BENEFITS GUIDE 2025 PLAN YEAR
WELCOME TO YOUR BENEFIT ENROLLMENT GUIDE 2025 PLAN YEAR
Sterling Estates is proud to offer you a comprehensive benefits package for the upcoming plan year. This enrollment guide will assist you in determining the coverage levels that will provide you and your family with the protection that gives you peace of mind. We encourage you to take the time to review the enrollment guide prior to enrollment. Keep in mind that the benefits you select during this enrollment will be effective January 1 st , 2025 and will continue through December 31 st , 2025.
Please note: This benefit guide contains the basic information about your benefits program. It does not cover every detail; but it does provide a general description of each benefit plan. Every effort has been made to ensure that the information is accurate. However, this guide is not an insurance policy. If there is any question as to coverage, benefit eligibility, or interpretation, the insurance contract and the Certificate of Coverage you receive from the insurance carrier will govern the administration of your benefits. If you would like additional or specific information, please contact the Human Resources Department.
About Deductions
In preparation of your enrollment, please have the following information readily available for you and your dependent(s): • Date(s) of birth: Mandatory • Social Security Number(s): Mandatory • Full name, relationship, and Social Security Number(s) for Life Beneficiary(ies). (Beneficiaries must be at least 18 years old or you will be required to name a guardian for him/her.) Information Needed for Enrollment Premiums for medical, dental and vision plans are all deducted on a pre-tax basis because they are covered under Section 125 of the Internal Revenue Code. Once you elect benefits you will not be approved to make changes to your election or drop coverage until the next Open Enrollment period, unless you have a qualifying event. Voluntary life and short-term disability insurance premiums are deducted on a post-tax basis and may be changed outside of the Open Enrollment period.
Eligibility Information
Qualifying Life Events
As an employee of Sterling Estates you may be eligible for enrollment in a variety of insurance products. Full-time employees may participate in the benefits package upon the 90th day from date of hire.
Qualifying events are events that cause an individual to lose his or her group health coverage. The type of qualifying event determines who the qualified beneficiaries are for that event and the period of time that a plan must offer continuation of coverage.
You may enroll your eligible dependents for coverage once you are eligible. Your eligible
Qualifying events include:
dependents include: • Your legal spouse • Your children up to age 26 (as identified in the plan document)
• Marriage • Divorce or legal separation • Birth or adoption of a child • Death of spouse or dependent child • Change in employment status • Loss of other coverage • Entitlement to Medicare or Medicaid • Child turning 26 years old
*Once your elections are effective, they will remain in effect through the plan year.
You must notify Human Resources within 30 days of the qualifying life event. Depending on the type of event, you may be asked to provide proof of the event. If you do not contact Human Resources within 30 days of the qualifying event, you will have to wait until the next annual enrollment period to make changes.
Medical and Pharmacy Coverage
Sterling Estates offers the following medical plans. Insurance Carrier:
Cigna Medical Insurance $3,000 / 80% Coinsurance Plan
Medical Plan:
In-Network: Primary Care Visits Specialist Care Visits
$30 Copay $60 Copay $75 Copay
Urgent Care
Emergency Room Care Preventative Visit Copay
$350 Copay; then 20% Coinsurance
$0
Diagnostic Testing & Blood Work (In Office)
Deductible; then 20% Coinsurance
Advanced Imaging Plan Coinsurance Employee Deductible Family Deductible
Deductible; then 20% Coinsurance
80%
$3,000 $9,000 $4,500 $9,000
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Inpatient Hospital
Deductible; then 20% Coinsurance Deductible; then 20% Coinsurance
Outpatient Hospital or Facility
Out-of-Network: Plan Coinsurance
60%
Employee Deductible Family Deductible
$4,500 $13,500 $13,500 $27,000
Employee Out-of-Pocket Max Family Out-of-Pocket Max Prescription Drugs 30-day supply Tier 1 - Typically Generic Tier 2 - Typically Preferred Brand Tier 3 - Typically Non-Preferred Brand
$15 Copay $35 Copay $60 Copay
Tier 4 - Typically Specialty
25% Coinsurance up to $250
Employee Semi-Monthly Deduction Employee Only
$88.75 $375.00 $225.00 $525.00
Employee + Spouse Employee + Child(ren)
Family
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Dental Coverage
Regular dental exams can help you and your dentist detect problems in the early stages when treatment is simpler and costs are lower. Keeping your teeth and gums clean and healthy will prevent most tooth decay and periodontal disease, and is an important part of maintaining your medical health. Your dental plan is through Cigna and offers “in and out-of-network” benefits.
Insurance Carrier:
Cigna Dental Insurance
Plan Type:
Base Plan
Buy-Up Plan
Calendar Year Deductible
$50 Individual / $150 Family
$50 Individual / $150 Family
Calendar Year Maximum
$750
$1,000
Preventive Services
100%
100%
Basic Services
80%
80%
Major Services
50%
50%
Employee Semi-Monthly Deduction Employee Only
$8.63
$18.92
Employee + Spouse
$16.56
$36.76
$25.82
$48.71
Employee + Child(ren)
$33.74
$66.55
Family
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Basic Life and AD&D Insurance Coverage
Sterling Estates provides all Full Time employees with Basic Life and Accidental Death & Dismemberment at no cost.
Insurance Carrier:
Anthem Basic Life AD&D Insurance
Basic Life AD&D
Full Time Employees (when electing medical coverage)
Eligibility Requirement
Life Insurance Benefit
$15,000
Guarantee Issue
Yes
Accidental Death & Dismemberment Benefit (AD&D)
$15,000
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Vision Coverage
You can help protect your eyesight by visiting an eye doctor regularly. Taking care of your eyes today can lead to a better quality of life later. The vision plan covers routine eye exams and also pays for all or a portion of the cost of glasses or contact lenses if you need them. Your vision plan is through Sun Life and offers “in and out-of-network” benefits.
Insurance Carrier:
Sun Life Vision Insurance
In-Network $10 Copay $25 Copay $25 Copay $25 Copay
Exam Copay
Lenses - Single lined Lenses - Bifocal lined
Lenses - Trifocal
Frames
$ 130 Allowance
Elective Contact Lenses (in place of lenses & frame)
$130 Allowance
Frequency for Exam / Lenses / Frames Employee Semi-Monthly Deduction Employee Only
12 months / 12 months / 24 months
$4.91 $9.82
Employee + Spouse Employee + Child(ren)
$10.81 $15.72
Family
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Voluntary Term Life & Disability Coverage
As a supplemental benefit, Sterling Estates allows eligible employees to purchase additional life insurance coverage for yourself and your dependents. Employee must be enrolled to purchase coverage for your family. This coverage is paid for by you and is offered through Sun Life. Rates for the Voluntary Term Life insurance are based on age, and volume, and benefits are subject to applicable age reductions.
Insurance Carrier: Voluntary Life AD&D Eligibility Requirement Employee Benefit Amounts Employee
Sun Life Voluntary Life AD&D Insurance
All Eligible Employees
Minimum of $20k up to $250k in increments of $10k
Spouse
Minimum of $5k up to $125k in increments of $5k
Child(ren)
Flat $10k
Disability Coverage The goal of Sterling Estates Disability Insurance Plan is to provide you with income replacement should you be unable to work due to a non-work-related illness or injury. The company provides all eligible employees with the option to purchase voluntary “Short-Term Disability” income benefits. Short-Term Disability coverage is offered through Sun Life. Insurance Carrier: Sun Life Short-Term Disability Insurance Plan Type: Voluntary Eligibility Requirement All Eligible Employees Benefit Percentage 60% Waiting Period - Accident 8 Days Waiting Period - Sickness 8 Days Maximum Weekly Benefit $1,000 Benefit Duration Executive Directors - 12 Weeks All Other Eligible Employees - 52 Weeks Pre-Existing Condition 3 / 12
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Accident Insurance
Accident Insurance
HELPS YOUR FINANCES AFTER A MISHAP. When you, your spouse or child has a covered accident, like a fall from a bicycle that requires medical attention, you can receive cash benefits to help cover the unexpected costs. HELPS COVER RELATED EXPENSES. While health plans may cover direct costs associated with an accident, you can use accident benefits to help cover related expenses like lost income, child care, deductibles and co-pays. PAYS CASH BENEFITS DIRECTLY TO YOU. Accident Insurance can be used however you want, and it pays in addition to any other coverage you may already have. Benefits are payable directly to you. And get this – there are no health questions or pre-existing conditions limitations. What’s more, all family members on your plan are eligible for a wellness-screening benefit, also paid directly to you once each year per covered person.
You can purchase this coverage for you and your family. Child coverage is available to age 26.
ACCIDENT FAST FACTS
Falls are the leading cause of injuries treated in emergency rooms every year, for people of all ages. 1
This coverage pays benefits for accidents that occur off the job.
Sun Life Assurance Company of Canada
1761669 ACC2 CL1 12/23/2021 11:52:23
800-247-6875 • sunlife.com/us
Accident Insurance
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Accident Insurance
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. The full list of benefits is listed here. DISLOCATIONS OPEN (SURGERY) CLOSED (NO SURGERY) Hip $4,000 $1,000 Knee or Shoulder $1,000 $400 Ankle or bones of the foot $1,000 $300 Elbow or wrist $800 $400 Collarbone or bones of the hand $1,600 $300 Finger(s) or toe(s) $200 $100 Lower jaw $1,000 $500 FRACTURES OPEN (SURGERY) CLOSED (NO SURGERY) Hip or thigh $3,000 $1,500 Skull-depressed $5,000 $2,500 Skull-simple $2,500 $1,250 Vertebral processes or Rib $1,200 $300 Bones of the face, Upper jaw or upper arm $750 $375 Nose, Heel or Finger $700 $175 Leg, Vertebrae, Sternum or Pelvis $1,600 $800 Lower jaw, Collarbone, Shoulder, Forearm, Hand, Wrist, Foot, Ankle, Kneecap or Elbow $650 $325 Toe $250 $125 Coccyx $400 $200 ADDITIONAL INJURIES Eye Injury - surgical repair $300 Eye Injury - object remove $65 Paralysis—paraplegia $25,000 Paralysis—quadriplegia $50,000 Coma $20,000 Concussion $100 BURNS 2ND DEGREE 3RD DEGREE 20-40 square centimeters $400 $1,000 41-65 square centimeters $800 $2,000 66-160 square centimeters $1,200 $6,000 161-225 square centimeters $1,600 $14,000 More than 225 square centimeters $2,000 $20,000 Skin graft 50% of the applicable Burn Benefit LACERATIONS No sutures and treated by doctor $35 Single laceration under 5 cm with sutures $65 5-15 cm with sutures (total of all lacerations) $250 Greater than 15 cm with sutures (total of all lacerations) $500
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Accident Insurance
What’s covered MEDICAL SERVICES Diagnostic Exam - Arteriogram, Angiogram, CT, CAT, EKG, EEG, or MRI (1 time per benefit year) Accident Emergency Treatment, non-emergency room (once per covered accident) Physician's Follow-up Treatment office visit (per visit, up to 6 times per covered accident)
$200
$75 $25 $25
Physical Therapy (per visit up to 10 visits per covered accident)
Medical Devices Prosthesis (one)
$125 $500 $200
Blood, Plasma, or Platelet Transfusion HOSPITAL Hospital Admission (once per benefit year)
$1,000
Hospital Confinement (per day up to 365 days per covered accident)
$250
Intensive Care Unit Admission (once per Benefit Year; payable instead of Hospital Admission benefit if Confined immediately to ICU) Intensive Care Unit Confinement (per day up to 30 days, payable in addition to any Hospital Confinement benefit)
$1,500
$500
Ambulance (Ground)
$200
Ambulance (Air)
$1,500
Emergency Room Admission
$150 $100 $600 $150
Family Lodging (per day up to 30 days per benefit year)
Transportation (100 or more miles up to 3 times per covered accident) Rehabilitation Unit (per day up to 365 days per covered accident)
SURGERY Miscellaneous Surgery requiring general anesthesia (not covered by any other benefit)
$300
Open Surgery
$1,250
Exploratory Surgery or Debridement
$300 $300 $625 $625 $625
Laparoscopic Surgery
Tendon/Ligament/Rotator Cuff Tear
Torn Knee Cartilage
Ruptured/Herniated Disc EMERGENCY DENTAL Emergency Dental extraction Emergency Dental crown WELLNESS Wellness Screening Benefit (once per benefit year)
$65
$200
$50
LIFE AND DISMEMBERMENT LOSSES* Accidental Death
$25,000 $100,000
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 irrecoverable loss of sight of both eyes
$15,000
Loss of one hand, foot, leg, or arm
$7,500 $7,500 $1,500
Loss of sight of one eye or loss of one eye
Two or more fingers or toes
One finger or one toe $1,500 *Benefits displayed for life and dismemberment are for the employee only. Spouse benefits are 100% of the employee benefit amount for death and 50% of the employee benefit amount for dismemberment. Dependent children benefits are 20% of the employee benefit amount for death and 50% of the employee benefit amount for dismemberment.
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Accident Insurance
Frequently asked questions
How do I file an accident claim? If you have an accident after the effective date of coverage, you can file a claim with us by downloading forms from our website. We’ll ask that you and your doctor provide information about the accident and the treatment provided. What happens once my claim is approved? The benefit amount you receive will depend on your injury and/or the treatment provided. Remember, benefits are payable only once for each covered accident, unless noted otherwise in the benefit schedule. Is there a time period that I need to follow? Injuries and other related benefits due to a covered accident must be diagnosed or treated within a defined period of time from the date of your accident. This could be as few as three days for certain benefits. Please refer to your Certificate for details. How do I get the Wellness Screening Benefit? You may be paid the benefit when you or a covered family member submit proof of a covered screening each year, like specific blood tests and cancer screenings, cardiac stress tests, immunizations, school sports exams and more (may vary by state). Our wellness screening benefit claim form can also be downloaded from our website. Can I take my insurance with me if I leave my employer? Depending upon state variations and your employer’s plan, you may have an option to continue group coverage when your employment terminates. Your employer can advise you about your options. Is my benefit taxable? If you or your employer pay for all or part of the cost of coverage on a pre-tax basis, some or all of your benefit amount will be tax reported on a Form 1099 as taxable income. Please reach out to a tax advisor or your employer if you have any questions.
Accident Plan Monthly Rates
Accident insurance is a limited benefit policy. The Certificate has exclusions that may affect any benefits payable. Benefits payable are subject to all terms and conditions of your Certificate.
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Read the Important information section for more details 1. “Health, United States, 2016,” US Department of Health and Human Services, Table 75.
Cancer Insurance
Cancer insurance Azalea Estates Assisted Living & Retirement Communities | All Eligible Employees | 925592 Protect your savings against the costs of cancer A cancer diagnosis may have crossed your mind over the years. Or you may have a family history. Recovering from cancer would be your main focus. Cancer also has a financial impact that can be hard to recover from. Cancer insurance pays you cash benefits for a variety of the ways your cancer is treated. How it works. Your employer is offering you and your coworkers this coverage as a group, at a group rate. You are responsible for paying a portion or all of the cost. The benefit schedule on the following pages lists what the plan pays for covered cancer treatments.
What did cancer insurance mean for Beth?
Beth was diagnosed with breast cancer in her mid-50s. She was concerned about her health, and about her finances. Beth filed claims with Sun Life as she received treatments. We reviewed her medical information and details from her physician. We approved her claims. She received cash benefits for hospital stays, radiation and chemotherapy treatments. These benefits helped her pay her medical deductible and copays, and travel expenses for medical appointments Did you know? A recent study shows that cancer patients spend 11% of their household income on expenses related to their cancer treatments.* This may prompt you to consider cancer insurance.
Benefits
Coverage is provided for
A covered person who is diagnosed with cancer after the effective date of insurance. Coverage is available for you and your family. An eligible child is defined as your child from birth to age . Benefits are payable directly to you, the employee This plan pays benefits in addition to any other coverage you may have.
Additional plan features
Sun Life Assurance Company of Canada sunlife.com 1-800-SUN-LIFE (247-6875)
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Cancer Insurance
Benefit schedule Once your coverage goes into effect, you can file a claim for covered cancer treatments for cancer diagnoses that occur after your insurance’s effective date. Unless otherwise specified, benefits are payable only once. The full list of benefits is listed here. Choose the plan (Level 1 or Level 2) that best meet your needs and your budget.
Covered service
Level 1
Level 2
Second Surgical Opinion
$200
$200
Surgery and General Anesthesia Benefits vary based on the procedure performed. Combined maximum for any one surgery is $2,000 for Level 1 and $7,500 for Level 2. Surgery for skin cancer and reconstruction is not covered under this benefit.
Anesthesia $50 to $1,815
Anesthesia $50 to $1,815
Surgical $150 to $5,500
Surgical $150 to $5,500
Hospital Confinement (limited to 90 days per period of confinement)
$200 Daily
$400 Daily
In-hospital and Outpatient Blood and Plasma
$50 Daily
$50 Daily
Ambulance (limited to 2 one-way trips per period of confinement per person)
$250
$250 Ground $2,000 Air
Cancer Screening Includes colonoscopy, CA 125 test, chest x-ray, flexible sigmoidoscopy, mammogram, pap smear, biopsy, PSA, CT scans or MRI scans, BRCA testing, or Hemocult stool specimen. This benefit is limited to once per benefit year.
$50
$75
In-hospital Doctor Visits Limited to a maximum of 75 visits.
$25 Daily
$25 Daily
Prosthesis Lifetime maximum for surgically implanted prosthesis is $4,000 for Level 1 and $6,000 for Level 2. Lifetime maximum for other devices is $400 for Level 1 and $600 for Level 2.
Surgically implanted $2,000
Surgically implanted $3,000
Other $300
Other $200
Skin Cancer Biopsy Only
$100 $250 $375 $600
$100 $250 $375 $600
Reconstructive surgery following previous excision of skin cancer
Excision of skin cancer without flap or graft Excision of skin cancer with flap or graft
Radiation and Chemotherapy Injected Cytotoxic Medications
$300 Weekly $1,000 Weekly
Pump Dispensed Cytotoxic Medications
$300 First Prescription and Per Refill $150 Per Prescription
$1,000 First Prescription and Per Refill $500 Per Prescription
Oral Cytotoxic Medications
Cytotoxic Medications Administration by Any Other Method
$300 Weekly $1,000 Weekly
External Radiation Therapy
$400 Weekly $450 Weekly $400 Weekly
$600 Weekly $750 Weekly $600 Weekly
Insertion of Interstitial or Intracavity Administration of Radioisotopes or Radium
Oral or IV Radiation This benefit is not payable for the same day the Experimental Treatment benefit is payable. These benefits are not payable for treatment planning, therapeutic devices, immunotherapy, laboratory tests, diagnostic x-rays, dosimetry or simulation associated with these procedures.
sunlife.com 1-800-SUN-LIFE (247-6875)
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Cancer Insurance
Covered service
Level 1
Level 2
Maximums apply: Oral Cytotoxic Medications are subject to a monthly maximum of $450 for Level 1 and $1,500 for Level 2, other listed treatments are subject to a yearly maximum of $4,000 for Level 1 and $12,000 for Level 2. Extended-care Facility This benefit is payable if the extended care confinement occurs within 30 days of a period of hospital confinement due to internal cancer and you have received a Hospital Confinement benefit. Limited to a maximum of 90 days per benefit year per covered person. This benefit is not payable for any day the Hospital Confinement benefit is payable. Hospice Limited to a maximum of 100 days during the covered person’s lifetime. This benefit is not payable for any day the Extended-Care Facility benefit, the Home Health Care benefit or the Hospital Confinement benefit is payable.
$200 Daily
$200 Daily
$100 Daily
$100 Daily
Additional benefits available if you enroll in Level 2 Covered service
Benefit amount
First Occurrence Payable if diagnosed with Internal Cancer for the first time. This benefit is only payable once per lifetime. National Cancer Institute Evaluation/Consultation This benefit is not payable for the same day the Second Surgical Opinion benefit is payable. This benefit is limited and only payable once per lifetime. Medical Imaging When a follow-up evaluation is performed using any imaging test as directed by a doctor after an initial diagnosis of internal cancer, (except breast mammography and breast ultrasound) this benefit is payable. You may receive this benefit twice per benefit year provided you or your covered dependent are charged for these procedures and they are performed on an outpatient basis. Home Health Care The service must begin within 7 days of the date you or your covered dependent are released from hospital confinement. This benefit is not payable for any day the Hospice benefit is payable. Caregivers must be licensed or certified. Limited to a maximum of 10 visits per period of hospital confinement; up to 30 visits per benefit year. Outpatient Hospital Surgical This benefit is not payable for surgery performed in a doctor’s office or if you or your covered dependent are hospital confined on the same day. Limited to a maximum of 3 days per procedure. Transportation The hospital or clinic must be more than 100 miles away from your or your covered dependent’s residence. Limited to 3 round trips per benefit year, per covered person. Lodging The hospital or clinic must be more than 100 miles away from your or your covered dependent’s residence. Limited to 1 benefit per day up to 90 days per benefit year, per covered person.
$5,000
$500
$100
$50 Per Visit
$250 Daily
$500
$100 Daily
Bone Marrow or Stem Cell Transplant A benefit is paid for either a bone marrow transplant or a stem cell transplant, not both. Payable once per lifetime, per covered person.
Bone Marrow $10,000 Donor ($1,500) Stem Cell $2,500
Nursing Services Care must be provided by a licensed registered graduate nurse or vocational nurse, but not by a family member. Limited to 30 days per benefit year per covered person.
$125 Daily
15 Sterling Estates 2025 Benefits Guide | sunlife.com 1-800-SUN-LIFE (247-6875)
Cancer Insurance
Covered service
Benefit amount
Immunotherapy We will not pay benefits under this provision for the same treatment under either the Radiation and Chemotherapy Benefit or the Experimental Treatment Benefit. Lifetime maximum of $3,500 applies, per covered person. Reconstructive Surgery In addition, 30% of the surgery amounts listed is paid for general anesthesia used during these procedures. Breast Symmetry (modification of the non-cancerous breast performed within 5 years of reconstructing the cancerous breast)
$450 Monthly
$350
Breast Reconstruction Facial Reconstruction
$700 $700
Breast Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
$2,500
Alternative Care Pays the amount shown per visit to an accredited practitioner for you or your covered dependent upon the diagnosis of internal cancer for Palliative care (acupuncture, massage therapy, bio- feedback and hypnosis), and Lifestyle training (smoking cessation, Yoga, meditation, relaxation techniques, Tai Chi and nutritional counseling). Limited to 20 visits per benefit year under either category, per covered person and lifetime maximum of 2 benefit years. There is also a one- time benefit ($150) for Integrative Assessment and Education when performed by an accredited practitioner following the diagnosis of internal cancer. Experimental Treatment Treatment must be administered by medical personnel in a doctor’s office, clinic, or hospital; maximum monthly benefit is $1,050. We will not pay benefits under this provision for laboratory tests, immunotherapy, diagnostic x-rays and therapeutic device or other procedures related to these treatments. This benefit is not payable for any day the Radiation or Chemotherapy benefit is payable.
$50 Per Visit
$150 Daily
Anti-nausea drugs
$100 Monthly
Post-hospital Doctor Visits This benefit is payable per doctor visit once every 6 months. Benefits payable up to 5 years after the diagnosis of internal cancer for the purpose of ongoing cancer evaluation.
$50 Per Visit
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sunlife.com
Cancer Insurance
Cancer insurance FAQs How do I file a claim?
premium, some or all of your benefit amount will be tax reported on a Form 1099 as taxable income. Please consult with a tax advisor or your employer if you have any questions. What if I have a pre-existing condition? If you submit a claim within 1 months of your insurance taking effect, or 1 months following any increase in your amount of insurance, we will not pay any benefit for any pre-existing condition. A pre-existing condition includes anything you have sought or received treatment for in the 6 months prior to your insurance becoming effective. Treatment can include consultation, advice, care, services or a prescription for drugs or medicine. Can I take my insurance with me if I leave my employer? Depending upon state variations and your employer’s plan, you may have an option to continue group coverage when your employment terminates. Your employer can advise you about your options.
We will ask for information from you and your doctor about your medical condition. You can download forms from our website. Please complete and sign all forms. Missing information or signatures can delay your claim. Can I receive benefits for more than one cancer diagnosis? Regardless of types of Cancer or number of diagnoses, you may receive benefits for covered Cancer treatments from your inforce policy. If you have Level 2 coverage, the First Occurrence Benefit provides a one-time payment for your initial Cancer diagnosis in addition to your covered treatment benefits. Is my benefit taxable? If you pay for your coverage all post-tax, your benefit will not be taxable income or tax reported by us to the IRS. If you pay for your coverage all pre-tax, if you pay for part of your coverage post-tax and your employer pays for the rest, or if your employer pays the entire
“Cancer insurance” is a limited benefit policy. The certificate has exclusions and limitations that may affect any benefits payable. Benefits payable are subject to all terms and conditions of the certificate .
Read the important plan provisions section for more information including limitations and exclusions. Cancer Indemnity Insurance Monthly Rates Level 1 * Even Insured Patients Are Overwhelmed By The Cost Of Cancer Care,” Duke University study, www.forbes.com, August 2017
Level 2
17 Sterling Estates 2025 Benefits Guide | sunlife.com 1-800-SUN-LIFE (247-6875)
Frequently Asked Questions
What is included in the Medical Out-of-Pocket maximum? What is included in the Pharmacy Out- of-Pocket maximum? The Medical Out-of-Pocket maximum is the maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible and any coinsurance member responsibility. The Pharmacy OOP includes only pharmacy co-pays. The Medical OOP does NOT include monthly premiums, or billing from out-of-network providers. What is an in-network vs out-of-network provider? Cigna contracts with a wide range of doctors, as well as specialists, hospitals, labs, radiology facilities and pharmacies. These are the providers that are considered “in your network”. Specifically, each of these providers has agreed to accept Cigna’s contracted rate for your medical care and services rendered. The contracted rate includes both Cigna’s share of the cost, and the member’s. Your share may be in the form of a co-payment, deductible, or co-insurance. For example, Cigna’s contracted rate for a primary care visit might be $125. The Plan has a $25 co-payment for the visit; the member will pay $25 of the cost and your insurance plan will pay the remaining $100. An “out-of-network” provider is a medical doctor or facility that is not in contract with Cigna. This means that the provider may charge members higher rates for medical services and care, outside of the standard “in-network” rates. For example, a out-of- network provider may charge $200 for a primary care visit. Cigna may pay an adjustment of an out-of-network benefit of $80 dollars to the provider, so the member may be balance-billed for the remaining $120 cost of the visit.
When can I change my beneficiary information for my Basic Life Insurance? Any time! It is important that all beneficiary information be kept up-to-date. You may need to change it after a marriage, divorce, or birth of a child. You can contact ADP anytime to update your beneficiary.
Term
Definition
Network Office Visit (PCP)
The “per visit” co-pay cost for a primary care or standard network doctor.
Specialist Office Visit
The “per visit” co-pay cost for a specialized doctor (cardiologist, OB/GYN, orthopedic, gastrointestinal, etc.) The amount of money a member owes for any In-network health care services before co- insurance coverage begins. These are generally services that are NOT covered under a standard co-pay (inpatient surgery, outpatient surgery, MRI, etc.) Deductibles run on a calendar year basis. After any applicable deductible is met, the remaining cost of any in-network health care service is divided between the insurance carrier and the member. A 70% / 30% network co-insurance would divide the cost of a service with 70% paid by the insurance carrier and 30% paid by the member. These are generally services that are NOT covered under a standard co-pay (inpatient surgery, outpatient surgery, MRI, etc.) The maximum amount a member must pay during the policy year for covered essential health benefits. The OOP includes a member’s deductible, any co-insurance member responsibility, primary care and specialist office visit co-pays, ER or Urgent Care co-pays, and prescription co-pays / costs. The OOP does NOT include monthly premiums, billing from out-of-network providers, or spending for non-essential health benefits. The cost of a one month supply of a prescription drug. All covered drugs are designated into tiered levels based on drug usage, cost, and clinical effectiveness. Tier 1 usually includes generics, while Tier 2 generally includes preferred brand name medications. Tier 3 typically includes non-preferred brand name medications, Tier 4 usually includes higher cost drugs and Specialty Drugs are covered under a separate tier.
Network Deductible
Co-Insurance
Network Out-of-Pocket Maximum (OOP)
Prescription Drug Tiers and Monthly Co-Pays
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Legal Notices
Medicaid and the Children’s Health Insurance Program (CHIP) Offer Free or Low-Cost Health Coverage to Children and Families If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www. healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow. gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2022. Contact your State for more information on eligibility –
ALABAMA - Medicaid Website: http://myalhipp.com/ Phone: 1-855-692-5447 ALASKA - Medicaid The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: Customer Service@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default. aspx ARKANSAS - Medicaid Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) COLORADO - Medicaid Website: http://www.colorado.gov/hcpf Customer Contact Center: 1-800-221-3943 KANSAS - Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512 KENTUCKY - Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570 LOUSIANA - Medicaid Website: http://dhh.louisiana.gov/index.cfm/ subhome/l/n/331 Phone: 1-888-695-2447
FLORIDA - Medicaid Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268 GEORGIA - Medicaid Website: http://dch.georgia.gov/medicaid - click on Health Insurance Premium Payment (HIPP) Phone: 404-656-4507 INDIANA - Medicaid Healthy Indiana Plan for Low-Income Adults 19-64 Website: http://www.hip.in.gov Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 1-800-403-0864 IOWA - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 MAINE - Medicaid Website: http://maine.gov/dhhs/ofi/public-assistance/ index.html Phone: 1-800-442-6003 TTY: Maine relay 711
MASSACHUSETTS - Medicaid and CHIP Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120 MINNESOTA - Medicaid Website: http://mn.gov/dhs/ma/ Phone: 1-800-657-3739
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Legal Notices
MISSOURI - Medicaid Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
RHODE ISLAND - Medicaid Website: http://www.eohhs.ri.gov/ Phone: 401-462-5300 SOUTH CAROLINA - Medicaid Website: http://www.scdhhs.gov Phone: 1-888-549-0820 SOUTH DAKOTA - Medicaid
Phone: 573-751-2005 MONTANA - Medicaid Website: http://dphhs.mt.gov/ MontanaHealthcarePrograms/HIPP
Phone: 1-800-694-3084 NEBRASKA - Medicaid
Website: http://www.dhhs.ne.gov/Children_Family_ Services/AccessNebraska/Pages/accessnebraska_ index.aspx Phone: 1-855-632-7633 NEVADA - Medicaid Website: http://dwss.nv.gov/ Phone: 1-800-992-0900 NEW HAMPSHIRE - Medicaid Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 NEW JERSEY - Medicaid and CHIP Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/ medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEW YORK - Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831 NORTH CAROLINA - Medicaid Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100 NORTH DAKOTA - Medicaid Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825 OKLAHOMA - Medicaid and CHIP Website: http://www.insureoklahoma.org Phone: 1-888-365-3742 OREGON - Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 PENNSYLVANIA - Medicaid Website: http://www.dhs.pa.gov/hipp Phone: 1-800-692-7462
Website: http://dss.sd.gov Phone: 1-888-828-0059 TEXAS - Medicaid Website: http://www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 UTAH - Medicaid and CHIP Medicaid Website: http://health.utah.gov/medicaid CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669 VERMONT - Medicaid Website: http://www.greenmountaincare.org Phone: 1-800-250-8427 VIRGINIA - Medicaid and CHIP Medicaid & CHIP Website: http://www.coverva.org/programs_premi- um_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282 WASHINGTON - Medicaid Website: http://www.hca.wa.gov/free-or-low-costhealth-care/pro- gram-administration/premiumpayment- program Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA - Medicaid Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/ default.aspx Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN - Medicaid and CHIP Website: http://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
Phone: 1-800-362-3002 WYOMING - Medicaid Website: http://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
To see if any more States have added a premium assistance program since January 31, 2022, or for more information on special enrollment rights, you can contact either:
U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
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Legal Notices
Important Notices about Medical Coverage
HIPAA Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself or your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 30 days after the marriage, birth, adoption, or placement for adoption. Effective April 1, 2009 special enrollment rights also exist in the following circumstances: • If you or your dependents experience a loss of eligibility for Medicaid or your State Children’s Health Insurance Program (SCHIP) coverage; or • If you or your dependents become eligible for premium assistance under an optional state of Medicaid or SCHIP program that would pay the employee’s portion of the health insurance premium. NOTE: In the two above listed circumstances only, you or your dependents will have sixty (60) days to request special enrollment in the group health plan coverage. An individual must request this special enrollment within sixty (60) days of the loss of coverage described at bullet one, and within sixty (60) days of when eligibility is determined as described in bullet two. Women’s Health and Cancer Rights Act of 1998 Annual Notice If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and co-insurance applicable to other medical and surgical benefits provided under this plan. Our plan complies with these requirements. Benefits for these items generally are compatible to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by consultation between the attending physician and the patient. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements. If you would like more information on WHCRA benefits, call Yates LLC at (706) 323-1600.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, not withstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.
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Medicare Part D
Medicare Part D Notice of Creditable Coverage Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Sterling Estates and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your currant coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Sterling Estates has determined that the prescription drug coverage offered by Cigna plans are on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join a Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens to Your Current Coverage if You Join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Sterling Estates coverage may or may not be affected. See pages 7-9 of the CMS Disclosure of Creditable Coverage to Medicare Part D Eligible Individuals Guidance (available at http:// www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions / options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current Sterling Estates coverage, be aware that you and your dependents may or may not be able to get this coverage back.
When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Sterling Estates and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without a creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For further information, call Yates LLC at (706) 323-1600. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Sterling Estates changes. You may also request a copy of this notice at any time. More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Medicare Part D Notice of Creditable Coverage, cont. Visit www.medicare.gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help. Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www. socialsecurity. gov , or call them at 1-800-772-1213 (TTY 1-800- 325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium.
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