and lipid level screening breast and ovarian cancer
Depression screening Behavioral counseling to promote a healthy
Diabetes screening diet
Prostate cancer screenings including digital rectal exam Primary care intervention to promote
and PSA test breastfeeding
Breast exam, breast cancer screening, including Counseling related to aspirin use for the
mammography prevention of cardiovascular disease
Pelvic exam and Pap test, including screening for cervical Screening and behavioral counseling
and ovarian cancer related to tobacco use
Screening for sexually transmitted diseases Screening and behavioral counseling
HIV test related to alcohol abuse
Bone density test to screen for osteoporosis Violence, interpersonal and domestic:
Colorectal cancer screening including fecal occult related screening and counseling
blood test, barium enema, flexible sigmoidoscopy
and screening colonoscopy Immunizations:
Routine blood and urine screenings Hepatitis A, B, and C
Aortic Aneurysm screening Tetanus, Diphtheria (Td)
Pregnancy screenings (including hepatitis, asymptomatic Varicella (chicken pox)
bacteriuria, Rh incompatibility, syphilis, iron deficiency Influenza (flu shot)
anemia, gonorrhea, chlamydia) Pneumococcal Conjugate (pneumonia)
Eye Chart Vision Screening Human Papilloma Virus (HPV)
Blood Pressure Measles, Mumps, Rubella (MMR)
Meningococcal Polysaccharide
Zoster (shingles)
10Dental Plan
This plan offers a full range of dental services, including preventive care. Although the dental plan allows
you to seek services from any licensed dental provider, you must use a Delta Dental participating dentist to
receive the maximum benefit under the plan.
Selecting Your Dentist
You will experience the greatest savings if you see a Delta Dental PPO or Premier dentist. Other benefits of
selecting a Delta Dental PPO or Premier dentist include:
Nationwide network of dentists – you have access to 119,000 Delta Dental dentists across the country.
Non-covered services billed at Delta Dental’s discounted rate.
To find a Delta Dental PPO or Premier dentist, log onto the Delta Dental of Colorado website at
www.deltadentalco.com or call the Customer Relations Department at 1-800-610-0201. If you would like
help selecting a new dentist, you can contact the Customer Relations Department to find an in-network
Delta Dental dentist in your area.
If you anticipate extensive dental services that will exceed $400, it is recommended that your dentist submit the
treatment plan to Delta Dental for review before any procedures are done. This is called a predetermination of
benefits. A predetermination of benefits allows both you and your dentist to know exactly what is covered and what
your plan will pay. There is no additional charge for having a predetermination done.
Remember, you can set aside money on a before-tax basis through the Health Care Flexible Spending Account
for out-of-pocket dental expenses for you and your family.
11Dental Plan Summary
Benefit Features
Diagnostic and Preventive Services The member is responsible for 0% of the Maximum Plan Allowance or
Example: Oral Evaluation and cleanings; the fees actually charged, whichever is less. These services do not apply
twice in each calendar year. Bite-wing X- toward the annual maximum.
Rays, Sealants, Fluoride Treatments, Space
maintainers; benefit varies based on age and
time period.
Basic Services The member is responsible for 20% of the Maximum Plan Allowance or
Example: Amalgam, Resin and Composite the fees actually charged, whichever is less.
Fillings, Endodontics (Root Canal),
Periodontics (Gum Disease) and Oral Surgery
(extractions).
Major Services The member is responsible for 50% of the Maximum Plan Allowance or
Example: Crowns, Dentures, Bridges, the fees actually charged, whichever is less.
Implants, Occlusal Guards (Night Guards).
Maximum Benefit Each eligible employee and each eligible dependent may receive up to
$1,500 of covered dental benefits in each calendar year for Basic and
Major Services. Each eligible dependent child, to age 19, may receive
up to $1,000 per lifetime for Orthodontic Services. Adult Orthodontic
Services are not covered.
Deductible The patient is responsible for the first $25 each calendar year.
(combined for in and out-of-network) Diagnostic, Preventive and Orthodontic Services are not subject to the
deductible. The $25 calendar year deductible is limited to $75 per
family.
Online Resources
Delta Dental sponsors a website to assist
participants in using their dental benefits. At
www.deltadentalco.com you can use the
Consumer Tool Kit to:
Locate network providers in your area
Review plan benefits
Download claim forms
Print a personalized ID card
Review your claims
12Vision Plan
Vision Service Plan (VSP) provides coverage for eye exams, lenses, frames and contacts. VSP offers a large
network of providers.
The plan covers services provided by doctors in the VSP network, as well as doctors not in the network. You
get the best value from your VSP benefit when you visit a VSP in-network doctor. Copays still apply if you
decide not to see a VSP doctor; however, in most cases you will receive a lesser benefit and typically pay
more out-of-pocket. Additionally, you would be required to pay the provider in full at the time of your
appointment and submit a claim to VSP for partial reimbursement.
Using the Vision Plan
Using the Vision Plan is easy because there are no ID cards and no claim forms. All you need to do is:
Find a VSP doctor at www.vsp.com or call 1-800-877-7195.
Make an appointment and tell the doctor you are a VSP member.
Your doctor and VSP will handle the rest.
Your VSP membership qualifies you and your family members for discounts on digital hearing aids
through TruHearing. See next page for more information.
Beginning in 2021, Walmart is an in-network provider.
Online Resources
Vision Service Plan sponsors a website to assist participants in using their vision benefit. At www.vsp.com
you can:
Locate network providers in your area
Review plan benefits
Download claim forms
Review your claims
Find special savings and discounts
Get information on eye health
Access VSP's TruHearing Program and save up to
60% on digital hearing aids
Download coupons for savings on hearing aid
batteries
13Vision Plan Summary
Benefit Features
Your Coverage Exam ....................................................................................................... every 12 months
Prescription Glasses
Lenses .............................................................................................. every 12 months
Single vision, lined bifocal and lined trifocal lenses, standard progressive lenses
and polycarbonate lenses for dependent children are at no charge. Protective
coatings, transitional lenses and other options are offered at an additional,
discounted charge.
Frames ............................................................................................ every 24 months
Frame of your choice covered up to $150 retail. Plus, a 20% discount applies if
you choose a more expensive frame.
— OR —
Contacts .................................................................................................. every 12 months
When you choose contacts instead of glasses, your $150 allowance applies to the cost
of your lenses and the fitting and evaluation exam. This exam is in addition to your
vision exam to ensure proper fit of contacts. If you choose contact lenses you will be
eligible for a frame 12 months from the date the contact lenses were obtained.
Copays with a Exam ............................................................................................................................ $10
Participating Provider Prescription Glasses .................................................................................................... $10
Contacts ................................... No copay applies. You may be charged a “fitting charge.”
Other Discounts You will receive discounts on other options, including anti-glare coatings, UV protection,
blue light protection with TechShield coating, etc. More information is available through
your optometrist or on the VSP website.
Reimbursement Amounts Exam .................................................................................................................. Up to $50
for Non-Participating Lenses
Providers Single Vision ....................................................................................... Up to $50
Lined Bifocal or Trifocal ....................................................................... Up to $75
Progressive Lenses ........................................................................... Up to $100
Frame ................................................................................................... Up to $70
Contact Lenses ................................................................................. Up to $105
Laser Vision Care Program VSP has arranged for members to receive laser vision correction at a discounted fee,
which could add up to hundreds of dollars of savings. Discounts vary by location but
will average 15% off the laser center’s usual and customary price or 5% off the center’s
promotional price. Please refer to www.vsp.com for more details.
TruHearing TruHearing is making hearing aids affordable by providing exclusive savings to all VSP
members. You can save up to $1,500 on a pair of hearing aids with TruHearing pricing. Your
dependents and even extended family members are eligible, too! Learn more about this
benefit at www.vsp.com/offers/special-offers/hearing-aids or call 1.877-372-4040.
Additional Benefits Medically necessary contacts (covered after materials copay).
Contact Lens Fitting (Copay of up to $60).
14Life Insurance and AD&D
Life Insurance helps protect your family from a sudden loss of income in the event of your death. As a benefit
eligible employee, the Southern Ute Indian Tribe provides the benefits shown below at no cost to you. The
insurance company is The Hartford.
Beneficiary Designation
You must name the person or persons who will receive the death benefit. It is a good idea to review your
named beneficiary each year to make sure death benefits are paid to the correct beneficiary.
Travel Assistance
Toll-free emergency assistance is available to you, your spouse, and your dependents 24 hours a day, 7 days
a week when traveling 100 miles or more from your primary home for 90 days or less. In addition, you have
access to a wide range of pre-trip informational services such as visa and passport requirements,
immunizations, and foreign exchange rates. While you're traveling, get assistance with locating lost items,
medication or eyeglass prescriptions, and more. The Travel Assistance Identification Number is GLD-09012.
Identity Theft Assistance is also available. Call Toll Free: 1-800-243-6108 for assistance.
Estate and Will Preparation Service
The group life insurance provided by the Southern Ute Indian Tribe provides employees with the opportunity
to create a simple Will online. The Hartford’s Estate Guidance service can be accessed online at
www.estateguidance.com/wills where you will be guided through the process. The will preparation service
is not ideal for handling complex will or trust documents. The promotion code for the Southern Ute Indian
Tribe is WILLHLF.
Funeral Planning and Concierge Services
The Hartford has partnered with Everest Funeral to offer you and your family assistance with funeral
planning. Funeral and Concierge Services through Everest include assistance from licensed funeral
directors. These services provide support as the family needs, assist in gathering pricing information and will
negotiate funeral service prices with local funeral homes.
The program can be accessed online at www.everestfuneral.com/hartford using Code HFEVLC. The phone
number is 1-866-854-5429.
Beneficiary Assist Counseling Services
The Hartford offers professional counseling services to you and your family after a loss or terminal illness.
Beneficiary Assist offers unlimited 24/7 phone access to help related to the death of yourself or a loved one.
Services include legal advice, financial planning, and emotional counseling; up to 5 face-to-face sessions are
also available.
15Life and AD&D Summary
Benefit Features
Life and Accidental Death Two times Annual Earnings, rounded to the next higher $1,000, if not already an even
and Dismemberment multiple thereof.
(AD&D) Amount
The maximum benefit is $500,000; minimum benefit is $10,000.
Term Life Insurance for Spouse Benefit ............................................................................................. $ 5,000
Dependents Child Benefit:
Live birth to 6 months ................................................................... $ 200
6 months to age 26 ....................................................................... $ 2,000
Basic Coverage for a spouse will follow the age benefit reduction schedule listed below.
Seatbelt Benefit The Hartford will pay an additional benefit if, at the time of the accident, the certificate
holder is wearing a factory installed seatbelt in a private passenger automobile.
This additional benefit will be equal to 10% of the principal sum.
Benefit Reductions Your benefit under your group Life and AD&D reduces as you get older and will terminate
when you end employment or retire. In no event will your basic amount of life insurance
be less than $10,000 due to age.
65% at age 65 but less than 70
45% at age 70 but less than 75
30% at age 75 but less than 80
20% at age 80 or older
16Optional Life Insurance
As a benefit eligible employee of the Southern Ute Indian Tribe, you have the option to purchase additional
term life insurance for yourself, your spouse, and dependent children through The Hartford.
You will pay your premiums through payroll deduction on an after-tax basis. The total amount of premium
depends on how much coverage you select, your age, your spouse’s age, and the amount of insurance you
buy for your children.
Guarantee Issue
Employee: If you elect Optional Life Insurance when you are initially eligible, you are guaranteed coverage
up to three (3) times your annual earnings or $250,000, whichever is less. Coverage over that amount will
be subject to medical underwriting.
In order to enroll in Optional Life Insurance for your spouse or dependent children you must first enroll in Optional
Life Insurance for yourself.
Spouse: If, at the time of initial eligibility, you elect coverage for your dependent spouse, your spouse will be
guaranteed coverage up to $25,000. Coverage over that amount will be subject to medical underwriting.
The amount of coverage you elect for your spouse may not exceed the amount you elect for yourself.
Dependent Children: Optional life insurance coverage for your dependent child or children is guarantee
issue at the time of initial eligibility, for a qualifying event, or during Open Enrollment. A $500 maximum
applies for children from birth to 6 months.
Q: What happens if I leave employment with the Southern Ute Indian Tribe?
A: The Plan allows you to continue all your Basic and Optional Life Insurance coverage at low group
rates if you leave the Southern Ute Indian Tribe. You must apply for portability within 31 days after
losing the coverage. Contact your Benefit Representative for more information on how to continue
your life insurance coverage after your employment with the Southern Ute Indian Tribe ends.
17Optional Life Summary
Benefit Features
Life Amount
Employee Coverage is available in increments of earnings up to $500,000, not
to exceed a maximum of five (5) times basic annual earnings.
Earnings are rounded to next highest $1,000 of coverage.
Dependent Spouse Coverage is available in $5,000 increments not to exceed a maximum
of $250,000, not to exceed 100% of the employee amount.
Dependent Child: Children 6 months Coverage is available in $2,000 increments up to $10,000. Minimum
to 26 years amount is $2,000.
Dependent Child: Children birth to 6 $500 in coverage is available.
months Employees must elect additional coverage for themselves in order to elect
additional coverage for their dependents.
Guarantee Issue
Employee Three (3) times annual earnings up to $250,000
Spouse $25,000
Dependent Child $10,000 for children 6 months to age 26. $500 for children under 6
months of age.
Other Features
Accelerated Benefit
You may request a minimum Accelerated Benefit amount of $3,000, and
a maximum of $500,000. However, in no event will the Accelerated
Benefit Amount exceed 80% of the terminally ill person’s amount of life
insurance. This option may be exercised only once for you and only once
for each of your dependents.
Age Reduction Schedule
Any Life Insurance benefit reduces as you get older. In no event will your
optional life insurance amount drop below $10,000 due to age.
65% at age 65 but less than 70
45% at age 70 but less than 75
30% at age 75 but less than 80
20% at age 80 or older
Optional Spouse Life benefits will reduce according to the same age
schedule.
18Long Term Disability
Did You Know?
In the United States, a fatal injury occurs every 6 minutes and a disabling injury occurs every 2 seconds?
Off the job occurrences account for 3 out of 5 disabling injuries suffered by workers in the U.S.?
Your most valuable asset is your ability to earn an income?
The Southern Ute Indian Tribe understands these facts and is concerned about your ability to sustain your
lifestyle during a period of disability.
As a benefit eligible employee of the Southern Ute Indian Tribe, you are provided with valuable disability
coverage at no cost to you.
Benefit Services
Benefit Percentage and 60% of your pre-disability earnings up to a maximum of $10,000/month
Maximum Payment
Pre-disability earnings mean your gross monthly rate of earnings from the Southern Ute
Amounts
Indian Tribe in effect just prior to the date disability begins.
The Hartford may reduce the amount they pay to you by other income amounts. Some
disabilities may not be covered under this plan. Please review your Summary Plan
Description for complete details and restrictions. Your Benefit Representative can assist
you in obtaining the necessary forms for filing a claim.
Minimum Payment $100 or 10% of the gross disability payment you receive from The Hartford, whichever is
Amount greater.
Waiting Period 90 days after the date disability begins.
Maximum Payment Age When Disability Begins Maximum Payment Duration
Duration Prior to age 63 To Normal Retirement Age or 48 months, if
greater
Age 63 42 months
Age 64 36 months
Age 65 30 months
Age 66 27 months
Age 67 24 months
Age 68 21 months
Age 69 and over 18 months
Other Services Ability Assist® Counseling Services. Telephonic access to counseling, financial
information, legal support and other resources are some of the services available to you.
Ability Assist offers three free counseling sessions using the ComPsych network.
Call 1-800-964-3577
19Flexible Spending Accounts
Flexible Spending Accounts (FSAs) offer you two ways to save on the taxes you pay each year.
Health Care Flexible Spending Account Dependent Care Flexible Spending Account
Eligible out-of-pocket medical, dental, and Eligible employment-related Dependent Care
vision expenses expenses
The Power of Pre-Tax
Contributions to the Flexible Spending Accounts (FSA) are deducted before FICA, federal income tax, and
most state and local tax deductions are taken. This means you pay less tax because your taxable income has
been reduced.
How the FSA Accounts Work
You decide your contribution amount to the Health Care or Dependent Care FSA. Your annual contribution
is spread over 24 pay periods. As you incur expenses for yourself or eligible dependents, you simply use your
FSA Debit Card or submit a claim to Discovery Benefits.
Grace Period
A 2-1/2 month grace period is included with the Health Care FSA. The grace period allows participants to
spend money in the 2021 Health Care FSA account through March 15, 2022.
Annual Contribution Limit *at the time of print
Health Care Flexible Spending Account Dependent Care Flexible Spending Account
You may contribute up to $2,800 per You may contribute up to $5,000 per calendar
calendar year year, or $2,500 if you are married but file separate
income tax returns
Some Important Rules for Flexible Spending Accounts
It is important to carefully choose how much you want to contribute because FSAs have specific rules and
regulations:
If you don’t use the full amount in your accounts by the end of the calendar year (Dependent Care
Account) or the grace period (Health Care Account), the IRS requires you forfeit the remainder.
Once enrolled, you can’t change the contribution amount without a qualified status change.
Funds cannot be transferred between your Health Care FSA and your Dependent Care FSA.
Only your out-of-pocket expenses are eligible for reimbursement.
Expenses reimbursed under a Health Care or Dependent Care FSA may not be used to claim any federal
income tax deduction or credit. Your taxable income has already been reduced through your payroll
deductions.
20Health Care Flexible Spending Account
Qualified expenses must be for out-of-pocket medical care provided to you, your spouse or eligible
dependent. The IRS defines medical care as amounts paid for:
The diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting any
structure or function of the body.
Transportation primarily for and essential to medical care as defined above.
Your dependents need not be covered under the Southern Ute Indian Tribes benefits in order for you to use
your funds to cover their out-of-pocket expenses.
Some Eligible Expense Examples: Some Ineligible Expense Examples:
Copays, Deductibles & Coinsurance Cosmetic Procedures (i.e., teeth whitening)
Prescription Glasses or Sunglasses Tips for providers (i.e., medical massage)
Acupuncture and Orthodontia Vitamins / Nutritional Supplements
Crowns and Oral Surgery
A complete list of eligible Health Care expenses is available online at www.irs.gov (Publication 502) or at
www.discoverybenefits.com/employees/eligible-expenses.
Special Rules Associated with Orthodontia Expenses
Generally, services associated with orthodontia are provided over an extended period of time and are often
impossible to match with actual costs. As a result, orthodontic expenses are processed over the life of the
payment plan. You may use your debit card or submit a claim for reimbursement for these charges as they
occur. Adult orthodontia (for those over the age of 19) is an eligible expense.
Dependent Care Flexible Spending Account
A Dependent Care flexible spending account is an employer-sponsored plan that allows you to set aside a
portion of your income on a pre-tax basis and then use that money to pay for eligible or employment-related
Dependent Care expenses incurred for a qualifying individual.
Qualifying Individual
Your dependent child under the age of 13 who lives
with you for more than half the year;
Your spouse or other qualifying dependent who is
physically or mentally incapable of self-care and lives
with you for more than half the year.
If you are divorced and you are the custodial parent, your
child is a qualifying individual even if you do not claim the
child as a tax dependent. A divorced, non-custodial parent
cannot be reimbursed under a Dependent Care FSA, even
if the divorced, non-custodial parent claims the child as a
tax dependent.
21"Employment-related" Expense
To be eligible for reimbursement under your Dependent Care FSA, an expense must be incurred so you (and
your spouse, if married) can work or look for work. For this purpose, “work” may include actively looking for
work but does not include unpaid volunteer work or volunteer work for a nominal salary. Your spouse is
considered to have “worked” if he or she is a full-time student for at least five calendar months during the
tax year or if he or she is physically or mentally incapable of self-care.
Expenses you pay for Dependent Care while you are off work due to illness generally are not eligible for
reimbursement. However, temporary absences from work may be disregarded if you are required to pay for
Dependent Care expenses during the absence. Whether an absence is short and temporary depends on the
facts and circumstances of the situation; however, IRS regulations state that an absence of up to two
consecutive weeks due to illness or vacation is a short-term or temporary absence.
Some Eligible Expense Examples: Some Ineligible Expense Examples:
Dependent Care centers Overnight camp
In-home Dependent Care Educational expenses
In-home elder care Tuition for kindergarten and above
Senior Dependent Care centers Food expenses (unless inseparable from care)
Before/after school programs Amounts paid to your spouse or your child under age 18
You may view a complete list of eligible and ineligible Dependent Care expenses online at www.irs.gov
(Publication 503) or at www.discoverybenefits.com.
What to Submit with a Dependent Care FSA Claim?
If the employee and provider certifications on the reimbursement request form are completed and signed,
no additional documentation is required. If the provider certification is not completed and signed, you must
submit an itemized statement from your provider including:
The date(s) of service
The name(s) and date(s) of birth of your dependent(s)
An itemization of charges
The Dependent Care provider’s name, address and Tax ID
or Social Security Number
Health Care Flexible Spending Account Dependent Care Flexible Spending Account
Regardless of how much you have deposited in You may be reimbursed up to the account balance
your account at the time you submit a claim, at the time of your claim. If your balance is
you may be reimbursed for an amount up to insufficient, you will receive a partial payment from
your total annual election. the funds available. As you continue to make payroll
deposits, you will be reimbursed for any remaining
claims.
22Receiving Payment from Your Accounts
When you incur an eligible expense, use your Discovery Benefits Visa Debit Card or submit a claim form with
documentation for the expense to Discovery Benefits. Here’s how each account pays claims:
The Health Care FSA Benefit Card
The Discovery Benefits Visa Debit Card allows you to pay for qualified medical expenses at health care
providers who have a health care-related merchant category code (such as doctors, dentists, vision care
offices, and other medical care providers). You may also use your card at grocery and discount stores, and
pharmacies that utilize an Inventory Information Approval System (IIAS).
When to Submit Claims
All active employees have 90 days after the end of the Plan Year (12/31) to submit claims for reimbursement.
All claims must be submitted for reimbursement by March 30th. Inactive employees have 90 days following
their date of separation to submit claims for the current Plan Year.
Over-The-Counter Items
You may use your card to pay for eligible over-the-counter (OTC) health care items (thermometers,
bandages, etc.); however, due to IRS regulations, your benefit card cannot be used to purchase most OTC
medicines and drugs (pain relievers, allergy and cold medicines, etc.), and you will need to pay for the items
using another form of payment and then submit the expense for reimbursement along with a prescription
from your doctor or a prescription receipt from a pharmacy.
KEEP YOUR DOCUMENTATION: Monthly account statements are housed on the Discovery Benefits employee
portal. When substantiation is needed to verify an FSA expense, Discovery Benefits will notify the
Participant. If no substantiation is received after 72 days, a Repayment Request is sent to the participant and
the debit card is temporarily deactivated. You can pay back the plan or submit an eligible claim to offset the
ineligible amount. Documentation can be submitted by upload to the Discovery Benefits web portal, mobile
upload, fax, email or by regular mail.
Your documentation should include the following information about the expense:
Name of the covered member and to whom the service was provided
The date of service
The service provider’s name
The cost of the service or item
A clear and detailed service description
A doctor’s prescription is required for over-the-counter medications, vitamins, nutritional supplements
or for medical massage therapy not provided by an Anthem in-network provider.
NOTE: Expect to be asked for documentation for all claims. No documentation is needed for copays.
Acceptable vs. Unacceptable "Receipts” or Documentation
Acceptable Documentation: Unacceptable Documentation:
Explanation of Benefit forms (EOBs) • Credit card or cash register receipt showing only the
Receipts containing all the information amount paid
described above • Estimates of Expenses
“Bag Tags” for prescriptions • Balance Forward Statements or Billing Statements
Statements of Services
23Warning: Failure to submit proper documentation will result in the deactivation of your card.
If you do not provide acceptable documentation or repay the plan for ineligible transactions within the allotted
timeframe, any subsequent non-card (paper) claims will be used to resolve the balance due (by reducing the
amount of your reimbursement by the amount of the balance due).Failure to repay the plan could result in
adverse tax consequences.
Other Reimbursement Options
The Discovery Benefits Visa Debit Card is not your only reimbursement option - you can also submit a claim
by portal upload, mobile upload, fax, or mail. You will receive reimbursement by check or Direct Deposit
into an account of your choice.
Discovery Benefits offers four methods of claim submission:
Submit claims online at www.discoverybenefits.com.
To utilize this feature, you must be able to scan or snap a photo of your receipts.
Mobile upload – iPhone and Android applications
Fax manual claims toll-free to: 1-866-451-3245
Mail manual claims to: Discovery Benefits, P.O. Box 2926, Fargo, ND 58108-2926
For claim questions contact a Discovery Benefits representative toll-free at 1-866-451-3399.
Online Resources
The Discovery Benefits website gives you access to many valuable tools and resources to assist you in
managing your flexible spending accounts. At
www.discoverybenefits.com you can:
Look up your account balance
Review the status of a claim
Download claim forms
Complete an online direct deposit enrollment form
Find a list of IRS qualified Health Care and Dependent Care expenses
Discovery Benefits Mobile App – for iPhone and Android
Subscribe to text alerts for receipt reminders, claim
confirmations and denials.
View claim transactions
View FSA payroll deductions
View account balances
Filing dates
*Works with AT&T, Nextel, Sprint, Verizon, T-Mobile, or Virgin Mobile
Did you know?
You can use your FSA debit card at the FSA Store website?
You can also use your FSA card on Amazon.com.
Search for “flexible spending eligible items.
24Employee Assistance Program (EAP)
The Southern Ute Indian Tribe provides an Employee Assistance Program (EAP) for all employees and their
household members. The EAP is administered by ComPsych and provides employees and their household
members up to eight confidential counseling sessions in a calendar year with an experienced, professional
counselor. There is no cost to you. ComPsych provides several resources and is available 24 hours a day, 7
days per week to offer live support by experienced clinicians or to refer you to local providers for mental
health, emotional or family concerns. COVID-19 support is also available.
Confidential Counseling - Someone to talk to
This no-cost counseling service helps you address stress, relationship and personal issues for you and your
family. Speak with highly trained master’s and doctoral level clinicians who will listen to your concerns and
quickly refer you to in-person counseling and other resources for:
Stress, anxiety & depression
Relationship/marital conflicts
Grief and loss
GuidanceResources® Online - Knowledge at your fingertips
GuidanceResources Online has expert information on the issues that matter most to you - relationships,
work, school, children, wellness, legal, financial, free time and more.
Timely articles, tutorials, streaming videos and self-assessments
“Ask the Expert” responses to personal questions
Child care, elder care, attorney and financial planner searches
Financial Information & Resources - Discover your best options
Speak with a Certified Public Accountant or a Certified Financial Planner on a wide range of financial issues,
including:
Getting out of debt
Retirement planning
Tax questions
Legal Support and Resources - Expert info when you need it
Talk to an attorney. If you require representation, you will be referred to a qualified attorney in your area for
a free, 30-minute consultation with a 25% reduction in customary legal fees thereafter.
Call about:
Divorce & family law
Debt and bankruptcy
Civil and criminal actions
Work-Life Solutions -Delegate your “to-do” list
Work-Life specialists will do the research for you, providing qualified referrals and customized resources for:
Child & elder care
Moving & relocation
Home repair
Call ComPsych® GuidanceResources® anytime for confidential assistance.
Phone: 1-877-616-0508 Website: www.guidanceresources.com Web ID: CN3906K
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