2015

Benefits Information

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CKFI BenefitsMedical – Aetna

Dental – Delta Dental

Vision – VSP

STD, LTD, Life AD&D - Unum

Vol Life AD&D - Assurant

Next Steps / Forms

McGohan Brabender Customer Care

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Aetna Medical HSA PlanOH PB HSA OAMC 16 Rx 2 In-Network Non-Network

Deductible$2,750 / $5,500

Embedded, Calendar Year$5,000 / $10,000

Embedded, Calendar Year

Coinsurance 80% / 20% 50% / 50%

Out-of-Pocket Maximum $4,000 / $8,000 $12,000 / $24,000

Office Visit Deducible & Coinsurance Deducible & Coinsurance

Preventive Care Covered in Full Deductible & Coinsurance

Emergency Room Co-pay Deducible & Coinsurance Covered as Network Benefit

Urgent Care Co-pay Deducible & Coinsurance Deductible & Coinsurance

Retail Pharmacy (30 day supply)

Deductible Applies$10 (Preferred Generic) / $40 (Preferred Brand) / $60 (Non-

Preferred) / 30% ($250 max Preferred Specialty)

Deductible Applies$10 (Preferred Generic) / $40 (Preferred Brand) / $60 (Non-

Preferred) / Specialty Not Covered

Mail Order Pharmacy (90 day supply)

Deductible Applies$20 (Preferred Generic) / $80 (Preferred Brand) / $120 (Non-

Preferred)

Not Covered

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Aetna Medical PPOOH OAMC 3 Rx 2 In-Network Non-Network

Deductible$1,000 / $2,000

Embedded / Calendar Year$3,000 / $6,000

Embedded / Calendar Year

Coinsurance 80% / 20% 50% / 50%

Out-of-Pocket Maximum $3,500 / $7,000 $10,500 / $21,000

Office Visit$20 Copay PCP

$50 Copay SpecialistDeductible & Coinsurance

Preventive Care Covered in Full Deductible & Coinsurance

Emergency Room Co-pay $200 Copay Covered as Network Benefit

Urgent Care Co-pay $50 Copay Deductible & Coinsurance

Retail Pharmacy (30 day supply)

$10 (Preferred Generic) / $40 (Preferred Brand) / $60 (Non-

Preferred) / 30% ($250 max Preferred

Specialty)

$10 (Preferred Generic) / $40 (Preferred Brand) / $60 (Non-

Preferred) / Specialty- Not Covered

Mail Order Pharmacy (90 day supply)

$20 (Preferred Generic) / $80 (Preferred Brand) / $120 (Non-

Preferred) Not Covered

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Medical Bi-Weekly CostsHSA PPO

Employee $0.00 $29.01

Employee + Spouse $158.56 $179.34

Employee +Domestic Partner $163.12 $184.38

Employee + Child(ren) $142.61 $161.20

Family $232.19 $262.46

Employee + Domestic Partner +Child(ren)

$236.65 $267.49

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AetnaCustomer Care888-982-3862

www.aetna.com

Aetna Mobile App• Access your health records, view claims and fi nd in -

network doctors all while you’re on the go.

Payment Estimator• Use your own plan details to compare costs before you go

to the doctor.

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Health Savings AccountA way to pay for your qualifi ed healthcare expenses and save on taxes.• Funds are deposited pre-tax• Money in the account rol ls over year to year (No “use it or lose it” rule)• The account belongs to the individual• Funds can be invested

Must be enrolled in the HSA plan.

Must not be covered by any non-qualifi ed health plan

Must not be enrolled in Medicare

**Fifth Third Bank for your Health Savings Account**

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Health Savings Account – Qualified Medical ExpensesMedical care expenses must be primarily used to alleviate or prevent a physical or mental defect or illness. They do not include expenses that are merely beneficial to general health, such as vitamins or a vacation.

• Co-pays, Co-insurance, Deductibles on your health plan• Prescription Medications• Dental & Vision Expenses• Much More! A comprehensive list can be found online:

http://www.irs.gov/pub/irs-pdf/p502.pdf

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Health Savings Account – IRS Maximum ContributionsIf you are enrolled in the HSA plan as an individual your 2015 maximum contribution is:

$3,350

If you are enrolled in the HSA plan and cover any member of your family your 2015 maximum contribution is:

$6,650

Eligible individuals (account holders) age 55 or over may make “catch-up” contributions of $1,000.

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Delta Dental

Deductible$50 / $150

Calendar Year

Preventive Care 100%

Basic Services 80%

Major Services 50%

Orthodontia Services 50%

Annual Maximum $1,500

Orthodontia Lifetime Maximum

$1,000

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Dental Bi-Weekly Costs

Employee $0.00

Employee + Family $11.32

Employee + Domestic Partner + Family

$11.59

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Delta DentalCustomer Care800-524-0149

www.deltadental.com

Manage your benefi ts anytime anywhere by downloading the mobile app to view claims and coverage and have your ID card right on your phone

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VSP Vision

Network Non-Network Frequency

Routine Eye Exam $10 Copay Up to $45 Every 12 months

Standard LensesBifocal LensesTrifocal Lenses

$25 CopayUp to $30Up to $50Up to $65

Every 12 months

Frames

$100 Allowance20% savings on the amount over your

allowance

Up to $70 Every 24 months

Elective Contacts $100 Allowance Up to $60 Every 12 months

Non-Elective $25 CoPay Up to $210 Every 12 months

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Vision Bi-Weekly Costs

Employee $0.00

Employee + Spouse $1.37

Employee + Domestic Partner $1.43

Employee + Child(ren) $1.40

Family $2.26

Employee + Domestic Partner + Family

$2.32

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VSP

Customer Care800-877-7195

www.vsp.com

• Register at vsp.com once your plan is eff ective, review your benefi t summary.

• No ID card necessary, if you would like one you can print it from vsp.com

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UNUM Unum is our carrier for Basic Life and Disability.  Everyone needs to complete a Unum beneficiary form.  These are company paid benefi ts provided to you.

Paid 100% by CKFI! No evidence of insurability needed.· Life Insurance equal to 1x employee annual earnings.· Accidental Death and Dismemberment equal to 1x employee annual earnings.Dependent Life Insurance: Unum· Option to purchase Life Insurance for your dependents.· Spouse: $10,000; Children: $5,000.

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ASSURANT

Voluntary Life Insurance Benefi ts: MyMBLife - Assurant·                 Option to purchase Life/AD&D for yourself or dependents.·                 Guarantee issue with no medical questions for new hires.·                 Employee: $150,000; Spouse: $50,000; Children: $10,000

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Next Steps: Everyone Must….• Complete the Benefi t Election Form

• Complete Aetna enrollment OR waiver form

• Complete Unum Life enrollment form (indicate Yes/No for Dependent coverage)

• IF ENROLLING in Dental and/or Vision, complete the carrier enrollment form(s)

• IF electing Domestic Partnership complete the Declaration of Domestic Partnership form

• Turn in all forms to HQ HR via email scan or fax (937-264-1364) within one week of your hire date.

All forms are located on the CKFI benefi ts website: www.benefi tsnapshot.com/comfortkeepers

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McGohan Brabender Customer Care Team

Should you encounter issues that you are unable to resolve by contacting the insurance carrier, you may

contact our McGohan Brabender Customer Care Team by calling:

937-260-4300 or 1-877-635-5372

or e-mail us at:

CustomerService@mcgohanbrabender.com

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McGohan Brabender -

1-844-388-6565

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Thank you!

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