Coulson Oil - Petro - 2021 Benefits Guide

2021 BENEFITS
ENROLLMENT GUIDE
COULSON OIL GROUP
Petro Plus Management, LLC
Effective 7/1/2021 to 6/30/2022

LETTER FROM COMPANY PRESIDENT
Our employees are our most valuable asset. Coulson Oil Group is committed
to offering a comprehensive employee benefits program that helps our employees
stay healthy, feel secure, and maintain a positive work/life balance.
Benefits offered through the workplace can help protect important items such
as your income and assets if you become sick or injured. Other benefits can help
cover expenses that might not be covered in your medical plan such as day care,
travel expenses, rent, mortgage payments, and everyday cost-of-living expenses.
These benefits are not only valuable, but also provide great protection for you and
your family while reducing financial exposure in your medical plan.
Coulson Oil Group works with BXS Insurance to ensure that the benefits we
offer are best-in-class. The voluntary benefits program that is offered also provides
value because these benefits work hand-in-hand with the medical plan in lowering
financial exposure for you and your family while providing benefits over and above
what is covered by a traditional medical plan.
We understand that life can be busy. But we encourage you to take the time to
read the material inside this booklet to familiarize yourself with the benefits
available to you.
Again, thank you for all you do for our company and we wish you only the
very best.
Sincerely,
John Harris, President and CEO

CONTENTS
4 Benefits Overview
7 Medical Insurance
10 Health Savings Account
13 Flexible Spending Accounts
16 Dental Insurance
16 Vision Insurance
19 Voluntary Life Insurance
22 Disability Insurance
25 Voluntary Accident Insurance
27 Voluntary Critical Illness/Cancer Insurance
31 Legal Services Program
35 Open Enrollment Instructions
36 Important Contacts
37 Carrier Resources
46 Glossary

BENEFITS
OVERVIEW
4

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
• Health Savings Account
• Flexible Spending Accounts
• Dental Insurance
• Vision Insurance
• Disability Insurance
• Voluntary Life Insurance
• Voluntary Accident Insurance
• Voluntary Critical Illness/Cancer Insurance
• Legal Services Plan
5

BENEFITS OVERVIEW
ELIGIBILITY
Full-time employees working at least 30 hours per week are eligible for benefits
on the first of the month following 30 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, and vision plan costs, and fund
the flexible spending accounts, 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. 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
6

MEDICAL
INSURANCE
7

MEDICAL INSURANCE
CARRIER: Arkansas Blue Cross Blue Shield / Health Advantage
Plan Options: A PPO plan (Option 1) or a high-deductible health plan (Option 2)
Please refer to the official plan documents for additional information on coverage and exclusions.
COVERED BENEFITS
Option 1
Traditional PPO Plan
Option 2
HSA Plan
In-Network Out-of-Network In-Network Out-of-Network
Year Deductible
Individual $1,000 $3,000 $3,000 $6,000
Family $3,000 $9,000 $6,000 $12,000
Out of Pocket Maximum
Individual $3,000 $11,000 $3,000 Unlimited
Family $9,000 $33,000 $6,000 Unlimited
Coinsurance (Plan Pays) 80% 60% 100% 80%
Preventive Care
Physician Services
Immunizations covered
in full; Exams $25 copay
40% after deductible Plan pays 100% 20% after deductible
Primary Care $25 copay 40% after deductible 0% after deductible 20% after deductible
Virtual Visit $25 copay Not covered $45 copay Not covered
Specialist $35 copay 40% after deductible 0% after deductible 20% after deductible
Urgent Care $35 copay 40% after deductible 0% after deductible 20% after deductible
Emergency Room
$100 copay,
20% coinsurance
$100 copay,
20% coinsurance
0% after deductible 0% after deductible
Hospital Services
Inpatient
Outpatient
Prescription Drugs
$200 copay,
20% coinsurance
$100 copay,
20% coinsurance
40% after deductible 0% after deductible 20% after deductible
40% after deductible 0% after deductible 20% after deductible
Tier 1 $10 copay Not covered 0% after deductible Not covered
Tier 2 $40 copay Not covered 0% after deductible Not covered
Tier 3 $60 copay Not covered 0% after deductible Not covered
8

WHICH MEDICAL INSURANCE PLAN IS
RIGHT FOR YOU?
Choosing the right medical plan is an important decision. Take the
time to learn about your options to ensure you select the right plan for
you and your family.
THINGS TO CONSIDER
1. Do you prefer to pay more for medical insurance out of your
paycheck, but less when you need care?
2. Or, do you prefer to pay less out of your paycheck, but more when
you need care?
3. What planned medical services do you expect to need in the
upcoming year?
4. Are you able to budget for your deductible by setting aside pre-tax
dollars from your paycheck in an HSA or FSA?
5. Do you or any of your covered family members take prescription
medications on a regular basis?
Option 1
Traditional PPO Plan
Option 2
HSA Plan
COVERAGE LEVEL
Monthly
Rate
Coulson
pays 75%
EE Rates per
52 Pay Periods
Monthly
Rate
Coulson
pays 75%
EE Rates per
52 Pay Periods
Employee Only $526.98 $395.24 $30.40 $425.00 $318.75 $24.52
Employee & Family $1,365.95 $1,024.46 $78.80 $1,101.61 $826.21 $63.55
COMPARING YOUR MEDICAL PLAN OPTIONS
• Higher cost per paycheck
• Lower deductible
• Can fund a Health Care Flexible Spending Account (FSA)
• Lower cost per paycheck
• Higher deductible
• Can fund a health savings account (HSA)
9

HEALTH
SAVINGS
ACCOUNT
10

HEALTH SAVINGS ACCOUNT
CARRIER: Consolidated Admin Services
If you enroll in the high-deductible health (HDHP) plan, you may be eligible to fund a
Health Savings Account (HSA). An HSA is a personal health care savings account that
you can use to pay out-of-pocket health care expenses with pre-tax dollars. Your
contributions are tax free and the money remains in the account for you to spend on
eligible expenses no matter where you work or how long it stays in the account.
WHO IS ELIGIBLE?
You are eligible to open and fund an HSA if:
● You are enrolled in the Arkansas Blue Cross Blue Shield / Health Advantage HSA Plan.
● You are not covered by a non-HSA plan, health care FSA, or health reimbursement arrangement.
● You are not eligible to be claimed as a dependent on someone else’s tax return
● You are not enrolled in Medicare
● You have not received Veterans Administration Benefits in the last three months
HSA EMPLOYER CONTRIBUTIONS
● Coulson will help you save by contributing $150 per
quarter; total $600 per year.
● Contributions to a health savings account (including the
employee contributions) cannot exceed the annual IRS
contribution maximums.
● Employees age 55+ by 12/31/2021 may contribute
additional funds to their HSA (up to $1,000 in 2021).
● You must open your HSA through Consolidated Admin
Services to receive contributions.
Coulson Oil Group
contributes $600 to your
HSA each year!
($150 per quarter)
$3,600
$7,200 $1,000
INDIVIDUAL
ALL
OTHER TIERS
AGE 55+
CATCH-UP
CONTRIBUTION
11

HEALTH SAVINGS ACCOUNT
MAXIMIZE YOUR TAX SAVINGS
• Contributions to an HSA are tax-free and can be made through payroll deduction on a pre-tax basis.
• This money in your HSA (including interest and investment earnings) grows tax-free.
• As long as you use the funds to pay for qualified medical expenses, the money is spent tax-free.
YOU INDIVIDUALLY OWN YOUR HSA
• You own and administer your HSA.
• You determine how much you will contribute to your account and when to use the money to pay for
eligible health care expenses.
• You can change your contributions at any time during the plan year without a qualifying event.
• Like a bank account, you must have a balance in order to pay for eligible health care expenses.
• Keep all receipts for tax documentation.
• An HSA allows you to save and “rollover” money from year to year.
• The money in the account is always yours, even if you change health plans or jobs.
• There are no vesting requirements or forfeiture provisions.
ACCESSING YOUR HSA FUNDS
Debit Card: Draws directly from your HSA and can be used to pay for eligible expenses at your doctor’s
office, pharmacy, or other locations where you purchase health related items or services.
USE YOUR HSA TO PAY QUALIFIED MEDICAL EXPENSES
• You can use your HSA money to pay for eligible expenses now or in the future.
• Funds in your HSA can be used for your expenses and those of your spouse and eligible dependents,
even if they are not covered by the Arkansas Blue Cross Blue Shield / Health Advantage HDHP plan
(Option 2).
• Eligible expenses include deductibles, doctor’s office visits, dental expenses, eye exams, prescription
expense and LASIK eye surgery.
• A complete list of eligible expenses can be found at www.irs.gov.
12

FLEXIBLE
SPENDING
ACCOUNTS
13

FLEXIBLE SPENDING ACCOUNTS
CARRIER: Consolidated Admin Services
Coulson offers two flexible spending account (FSA) options – the health care FSA and the dependent
care FSA – that allow you to pay for eligible health care and dependent care expenses with the pre-tax
dollars.
Log into your account at www.consolidatedadmin.com to view your account balance(s), calculate tax
savings, view eligible expenses, download forms, view transaction history, and more.
HEALTH CARE FSA
• Set aside pre-tax money from your paycheck to pay for eligible out-of-pocket expenses, such as
deductibles, copays, and other health-related expenses, that are not paid by the medical, dental, or
vision plans.
• Over-the-counter (OTC) medications are eligible for reimbursement without a prescription.
DEPENDENT CARE FSA
• Set aside pre-tax money from your paycheck for daycare expense to allow you and your spouse to
work or attend school full time.
• Eligible dependents are children under age 13 or a child over 13, spouse, or elderly parent residing in
your house who is physically or mentally unable to care for himself or herself.
• Examples of eligible expenses are daycare facility fees, before and after-school care, and in-home
babysitting fees (income must be reported by your care provider).
HEALTH CARE FSA
DEPENDENT CARE FSA
$2,750 $5,000
$2,500
married filing jointly or
single / head of household
married filing separately
14

FLEXIBLE SPENDING ACCOUNTS
HOW DOES AN FSA WORK?
You decide how much to contribute to each FSA on a plan year basis up to the maximum allowable amounts.
Your annual election will be divided by the number of pay periods and deducted evenly on a pre-tax basis
from each paycheck throughout the year.
You will receive a debit card from Consolidated Admin Services, which can be used to pay for eligible health
care expenses at the point of service. If you do not use your debit card or if you have dependent care
expenses to be reimbursed, submit a claim form and a bill or itemized receipt from the provider to
Consolidated Admin Services. Keep all receipts in case Consolidated Admin Services requires you to verify the
eligibility of a purchase.
THINGS TO CONSIDER
• Both healthcare and dependent care FSA dollars are use it or lose it. However, you have an additional
two and a half months to incur and be reimbursed for expenses after the end of the plan year.
• You cannot take income tax deductions for expenses you pay with your FSA(s)
• You cannot stop or change your FSA contribution(s) during the plan year unless you experience a
qualifying life event.
SPECIAL FSA ACCOUNT FEATURES
RUNOUT
Runout is the 30 days after
your plan year ends during
which you may submit last
year’s expenses to be
reimbursed with last year’s
FSA funds.
NO GRACE PERIOD
ROLLOVER
You have the ability to
rollover your full
remaining balance from
the plan year that has
ended 6/30/2021
15

DENTAL & VISION
INSURANCE
16

DENTAL INSURANCE
CARRIER: Delta Dental
● You will pay less out of pocket when you choose an in-network provider.
● Locate an in-network provider at www.deltadentalar.com
● 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.
● Late Entrant Waiting Periods may apply if an employee did not enroll when initially eligible.
DENTAL RATES
MONTHLY
COST
52 PAY
PERIODS
Employee Only $25.28 $5.83
Employee & Family $76.04 $17.55
COVERED BENEFITS In-Network Out-of-Network
Deductible (per calendar year)
$50 per person,
3 per family
$50 per person,
3 per family
Annual Plan Benefit Maximum $1,000 $1,000
Preventive Care (deductible waived)
Oral exams, cleanings, X-rays, fluoride, sealants
Basic Services
Fillings, simple extractions, space maintainers, endodontics, oral surgery
Major Services
Bridges, crowns, implants, dentures, surgical/non-surgical periodontics
100% 90%
80% 72%
50% 45%
Orthodontia Services (Dependent Children to age 19) 50% 45%
Lifetime Orthodontia Plan Max $750 $750
Annual Maximum Carryover*
Carryover Benefit • Member receives annual maximum January 1st
• Member must have one covered dental service during the year
• Paid claims for the benefit year must be less than half of the annual maximum
• A quarter of the annual maximum will be carried over for future use
• Carry over benefit maximum is up to $1,000
Limitations
Late Entrant Policy
Claims must not exceed $499 for the plan year
The benefit allowance for services of an out of network dentist will be reduced by 10% for eligible services as
determined by Delta Dental after applying the applicable deductibles, copays, and maximums. This means your
out-of-pocket expense may be greater if you choose an out of network dentist. There is a 12 month waiting
period on the replacement of existing appliances for employees not covered for 12 months on a prior group
dental plan. After 12 months, replacement of an existing appliance will be covered if it is more than 5 years old.
Dependents may be covered up to age 26.
If a member elects to waive the dental plan when they are first eligible to enroll and later they decide to elect
dental coverage there will be a 12 month late entrant penalty for all major services.
17

VISION INSURANCE
CARRIER: Delta Dental / Superior Vision
● You will pay less out of pocket when you choose an in-network provider.
● Locate an in-network provider at www.deltadentalar.com
● You must submit a claim form for out-of-network expenses.
● LASIK surgery discounts available
VISION RATES
MONTHLY
COST
52 PAY
PERIODS
Employee Only $8.48 $1.96
Employee & Family $22.90 $5.28
COVERED BENEFITS IN-NETWORK OUT-OF-NETWORK
Eye Exam (every 12 months) $10 copay $36 allowance
Standard Plastic Lenses (every 12 months)
Single / Bifocal / Trifocal / Lenticular
$10 copay $28 / $42 / $56 / $78 allowance
Frames (every 12 months) $150 allowance $70 allowance
Contact Lenses, in lieu of glasses (every 12 months)
Elective
Medically Necessary
$150 allowance
Plan Pays 100%
$100 allowance
$210 allowance
18

VOLUNTARY
LIFE
INSURANCE
19

VOLUNTARY LIFE INSURANCE
CARRIER: MetLife
WHAT IS VOLUNTARY LIFE INSURANCE? Voluntary 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 IF you elect coverage for
yourself.
Employee Benefits
● $10,000 increments to a maximum of the lesser of 5x salary or $300,000
● Guarantee Issue Amount for New Hires: $100,000
● AD&D Amount: 100% of supplemental life benefit amount
● AD&D Maximum: Same as supplemental term life coverage
Spouse Benefits
● $5,000 increments to a maximum of $100,000, not to exceed $100,000
● Guarantee Issue Amount: $25,000
● AD&D Amount: 100% of supplemental life benefit amount
● AD&D Maximum: Same as supplemental term life coverage
● Spouse cost is based on employee’s age
Child(ren) Benefits
● Benefit Options: $1,000 / $2,000 / $4,000 / $5,000 / $10,000
● Guarantee Issue Amount: $10,000
● AD&D Amount: 100% of supplemental life benefit amount
● AD&D Maximum: Same as supplemental term life coverage
REMINDER
Review your beneficiary designations
20

VOLUNTARY LIFE INSURANCE
CARRIER: MetLife
Will Preparation Service
Like life insurance, a carefully prepared Will is important. With a Will, you can define your most important
decisions such as who will care for your children or inherit your property. By enrolling for Supplemental Term
Life coverage, you will have in person access to Hyatt Legal Plans’ network of 11,500+ participating attorneys
for preparing or updating a will, living will and power of attorney. When you enroll in this plan, you may take
advantage of this benefit at no additional cost to you if you use a participating plan attorney.
MetLife Estate Resolution Services (ERS)
A valuable service offered under the group policy. A Hyatt Legal Plan attorney will consult with your
beneficiaries by telephone on in person regarding the probate process for your estate. The attorney will also
handle the probate of your estate for your executor or administrator. This can help alleviate the financial and
administrative burden upon your loved one in their time of need.
Portability
If your present employment ends, you can choose to continue your current life benefits.
Employee & Spouse Coverage
Monthly Premium
AGE $1,000 $10,000 $20,000 $40,000 $50,000 $100,000
Under 30 $0.08 $0.75 $1.50 $3.00 $3.75 $7.50
30-34 $0.08 $0.83 $1.66 $3.32 $4.15 $8.30
35-39 $0.10 $0.98 $1.96 $3.92 $4.90 $9.80
40-44 $0.12 $1.25 $2.50 $5.00 $6.25 $12.50
45-49 $0.18 $1.75 $3.50 $7.00 $8.75 $17.50
50-54 $0.26 $2.55 $5.10 $10.20 $12.75 $25.50
55-59 $0.44 $4.41 $8.82 $17.64 $22.05 $44.10
Dependent Child Coverage
Monthly Premium
AMOUNT
RATE
$1,000 $0.29
$2,000 $0.58
$4,000 $1.15
$5,000 $1.44
$10,00 $2.88
60-64 $0.63 $6.26 $12.52 $25.04 $31.30 $62.60
65-69 $1.12 $11.15 $22.30 $44.60 $55.75 $111.50
70+ $1.88 $18.80 $37.60 $75.20 $94.00 $188.00
● Employees currently enrolled in coverage can increase their benefit by 1 increment of $10,000 as long as it does not
exceed the Guarantee Issue amount.
● If an employee does not have current coverage, and is past their 31 day initial enrollment window, you must complete
an Evidence of Insurability form.
● If your spouse currently has coverage, you may increase their benefit by 1 increment of $5,000.
● If a child does not have current coverage, and is past their 31 day initial enrollment window, you must complete an
Evidence of Insurability form.
REMINDER
Review your beneficiary designations
21

DISABILITY
INSURANCE
22

DISABILITY INSURANCE
CARRIER: MetLife
SHORT-TERM DISABILITY INSURANCE
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. This is a voluntary plan;
employees are responsible for 100% of the cost. Premiums are calculated as a percentage of
your annual base salary. Benefit may be offset due to other benefits such as paid sick leave,
workers’ compensation.
●
●
●
●
Benefit Amount: 60% of base weekly salary up to $2,000 per week
Elimination Period: 1 st day Accident / 8 th day Illness
Benefit Durations: Up to 26 weeks
Pre-Existing Condition Waiting Period: 3 months Look Back; 6 months Forward
STD MONTHLY PREMIUM
Based on Employee’s Age
Weekly Benefit

DISABILITY INSURANCE
CARRIER: MetLife
LONG-TERM DISABILITY INSURANCE
LTD insurance is designed to help you meet your financial needs during longer disability
periods. Benefit may be offset due to other benefits such as paid sick leave, workers’
compensation. This is a voluntary plan; employees are responsible for 100% of the cost.
Premiums are calculated as a percentage of your annual base salary. Benefit may be offset
due to other benefits such as paid sick leave, workers’ compensation.
●
●
●
●
●
Benefit Amount: 60% of base monthly salary up to $5,000 per month
Elimination Period: 180 days from onset of disability injury or illness
Benefit Duration: Until Social Security Normal Retirement Age or the period shown in
the Duration Schedule found in the Certificate of Coverage, whichever occurs first.
Pre-Existing Condition Waiting Period: 12 months Look Back; 12 months Forward
Evidence of Insurability: If employee does not elect coverage during the initial
enrollment period, an Evidence of Insurability (EOI) form must be completed.
LTD MONTHLY PREMIUM
Per $100
AGE
RATE

VOLUNTARY
ACCIDENT
INSURANCE
25

VOLUNTARY ACCIDENT INSURANCE
CARRIER: MetLife
Accident insurance supplements your existing medical insurance in
case you 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
Voluntary
Accident
Rates
Employee
Contribution
52 Pay Periods
Employee Only $2.49
EE & Spouse $4.89
EE & Child(ren) $5.22
EE & (Family) $6.54
Benefit Type 1
Injuries
MetLife Accident
Insurance Pays YOU
Fractures 2 $100 – $4,000
Dislocations 2 $100 – $4,000
Second and Third Degree Burns $100 – $5,000
Concussions $600
Cuts/Lacerations $50 – $400
Eye Injuries $200
Medical Services & Treatment
Ambulance $200 – $600
Emergency Care $50 – $200
Non-Emergency Care $50
Physician Follow-Up $75
Therapy Services
(including physical therapy)
$25
Medical Testing Benefit $200
Medical Appliances $50 – $500
Inpatient Surgery $200 – $2,000
Hospital 3 Coverage (Accident)
Admission
Confinement
Inpatient Rehab (paid per accident)
Accidental Death
Employee receives 100% of amount
shown, spouse receives 50% and
children receive 20% of amount
shown.
Dismemberment, Loss & Paralysis
Dismemberment, Loss & Paralysis
Other Benefits
Lodging 6 - Pays for lodging for
companion up to 31 nights per calendar
year
$1,000 per accident
$200 a day (non-ICU) – up to 31 days
$400 a day (ICU) – up to 31 days
$200 a day, up to 15 days
$25,000
$75,000 for common carrier 5
$500 – $30,000 per injury
$200 per night, up to 31 nights; up to
$6,200 in total lodging benefits available
per calendar year
26

VOLUNTARY
CRITICAL ILLNESS
with CANCER
INSURANCE
27

VOLUNTARY CRITICAL ILLNESS with
CANCER INSURANCE
CARRIER: MetLife
Critical illness insurance supplements your existing medical insurance in case you are
diagnosed with a covered condition, like a heart attack or stroke; 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 diagnosis.
Critical illness insurance may not cover all types of cancer, but it does cover heart and vascular
conditions, cancer-related conditions, and major organ failure.
COVERAGE OPTIONS
Eligible Individual Initial Benefit Requirements
Employee $10,000 or $20,000 Coverage is guaranteed provided you are actively at work.
Spouse
Child(ren)
50% of the employee’s initial benefit
50% of the employee’s initial benefit
BENEFIT PAYMENT
Coverage is guaranteed provided you are actively at work and the
spouse is not subject to a medical restriction as set forth on the
enrollment form and in the Certificate.
Coverage is guaranteed provided you are actively at work and the
spouse is not subject to a medical restriction as set forth on the
enrollment form and in the Certificate.
Your Initial Benefit provides a lump-sum payment upon the first diagnosis of a Covered Condition. Your plan pays a Recurrence
Benefit 4 for the following Covered Conditions: Heart Attack, Stroke, Coronary Artery Bypass Graft, Full Benefit Cancer and Partial
Benefit Cancer. A Recurrence Benefit is only available if an Initial Benefit has been paid for the Covered Condition. There is a Benefit
Suspension Period between Recurrences.
The maximum amount that you can receive through your Critical Illness Insurance plan is called the Total Benefit and is 3 times the
amount of your Initial Benefit. This means that you can receive multiple Initial Benefit and Recurrence Benefit payments until you reach
the maximum of 300% or $30,000 or $60,000.
Please refer to the table below for the percentage benefit amount for each Covered Condition.
Covered Conditions Initial Benefit Recurrence Benefit
Full Benefit Cancer 5 100% if Initial Benefit 50% of Initial Benefit
Partial Benefit Cancer 5 25% of Initial Benefit 12.5% of Initial Benefit
Heart Attack 100% if Initial Benefit 50% of Initial Benefit
Stroke 6 100% if Initial Benefit 50% of Initial Benefit
Coronary Artery Bypass Graft 7 100% if Initial Benefit 50% of Initial Benefit
Kidney Failure 100% if Initial Benefit Not applicable
Alzheimer’s Disease 8 100% if Initial Benefit Not applicable
Major Organ Transplant Benefit 100% if Initial Benefit Not applicable
22 Listed Conditions 25% of Initial Benefit Not applicable
22 Listed Conditions
MetLife Critical Illness Insurance will pay 25% of the Initial Benefit Amount for each of the 22 Listed Conditions until the Total Benefit
Amount is reached. A Covered Person may only receive one payment for each Listed Condition in his/her lifetime. The Listed Conditions
are Addison’s disease (adrenal hypofunction); amyotrophic lateral sclerosis (Lou Gehrig’s disease); cerebrospinal meningitis (bacterial);
cerebral palsy; cystic fibrosis; diphtheria; encephalitis; Huntington’s disease (Huntington’s chorea); Legionnaire’s disease; malaria;
multiple sclerosis (definitive diagnosis); muscular dystrophy; myasthenia gravis; necrotizing fasciitis; osteomyelitis; poliomyelitis; rabies;
sickle cell anemia (excluding sickle cell trait); systemic lupus erythematosus (SLE); systemic sclerosis (scleroderma); tetanus; and
tuberculosis
28

VOLUNTARY CRITICAL ILLNESS with
CANCER INSURANCE
CARRIER: MetLife
Did you know?
● 1 in 5 men suffer a critical illness before their normal retirement age.
● 1 in 6 women suffer a critical illness before their normal retirement age.
● The probability of surviving a critical illness before age 65 is almost twice as great as dying.
● Approximately 1.5 million Americans suffer a heart attack each year, of those 1.1 million
will survive at least 3 years.
Example of Initial & Recurrence Benefit Payments
The example below illustrates an employee who elected an Initial Benefit of $10,000 and has a Total Benefit of 3
times the Initial Benefit Amount or $30,000.
Illness – Covered Condition Payment Total Benefit Remaining
Heart Attack – first diagnosis
Heart Attack – second diagnosis, two years later
Kidney Failure – first diagnoses, three years later
Initial Benefit payment of
$10,000 or 100%
Recurrence Benefit payment of
$5,000 or 50%
Initial Benefit payment of
$10,000 or 100%
$20,000
$15,000
$5,000
SUPPLEMENTAL BENEFITS
MetLife provides coverage for the Supplemental Benefits listed below. This coverage would be in addition to the Total Benefit
Amount payable for the previously mentioned Covered Conditions.
Health Screening Benefit 10
MetLife will provide an annual benefit* of $75 per calendar year for taking one of the eligible screening/prevention measures.
MetLife will pay only one health screening benefit per covered person per calendar year. For a complete list of eligible
screening/prevention measures, please refer to the Disclosure Statement/Outline of Coverage.
29

VOLUNTARY CRITICAL ILLNESS with
CANCER INSURANCE Rates
CARRIER: MetLife
Age
$10,000 Plan
Monthly Premium for Non-Tobacco
Employee
Only
Employee +
Spouse
Employee +
Child(ren)
Employee +
Family
25-29 $5.50 $ 10.00 $10.40 $14.90
30-34 $6.90 $12.10 $11.70 $16.90
35-39 $8.80 $15.10 $13.70 $20.00
40-44 $12.50 $20.70 $17.30 $25.50
45-49 $17.80 $28.80 $22.60 $33.70
50-54 $24.90 $39.80 $29.80 $44.70
55-59 $34.20 $54.10 $39.00 $59.00
60-64 $48.70 $76.70 $53.60 $81.50
65-69 $72.40 $113.40 $77.30 $118.30
Age
$10,000 Plan
Monthly Premium for Tobacco
Employee
Only
Employee +
Spouse
Employee +
Child(ren)
Employee +
Family
25-29 $6.70 $11.80 $11.60 $16.70
30-34 $9.00 $15.30 $13.90 $20.20
35-39 $12.50 $20.60 $17.30 $25.50
40-44 $18.70 $30.10 $23.60 $35.00
45-49 $28.20 $44.60 $33.00 $49.50
50-54 $40.80 $64.10 $45.70 $69.00
55-59 $57.20 $89.60 $62.10 $94.40
60-64 $83.10 $129.70 $87.90 $134.50
65-69 $125.70 $195.60 $130.50 $200.40
Age
$20,000 Plan
Monthly Premium for Non-Tobacco
Employee
Only
Employee +
Spouse
Employee +
Child(ren)
Employee +
Family
25-29 $11.00 $20.00 $20.80 $29.80
30-34 $13.80 $24.20 $23.40 $33.80
35-39 $17.60 $30.20 $27.40 $40.00
40-44 $25.00 $41.40 $34.60 $51.00
45-49 $35.60 $57.60 $45.20 $67.40
50-54 $49.80 $79.60 $59.60 $89.40
55-59 $68.40 $108.20 $78.00 $118.00
60-64 $97.40 $153.40 $107.20 $163.00
65-69 $144.80 $226.80 $154.60 $236.60
Age
$20,000 Plan
Monthly Premium for Tobacco
Employee
Only
Employee +
Spouse
Employee +
Child(ren)
Employee +
Family
25-29 $13.40 $23.60 $23.20 $33.40
30-34 $18.00 $30.60 $27.80 $40.40
35-39 $25.00 $41.20 $34.60 $51.00
40-44 $37.40 $60.20 $47.20 $70.00
45-49 $56.40 $89.20 $66.00 $99.00
50-54 $81.60 $128.20 $91.40 $138.00
55-59 $114.40 $179.20 $124.20 $188.80
60-64 $166.20 $259.40 $175.80 $269.00
65-69 $251.40 $391.20 $261.00 $400.80
30

LEGAL
SERVICES
31

LEGAL SERVICES
CARRIER: MetLaw
MetLaw allows employees to have convenient access to experts who can assist you with a broad range
of personal legal needs you might face throughout your life.
Key Benefits
● Nationwide Network of Attorney’s - 15,000 Network Attorney’s
●
●
Nation’s largest provider of group legal plans
Extensive Legal Services
o
o
o
o
o
o
o
Preparation of Wills & Trusts
Real estate matters
Debit matters, including identity theft defense
Consumer protection
Document preparation and review
Traffic and juvenile matters
Family law, including adoptions
MetLaw Monthly Rate
52 Pay Periods
$4.85
Includes coverage for spouse & dependent
32

33

34

OPEN ENROLLMENT INSTRUCTIONS
STEP 1: Log into MyPay at
www.hralliance.net/ee
STEP 2: Click on the TO DO tab
STEP 3: Find and click on the 2021-2022
Annual Enrollment
STEP 4: Agree to the Terms on the
Welcome page to begin your enrollment.
Click the arrow on the lower right of the
screen to proceed to the next selection.
STEP 5: If everything is correct, click the Submit button and enter your MyPay password as your electronic
signature.
Note: IF you are covering a spouse and /or child, please have their full name, DOB, and SSN available.
To help you better understand your benefits and help make plan
choices that best fit your needs, click on the link within your
enrollment platform (www.hralliance.net/ee) to access Video Benefits
Guy.
http://meeting.videobenefitsguy.com/coulson-petro2021
REMEMBER: Open 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 Coulson’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 Coulson maintains its benefit plans on an ongoing basis, Coulson reserves the right to terminate or amend
each plan, in its entirety or in any part at any time.
35

IMPORTANT CONTACTS
BENEFIT CARRIER PHONE WEBSITE
Medical Insurance
Health Savings Account
Flexible Spending Account
Health Advantage
Arkansas Blue Cross Blue Shield
Consolidated
Admin Services
Consolidated
Admin Services
800-843-1329 www.healthadvantage-hmo.com
501-941-5956 www.consolidatedadmin.com
501-941-5956 www.consolidatedadmin.com
Dental Insurance Delta Dental 800-462-5410 www.deltadentalar.com
Vision Insurance Delta Dental / Superior Vision 800-462-5410 www.deltadentalar.com
Disability Insurance MetLife 800-638-5433 www.metlife.com
Voluntary Life Insurance MetLife 800-638-5433 www.metlife.com
Voluntary Accident Insurance MetLife 800-638-5433 www.metlife.com
Voluntary Critical
Illness/Cancer Insurance
MetLife 800-638-5433 www.metlife.com
Legal Services MetLaw / MetLife 800-821-6400 www.metlife.com
Coulson Oil Group
Human Resources
Donna Cook 501-244-5219 Donna.c@coulsonoil.com
YOUR BXS INSURANCE ACCOUNT REPRESENTATIVES:
Ellen Cother
501-614-1562
Ellen.Cother@bxsi.com
Ashley Bray
501-614-1562
Ashley.Bray@bxsi.com
DiAlma Young
870-974-7424
DiAlma.Young@bxsi.com
36

CARRIER
RESOURCES
37

38

39

40

41

42

43

44

45

GLOSSARY
46

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.
Flexible Spending Accounts (FSA): An option that allows participants to set aside pre-tax dollars to pay for
certain qualified expenses during a specific time period (usually a 12-month period).
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.
Health Savings Account (HSA): A personal health care bank account funded by your or your employer’s taxfree
dollars to pay for qualified Medical expenses. You must be enrolled in a HDHP to open an HSA. Funds
contributed to an HSA roll over from year to year and the account is portable, meaning if you change jobs,
your account goes with you.
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-ofpocket
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.
Out-of-Pocket Maximum: The maximum amount of money you will pay for medical services during the plan
year. The out-of-pocket maximum is the sum of your deductible and coinsurance payments.
47

COULSON OIL GROUP
Petro Plus, LLC
DONNA.C@COULSONOIL.COM | 501.244.5219