Sealevel Construction Flipbook 2021

BENEFITS
ENROLLMENT GUIDE
2021-2022
1

CONTENTS
4-5 Benefits Overview
7-12 Medical Insurance
14
Company Paid Basic Life and Accidental Death &
Dismemberment Insurance
15 Voluntary Life Insurance
17 Short Term Disability Insurance
18 Long Term Disability Insurance
20-21 Dental Insurance
22-23 Vision Insurance
25-27 Accident Insurance
28-29 Cancer Insurance
31 Cancer Treatment Advocate
32 Surgery and Imaging Program
33-34 Gym Discount Program
35 Enrollment Instructions
36 Important Contacts
38 Glossary
2

BENEFITS
OVERVIEW
3

BENEFITS OVERVIEW
ENROLLMENT
You can enroll in benefits or change your elections at the following times:
• 30 days prior to your initial eligibility date (as a newly hired employee)
• During the annual benefits open enrollment period
• Within 30 days of experiencing a qualifying life event
OPTIONS
We offer a comprehensive benefits package consisting of:
• Medical Insurance
• Dental Insurance
• Vision Insurance
• Basic Life and Accidental Death & Dismemberment Insurance
• Voluntary Life Insurance
• Short Term Disability Insurance
• Long Term Disability Insurance
• Accident
• Cancer
4

BENEFITS OVERVIEW
ELIGIBILITY
Full-time employees working at least 30 hours per week are eligible for
benefits on the first of the month following or coinciding with 60 days of
employment. Many of the plans offer coverage for eligible dependents,
including:
• Your legal spouse
• Your children to age 26, regardless of student, marital, or tax-dependent
status (including stepchild, legally adopted child, a child placed with you for
adoption, or a child for whom you are the legal guardian)
• Your dependent children over age 26 who are physically or mentally unable
to care for themselves
CHANGING BENEFITS AFTER OPEN ENROLLMENT
You may pay your portion of the medical, dental, vision, and cancer plan costs
on a pre-tax basis. Thus, due to IRS regulations, once you have made your
elections for the plan year, you cannot change your benefits until the next
annual open enrollment period. The only exception is if you experience a
qualifying event, and election changes must be consistent with your life event.
To request a benefits change, notify Human Resources within 30 days of the
qualifying life event at 985-448-0970. Change requests submitted after 30
days cannot be accepted. You may need to provide proof of the life event.
Qualifying life events include, but are not limited to:
• Marriage, divorce, or legal separation
• Birth or adoption of an eligible child
• Death of your spouse or covered child
• Change in your spouse’s work status that affects his or her benefits
• Change in your child’s eligibility for benefits
• Qualified Medical Child Support Order
5

MEDICAL
INSURANCE
6

MEDICAL INSURANCE
CARRIER: United Healthcare
Plan Options: Two Plan Options
Medical Plan Summary
Please refer to the official plan documents for additional information on coverage
and exclusions.
COVERED BENEFITS Plan A Plan B
Year Deductible Individual/Family
In-Network Out-of-Network In-Network Out-of-Network
$1,000/$3,000 $1,250/$3,500 $2,000/$6,000 $4,000/$12,000
Out of Pocket Maximum Individual/Family
(includes deductible, copays, and coinsurance
$2,000/$4,000 $2,500/$5,000 $6,250/$12,500 $12,500/$25,000
Preventive Care Plan pays 100% 40% after deductible Plan pays 100% 40% after deductible
Office Visit
Premium Designation
$25 / $25 specialist 40% after deductible $25 / $55 specialist 40% after deductible
Office Visit
Non-Premium Designation
$40 / $40 specialist 40% after deductible $40 / $55 specialist 40% after deductible
Urgent Care $40 Copay 40% after deductible $55 copay 40% after deductible
Emergency Room 60% after deductible 60% after deductible 60% after deductible 60% after deductible
7

MEDICAL INSURANCE
CARRIER: United Healthcare
Plan Options: Two Plan Options
Medical Plan Summary Continued...
Please refer to the official plan documents for additional information on
coverage and exclusions.
COVERED BENEFITS Plan A Plan B
In-Network Out-of-Network In-Network Out-of-Network
Hospital Services
Inpatient
60% after deductible 40% after deductible 60% after deductible 40% after deductible
Outpatient 60% after deductible 40% after deductible 60% after deductible 40% after deductible
Prescription Drugs
Generic
$7
$15 after deductible
Preferred Brand $30 Reimbursement based $40 after deductible
on lowest contracted
amount.
Non-Preferred Brand $55 $70 after deductible
Reimbursement based
on lowest contracted
amount.
Specialty $50
10% copay with $150
max
8

MEDICAL INSURANCE
CARRIER: United Healthcare
Plan Options: Two Plan Options
PER PAY PERIOD RATES
Note: If you participate and complete the Wellness Screening, your annual premium amount will decrease
by $600. Employees hired on or after 1/1/2021 are eligible for the wellness screening rate until 1/1/2022
MEDICAL RATES Plan A Plan B
PAY PERIOD Weekly (48) Weekly (48)
WELLNESS SCREENING
With Wellness
Screening
Without Wellness
Screening
With Wellness
Screening
Without Wellness
Screening
Employee Only $37.55 $50.05 $21.57 $34.07
EE & Spouse $150.10 $162.60 $118.14 $130.64
EE & Child(ren) $133.22 $145.72 $103.65 $116.15
EE & (Family) $245.78 $258.28 $200.23 $212.73
MEDICAL RATES Plan A Plan B
PAY PERIOD Bi-Weekly (24) Bi-Weekly (24)
WELLNESS SCREENING
With Wellness
Screening
Without Wellness
Screening
With Wellness
Screening
Without Wellness
Screening
Employee Only $75.11 $100.11 $43.14 $68.14
EE & Spouse $300.21 $325.21 $236.38 $261.28
EE & Child(ren) $266.44 $291.44 $207.31 $232.31
EE & (Family) $491.55 $516.55 $400.45 425.45
9

10

11

12

LIFE
INSURANCE
13

COMPANY PAID LIFE INSURANCE
CARRIER: AUL
LIFE and ACCIDENTAL DEATH & DISMEMBERMENT (AD&D)
Basic life and AD&D insurance are automatically provided to all eligible
employees at no cost. If you die as a result of an accident, your beneficiary
would receive both the life and the AD&D benefit.
Life Insurance Amount: $10,000
AD&D Amount: $10,000
Benefit Reduction Schedule:65% at 65, 45% at 70, 30% at 75, 20% at 80, 15%
at 85, 10% at 90
Cost per Pay Period $0.00
REMINDER
Review your beneficiary designations
14

VOLUNTARY LIFE INSURANCE
CARRIER: AUL
WHAT IS VOLUNTARY LIFE
INSURANCE?
Voluntary life insurance, also called group life
insurance, is offered through an employer but is
paid by employees.
WHY PURCHASE VOLUNTARY LIFE
INSURANCE?
● This type of life insurance has limited
underwriting required. This allows for
people with health conditions or lifestyles
that might otherwise disqualify them to
qualify for life insurance.
● The group rates are lower than what you
could purchase on your own.
● You may purchase a policy for your spouse
and children.
For a quote, Please see attached illustration in
your new hire packet or contact Brooks Foret at:
(985) 446-8767
Employee
Coverage Range 5x Annual Salary to $500,000
Minimum Benefit $10,000
Guarantee Issue $100,000
Age Reduction Schedule 45% at 70, 30% at 75, 20% at 80, 15% at 85, 10% at 90
Spouse
Coverage Range
$5,000 to $250,000 (not to exceed 50% of employee amount)
Minimum Benefit $5,000
Guarantee Issue $20,000
**Coverage ends when your spouse turns age 70*
Dependent Children
Available Benefits $2,500 , $5,000 , $7,500 , $10,000
15

SHORT AND LONG TERM
DISABILITY INSURANCE
16

SHORT TERM DISABILITY INSURANCE
CARRIER: Sunlife
Short-Term Disability (STD) insurance is designed to help you meet your financial needs
if you become unable to work due to a non-work related illness or injury.
• Weekly Benefit – 60% of your total weekly earnings up to $2,700 each week
• Elimination Period: 7 days for Injury & Sickness
• Benefit Durations: Up to 25 weeks
• Guaranteed Issue: As a new hire, you are not required to submit health questions. If
coverage is waived when you are first eligible and you want to elect coverage at a
later date, a health questionnaire will need to be submitted and approved by Sunlife.
Please see attached illustration in
your benefits enrollment packet to
calculate your per pay period cost.
REMINDER
17

LONG TERM DISABILITY INSURANCE
CARRIER: Sunlife
LTD insurance is designed to help you meet your financial needs if your disability extends beyond the
short-term disability period.
• Monthly Benefit – 60% of your total monthly earnings
• Max Monthly Benefit - $10,000
• Elimination Period: 180 days
• Benefit Duration– Until Social Security Normal Retirement Age
• Guaranteed Issue: As a new hire, you are not required to submit health questions. If coverage is
waived when you are first eligible and you want to elect coverage at a later date, a health
questionnaire will need to be submitted and approved by Sunlife.
Please see attached illustration in
your benefits enrollment packet to
calculate your per pay period cost.
18

DENTAL
& VISION
INSURANCE
19

DENTAL INSURANCE
CARRIER: SunLife
● You will pay less out of pocket when you choose an in-network provider.
● Locate an in-network provider at www.sunlife.com/us
● Be sure to ask for a pre-treatment estimate.
● Out-of-network providers can balance bill, or bill you for the difference
between the provider’s charge and the allowed amount.
ELECTION
WEEKLY(48)
DENTAL
PREMIUM
BI-WEEKLY(24)
DENTAL
PREMIUM
Employee Only $5.77 $11.54
EE & Spouse $11.72 $23.44
EE & Child(ren) $16.23 $32.46
EE & (Family) $22.18 $44.36
COVERED BENEFITS
Deductible (per calendar year)
Annual Plan Maximum
Preventive Care
Oral exams, cleanings, X-rays
Basic Services
New fillings, extractions, general anesthesia
Major Services
Bridges, crowns (inlays/outlays), dentures (full/partial),
Endodontics, Periodontics
PLAN PAYS
$50 per person, $150 per family
$1,500
100%
80%
50%
20

21

VISION INSURANCE
CARRIER: Sunlife
● You will pay less out of pocket when you choose an in-network provider.
● Locate an in-network provider at www.vsp.com
● You must submit a claim form for out-of-network expenses.
● LASIK surgery discounts available
ELECTION
WEEKLY(48)
VISION
PREMIUM
BI-WEEKLY(24)
VISION
PREMIUM
Employee Only $1.52 $3.05
EE & Spouse $3.04 $6.09
EE & Child(ren) $3.35 $6.69
EE & (Family) $4.87 $9.73
COVERED BENEFITS
IN-NETWORK
Eye Exam (every 12 months)
$10 copay
Standard Plastic Lenses (every 12 months)
Single / Bifocal / Trifocal / Lenticular
$25 copay
Frames (every 24 months)
$130 allowance + 20% off balance
Contact Lenses (every 12 months in lieu of
standard plastic lenses)
Elective
Medically Necessary
$130 allowance
$25 copay
22

23

Accident and Cancer
Insurance
24

VOLUNTARY ACCIDENT INSURANCE
CARRIER: Sunlife
Accident insurance supplements your
existing medical insurance in case you are
have an accident; medical insurance alone
may not be enough to cover your expenses.
The plan pays a cash benefit during the term
of your coverage following a covered
accident and could help cover:
●
●
●
●
Out-of-pocket expenses such as
copays and deductibles
Transportation
Lodging costs
Emergency room expenses
ELECTION WEEKLY(48) BI-WEEKLY(24)
Employee Only $1.63 $3.26
EE & Spouse $2.69 $5.38
EE & Child(ren) $2.97 $5.95
EE & (Family) $4.03 $8.07
25

What’s covered?
Once your coverage goes into effect you can file a claim for covered accidents that occur after your
insurance plan’s effective date. Unless otherwise specified, benefits are payable only once for each
covered accident as applicable.
Dislocations Open (Surgery) Closed (no surgery)
Hip $2,000 $1,000
Knee, ankle, or bones of the foot $1,000 $500
Elbow, wrist, or lower jaw $400 $200
Shoulder $500 $250
Collarbone or bones of the hand $800 $400
Finger(s) or toe(s) $100 $50
Fractures
Hip or Thigh $2,000 $1,000
Skull-depressed $3,000 $1,500
Skull-simple $1,500 $750
vertebral processes, bones of the face or nose $350 $175
Leg $1,000 $500
vertebrae, stamum or pelvis $800 $400
upper jaw or upper arm $375 $190
lower jaw, collarbone, shoulder, forearm, hand, wrist, foot, ankle, kneecap, elbow, or heel $325 $170
Rib, Finger, Toe, Coccyx $175 $90
Multiple Ribs $500 $250
Additional Injuries
Eye Injury - surgical repair $125
Eye Injury - object remove $125
Gunshot wound $250
Paralysis - paraplegia $12,500
Paralysis - quadriplegia $25,000
Coma $5,000
Concussion $50
Burns 2nd Degree 3rd Degree
20-40 square centimeters $200 $500
41-65 square centimeters $400 $1,000
66-160 square centimeters $600 $3,000
161-225 square centimeters $800 $7,000
more than 225 square centimeters $1,000 $10,000
Skin Graft
Lacerations
50% of the applicable Burn Benefit
no sutures and treated by doctors $20
single laceration under 5cm with sutures $35
5-15 cm with sutures (total of all lacerations) $125
Greater than 15 cm with sutures (total of all lacerations) $250
26

Medical Services
Diagnostic Exam - Arteriogram, Angiogram, CT, CAT, EKG, EEG, or MRI (1 time per benefit year) $100
Diagnostic Exam - X-ray (1 time per covered accident) $25
Accident Emergency Treatment, non-emergency room (once per covered accident) $25
Physician's Follow-up Treatment, non-emergency room (once per covered accident) $25
Physical Therapy (per visit up to 10 visits per covered accident) $25
Medical Devices $100
Epidural Pain Management (up to 2 times per covered accident) $25
Prescription Drug $15
Prosthesis (one) $250
Prosthesis (two) $500
Blood, Plasma, or Platelet Transfusion $100
Hospital
Hospital Admission (once per benefit year) $500
Hospital Confinement (per day up to 3654 days per covered accident) $150
Intensive Care Unit Admission (once per Benefit Year: payable instead of Hospital Admission benefit if confined immediately
to ICU)
$750
Intensive Care Unit Confinement (per day up to 14 days, payable instead in addition to any Hospital Confinement benefit) $300
Ambulance (Ground) $100
Ambulance (air) $750
Emergency Room Admission $100
Family Lodging (per day up to 30 days per benefit year) $50
Transportation (100 or more miles up to 3 times per covered accident) $250
Rehabilitation Unit (per day up to 30 days per covered accident) $50
Surgery
Miscellaneous Surgery requiring general anesthesia (not covered by any other benefit) $150
Open Surgery $625
Exploratory Surgery or Debridement $125
Tendon/Ligament/Rotator Cuff Tear $300
Tom Knee Cartilage $300
Ruptured/Herniated Disc $300
Emergency Dental
Emergency Dental Extraction $30
Emergency Dental Crown $100
Wellness
Wellness Screening Benefit (once per benefit year) $50
Life and Dismemberment Losses*
Accidental Death $15,000
Accidental Death Common Carrier (pays an additional benefit if accidental death occurs while traveling as a fare-paying
passenger on a public conveyance)
Catastrophic Loss: Both arms or both hands, both legs or both feet, one hand and one foot or one arm and one leg, or
irrevocable loss of sight or both eyes
$30,000
$7,500
Loss of one hand, foot, leg or arm $3,750
Loss of sight of one eye or loss of one eye $3,750
Two or more fingers or toes $750
One finger or one toe $375
27

VOLUNTARY CANCER INSURANCE
CARRIER: Aflac
Cancer insurance supplements your
existing medical insurance in case you are
diagnosed with cancer; medical insurance
alone may not be enough to cover your
expenses. The plan pays a cash benefit
during the term of your coverage
following a positive diagnosis of an
internal cancer.
For more information, please contact
Heather Heaton at: 504-233-3709 or
heather_heaton@us.aflac.com
WHY PURCHASE CANCER INSURANCE?
You and your loved ones can rest a little easier knowing you have protection in place to help avoid
depleting your bank accounts or taking on additional debt to cover day-to-day living expenses.
●
●
●
●
Help cover medical plan deductibles, co-pays and other out-of-pocket costs
Help cover everyday living expenses such as groceries, rent and mortgage payments
Hire extra help for around the house, such as in-home caregivers
Pay for travel to treatment facilities away from home as well as family visits
ELECTION WEEKLY(48) BI-WEEKLY(24)
Employee Only $8.38 $16.75
EE & Spouse $14.41 $28.82
EE & Child(ren) $8.38 $16.75
EE & (Family) $14.41 $28.82
28

29

Cancer Treatment Advocate
Surgery & Imaging Program
Gym Discount Program
30

31

32

33

Global Fit ID: P576
34

ENROLLMENT INSTRUCTIONS
During the Employee Benefits Enrollment process, a representative will cover the extensive benefits
package that Sealevel Construction offers eligible employees, including Medical/Dental/Vision insurance,
Basic and Voluntary Life Insurance, Short-Term Disability and Long-Term Disability , Accident, and Aflac
Cancer.
You will need to complete the enrollment form and submit it to:
Sealevel Construction’s Human Resources Department
yvu@sealevelinc.com
985-448-0970
REMEMBER: Enrollment must be completed by the deadline or you
may not be able to enroll yourself and/or your eligible dependents until our next
open enrollment, or a qualifying event occurs.
This summary of benefits is not intended to be a complete description of the terms of Company Name’s insurance benefit plans. Please refer to the plan
document(s) for a complete description. Each plan is governed in all respects by the terms of its legal plan document, rather than by this or any other
summary of the insurance benefits provided by the plan. In the event of any conflict between a summary of the plan and the official document, the
official document will prevail. Although Company Name maintains its benefit plans on an ongoing basis, Company Name reserves the right to terminate 35
or amend each plan, in its entirety or in any part at any time.

IMPORTANT CONTACTS
BENEFIT CARRIER PHONE WEBSITE
Medical Insurance UMR 800-826-9781 www.umr.com
Dental Insurance Sunlife 1-800-522-1313 www.sunlife.com
Vision Insurance Sunlife 1-800-877-7195 www.sunlife.com
Basic Life / Vol Life and
AD&D Insurance Brooks Foret 985-446-8767 brooksforet@bellsouth.net
Short Term and Long Term
Disability Insurance
Sunlife 1-800-786-5433 www.sunlife.com
Cancer Insurance
Aflac/
Heather Heaton
504-233-3709 www.aflac.com
Accident Sunlife 1-800-522-1313 www.sunlife.com
Sealevel Human Resources
Administrator
Yen Vu 985-448-0970 yvu@sealevelinc.com
Plan and Premium Contact Brooks Foret 985-446-8767 brooksforet@bellsouth.net
BXS Insurance Account
Manager
Ashley Fernandes 225-621-0037 ashley.fernandes@bxsi.com
YOUR BXS INSURANCE ACCOUNT REPRESENTATIVE:
Ashley Fernandes
225-621-0037
ashley.fernandes@bxsi.com
36

GLOSSARY
37

GLOSSARY
Coinsurance: Your share of the cost of a covered health care service, calculated as a percent (for
example, 20%) of the allowed amount for the service, typically after you meet your deductible.
For instance, if your plan’s allowed amount for an office visit is $100 and you’ve met your
deductible (but haven’t yet met your out-of-pocket maximum), your coinsurance payment of
20% would be $20. Your plan sponsor or employer would pay the rest of the allowed amount.
Copay: The fixed amount, as determined by your insurance plan, you pay for health care
services received.
Deductible: The amount you owe for medical services before your medical insurance or plan
sponsor (employer) begins to pay its portion. For example, if your deductible is $3,000, your
plan does not pay anything until you’ve met your $3,000 deductible for covered health care
services. This deductible may not apply to all services, including preventive care. Preventive
care is 100% covered by the plan.
Explanation of Benefits (EOB) / Personal Health Statement (PHS): A statement sent by your
insurance carrier that explains which procedures and services were provided, how much they
cost, what portion of the claim was paid by the plan, and what portion is your liability, in
addition to how you can appeal the insurer’s decision. These statements are also posted on the
carrier’s website for your review.
Health Care Cost Transparency: Also known as Market Transparency or Medical Transparency.
Health care provider costs can vary widely, even within the same geographic area. To make it
easier for you to get the most cost-effective health care products and services, online cost
transparency tools, which are typically available through health insurance carriers, allow you to
search an extensive national database to compare costs for everything from prescription drugs
and office visits to MRIs and major surgeries.
Employee Contribution: The weekly amount you pay for your insurance coverage.
High Deductible Health Plan (HDHP): Plan option that provides choice, flexibility and control
when it comes to spending money on health care. Preventive care is covered at 100% with
in-network providers, there are no copays, and all qualified employee-paid Medical expenses
count toward your deductible and your out-of-pocket maximum.
In-Network: In-network providers are doctors, hospitals and other providers that contract with
your insurance company to provide health care services at discounted rates.
Out-of-Network: Out-of-network providers are doctors, hospitals and other providers that are
not contracted with your insurance company. If you choose an out-of-network doctor, services
will not be provided at a discounted rate and your cost sharing (deductibles and coinsurance)
will increase. 38

Sealevel Construction
www.sealevelinc.com| 985-448-0970
39