HomeMy WebLinkAbout2010 Florida Combined Life - BCBS - DentalSummary of Benefits
PPO Plan
Network
DentalBlue
Calendar Year Benefit Maximum
In- Network
Out -of- Network
Per Member
$1,000
Calendar Year Deductible
In- Out -of- Network Combined
Per Member
$50
Per Family
$150
Waived for Class I Services?
Yes
Class I Services: Diagnostic Preventative
In- Network
Out -of- Network
Office Visit
Plan Coinsurance: 100%
Member Coinsurance: 0%
(Deductible Waived)
Plan Coinsurance: 80%
Member Coinsurance: 20%
(Deductible Waived)
Routine Oral Exam Every 6 Months
Routine Cleanings Every 6 Months
Bitewing X -rays
Fluoride Treatments up to Age 14 Every 6 Months
Class II Services: Basic Restorative
In- Network
Out -of- Network
Emergency Care to Relieve Pain
Plan Coinsurance: 80%
Member Coinsurance: 20%
Plan Coinsurance: 80%
Member Coinsurance: 20%
Complete X -rays
Sealants up to Age 16
Space Maintainers (non orthodontic treatment)
Fillings
Simple Extractions
Root Canal Therapy
Periodontics
Oral Surgery
General Anesthesia
Class III Services: Major Restorative
In- Network
Out -of- Network
Bridges, Crowns and Dentures
Plan Coinsurance: 50%
Member Coinsurance: 50%
Plan Coinsurance: 50%
Member Coinsurance: 50%
Class IV Services: Orthodontia
Lifetime Maximum
$1,000
Benefit
50 No Deductible
Age Limitation
To Age 19
Dental Insurance Plan At A Glance
*In order for an Implant to be considered an eligible expense, the tooth must not have been missing prior to the patient's
coverage under the dental plan.
For any dental work expected to cost $300 or more, the plan will provide a "Pre- Determination of Benefits" upon the request
of your dental provider. This will assist you with determining your approximate out -of- pocket costs should you have the
dental work performed.
This benefits summary has been provided as a convenient reference. Complete details regarding all the plan's
coverages, exclusions, and stipulations may be found in your certificate of coverage or by contacting the carrier.
Out of Network charges may be subject to Maximum Allowable Charge (MAC) limitations and Balance Billing.
8 All benefits in this booklet are subject to change. This is an Employee Benefits Highlights Summary and not a contract. All benefits are subject to the provisions and exclusions of the master contract.
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PPO Dental Insurance RFP Evaluation
Effective Date: July 1, 2010
050410 City of Seb
P.O.Box 45132 Phone (904) 425 -5800
Jacksonville, FL 32232 Fax (904) 425 -7180
May 30, 2009
Debbie Kruger
City of Sebastian
1225 Main Street
Sebastian, FL, 32958
RE: Group Policy Number: Renewal Date: October 01, 2009
25X0022
Dear Debbie Kruger
Thank you for choosing Florida Combined Life Insurance Company, Inc. for your group Dental Insurance benefits. We value you as a
customer and appreciate your business.
Your Group Dental Insurance Plan is about to renew. We have completed our annual review of your coverage with FCL, taking into
account a variety of factors that affect rate development. After careful consideration and analysis, we have established your renewal
rates for the next plan year. Your current and renewal rates are shown below. The renewal rates will take effect on your renewal date
and are guaranteed for the following 12 months, subject to the terms and conditions of your group contract.
BlueDental Choice Plus True Group 25X0022
We look forward to continuing our relationship well into the future. Should you have any questions regarding this letter please contact
your local Blue Cross and Blue Shield sales representative or telephone our office at 1- 800 772 -8244 ext. 7145.
Sincerely,
Current Rates New Rates
Employee $28.50 $28.50
Employee Spouse $57.18 $57.18
Employee Child(ren) $71.50 $71.50
Family $99.36 $99.36
Joe Bowman
Group Dental Underwriting
cc: Agency: The Gehring Group
Sales Rep: George Prieto
Florida Combined Life Insurance Company, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc.,
is an Independent Licensee of the Blue Cross and Blue Shield Association.
100% of the AD &D benefit will be paid for the loss of
50% the AD &D benefit will be paid for the loss of
Life (accidental); or
Both hands or both feet; or
Sight of both eyes; or
Any 2 or more: 1foot, 1 hand, or the sight of 1 eye.
One hand; or
One foot; or
Sight of one eye
Thumb and index finger of the same hand.
Ai Life Insurance
Florida Combined Life
Customer Service: (877) 947 9921
www.bcbsfl.com
Basic Term Life Insurance
The City provides a Basic Life insurance benefit through Florida Combined Life (FCL) to all eligible Full -Time employees at
no cost. All full time employees working a minimum of 40 hours per week are covered for a flat benefit amount of $10,000.
Basic Accidental Death Dismemberment Insurance
The City provides Accidental Death Dismemberment (AD &D) insurance, which pays in addition to the Basic Life benefit
when death occurs as a result of an accident. The AD &D benefit amount equals the Basic Term Life benefit, and a partial
benefit is also payable based on the schedule below.
Voluntary Employee AD &D Life Insurance
Eligible employees may elect to purchase additional Life AD &D insurance on a voluntary
basis through FCL. This coverage may be purchased in addition to the Basic Term Life
coverage. The Voluntary Life ADD &D insurance plan offers coverage for yourself, your
spouse and /or child(ren) at different benefit levels.
New Hires: There is a 1 time "special enrollment" to purchase voluntary employee
life insurance without having to go through Medical Underwriting, also known as
Evidence of Insurability (EOI) up to the guaranteed issue amount of $100,000
(through age 59).
Units can be purchased in increments of $10,000 from a minimum of $10,000 to a
maximum of 5 times salary or $500,000.
Coverage amounts subject to the age reduction schedule: 35% at 65, 50% at 70, and
25% at 75.
Premium calculation: Elected Coverage $1,000 X Employee Rate (see table)
Monthly Premium.
Voluntary Spouse Life Insurance
An employee must participate in the voluntary plan for his/her spouse to participate.
Units can be purchased in increments of $5,000 to a maximum of $250,000, however,
coverage cannot exceed 50% of the employee's voluntary coverage amount.
Premium calculation: Elected Coverage $1,000 X Employee Rate (see table) Monthly
Premium. Note: Spouse life insurance rate is based on employee's age.
New Hires: There is a 1 time "special enrollment" to purchase voluntary spouse life
insurance without having to go through Medical Underwriting, also known as
Evidence of Insurability (EOI) up to the guaranteed issue amount of $30,000
(through age 59).
Dependent Child(ren) Life Insurance
An employee must participate in the voluntary plan for dependent children to participate.
Dependent child less than 6 months old: maximum benefit amount is $500.
Children 6 months and older: flat $10,000 benefit amount can be purchased for a flat rate of $3.00 per month.
Life Insurance Imputed Income
The IRS requires that the imputed cost of employer paid Employee Life Insurance benefit in excess of $50,000 must be
included in income and is subject to Social Security and Medicare taxes.
10 All benefits in this booklet are subject to change. This is an Employee Benefits Highlights Summary and not a contract. All benefits are subject to the provisions and exclusions of the master contract.
Voluntary Life
Monthly
Employee
Rates
Age
per $1,000
18
29
0.08
30
34
0.12
35
39
0.15
40
44
0.25
45
49
0.41
50
54
0.66
55
59
1.12
60
64
1.16
65
69
2.59
70
-74
4.26
75
7.08
Ai Life Insurance
Florida Combined Life
Customer Service: (877) 947 9921
www.bcbsfl.com
Basic Term Life Insurance
The City provides a Basic Life insurance benefit through Florida Combined Life (FCL) to all eligible Full -Time employees at
no cost. All full time employees working a minimum of 40 hours per week are covered for a flat benefit amount of $10,000.
Basic Accidental Death Dismemberment Insurance
The City provides Accidental Death Dismemberment (AD &D) insurance, which pays in addition to the Basic Life benefit
when death occurs as a result of an accident. The AD &D benefit amount equals the Basic Term Life benefit, and a partial
benefit is also payable based on the schedule below.
Voluntary Employee AD &D Life Insurance
Eligible employees may elect to purchase additional Life AD &D insurance on a voluntary
basis through FCL. This coverage may be purchased in addition to the Basic Term Life
coverage. The Voluntary Life ADD &D insurance plan offers coverage for yourself, your
spouse and /or child(ren) at different benefit levels.
New Hires: There is a 1 time "special enrollment" to purchase voluntary employee
life insurance without having to go through Medical Underwriting, also known as
Evidence of Insurability (EOI) up to the guaranteed issue amount of $100,000
(through age 59).
Units can be purchased in increments of $10,000 from a minimum of $10,000 to a
maximum of 5 times salary or $500,000.
Coverage amounts subject to the age reduction schedule: 35% at 65, 50% at 70, and
25% at 75.
Premium calculation: Elected Coverage $1,000 X Employee Rate (see table)
Monthly Premium.
Voluntary Spouse Life Insurance
An employee must participate in the voluntary plan for his/her spouse to participate.
Units can be purchased in increments of $5,000 to a maximum of $250,000, however,
coverage cannot exceed 50% of the employee's voluntary coverage amount.
Premium calculation: Elected Coverage $1,000 X Employee Rate (see table) Monthly
Premium. Note: Spouse life insurance rate is based on employee's age.
New Hires: There is a 1 time "special enrollment" to purchase voluntary spouse life
insurance without having to go through Medical Underwriting, also known as
Evidence of Insurability (EOI) up to the guaranteed issue amount of $30,000
(through age 59).
Dependent Child(ren) Life Insurance
An employee must participate in the voluntary plan for dependent children to participate.
Dependent child less than 6 months old: maximum benefit amount is $500.
Children 6 months and older: flat $10,000 benefit amount can be purchased for a flat rate of $3.00 per month.
Life Insurance Imputed Income
The IRS requires that the imputed cost of employer paid Employee Life Insurance benefit in excess of $50,000 must be
included in income and is subject to Social Security and Medicare taxes.
10 All benefits in this booklet are subject to change. This is an Employee Benefits Highlights Summary and not a contract. All benefits are subject to the provisions and exclusions of the master contract.
Lincoln Financial
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Age 70 Benefit reduces by 60%
Age 75 Benefit reduces by 75%
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All Eligible Employees
All Eligible Spouses
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050410 City of Sebastian RFP E
P.O.Box 45132 Phone (904) 425 -5800
Jacksonville, FL 32232
July 29, 2009
CITY OF SEBASTIAN
1225 MAIN STREET
SEBASTIAN, FL, 32958
Attn: DEBRA KRUEGER
Your Group Insurance Program with Florida Combined Life Insurance Company is approaching its policy anniversary
date. Each year, we review your benefit program to ensure that your premium rates appropriately reflect the liability that
Florida Combined Life has assumed by underwriting your program.
Your rates have been recalculated based on the current employees insured. The new rates indicated below will become
effective on your group's anniversary date indicated above. Your group bill will be changed accordingly.
Long Term Disability
Voluntary AD &D
Voluntary AD &D Spouse
Voluntary AD &D Child
Group Term Life
Group AD &D
Sincerely,
Tracy Seamann
Group Life Underwriting
cc: Agency: 2913
Sales Rep: George Prieto
BCBSF
Current Rate
$0.49
Current Rate
$0.05
$0.04
$0.06
Current Rate
$0.33
$0.04
Policy Anniversary Date: October 01, 2009
Group Number: 94085
New Rate
$0.54
New Rate
$0.05
$0.04
$0.06
New Rate
$0.33
$0.04
Fax (904) 425 -7180
Per $100 Monthly Covered Payroll
Per $1,000 of Benefit
Per $1,000 of Employee Coverage
Per $1,000 of Employee Coverage
Per $1,000 of Benefit
Per $1,000 of Benefit
Florida Combined Life appreciates the opportunity to serve you. If you have any questions, or need any assistance with your
program, please be sure to contact your local Blue Cross and Blue Shield Sales Representative or telephone this office at
1- 800 333 -3256.
Florida Combined Life Insurance Company, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc.,
is an Independent Licensee of the Blue Cross and Blue Shield Association.