Coulson Oil - Petro - 2022 Benefits Guide

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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 EE & 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* Claims must not exceed $499 for the plan year 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 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
Page 1 and 2: 2022 BENEFITS ENROLLMENT GUIDE Effe
Page 3 and 4: CONTENTS 4 Benefits Overview 7 Medi
Page 5 and 6: BENEFITS OVERVIEW ENROLLMENT You ca
Page 7 and 8: MEDICAL INSURANCE 7
Page 9 and 10: WHICH MEDICAL INSURANCE PLAN IS RIG
Page 11 and 12: HEALTH SAVINGS ACCOUNT CARRIER: Con
Page 13 and 14: FLEXIBLE SPENDING ACCOUNTS 13
Page 15: FLEXIBLE SPENDING ACCOUNTS HOW DOES
Page 19 and 20: VOLUNTARY LIFE INSURANCE 19
Page 21 and 22: VOLUNTARY LIFE INSURANCE CARRIER: M
Page 23 and 24: DISABILITY INSURANCE CARRIER: MetLi
Page 25 and 26: VOLUNTARY ACCIDENT INSURANCE CARRIE
Page 27 and 28: VOLUNTARY CRITICAL ILLNESS with CAN
Page 29 and 30: LEGAL SERVICES 29
Page 31 and 32: IMPORTANT CONTACTS BENEFIT CARRIER
Page 33 and 34: GLOSSARY Coinsurance: Your share of
Page 35 and 36: NOTES 35

Coulson Oil - Petro - 2022 Benefits Guide

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