2013 Flexible Benefits Program

2013
Department of Administrative Services
FLEXIBLE BENEFITS PROGRAM
2013
Your benefits are a reflection of you.
www.GaBreeze.ga.gov

2013
TABLE OF CONTENTS
Welcome ................................................................................................................................................................2
General Eligibility and Enrollment Information .....................................................................................3 Eligibility and Enrollment ....................................................................................................................3 Dependents Eligible For Coverage..................................................................................................3 Benefit Salary...........................................................................................................................................3 Pre-Tax Premiums ................................................................................................................................. 4 Important Information If You Are A New Employee................................................................ 4 After You Enroll For Coverage ..........................................................................................................5 When Coverage Begins........................................................................................................................5 Confirming Your Choices.....................................................................................................................5 To Change Your Decisions At Annual Enrollment......................................................................6 To Change Your Decisions Outside Annual Enrollment...........................................................6 Continuation of Benefits During Leave or End of Employment...................................... 6-8
Your Benefit Options Dental.................................................................................................................................................... 9-12 Vision ..................................................................................................................................................13-15 Employee, Spouse, and Child Life Insurance and AD&D..................................................16-18 Short and Long-Term Disability .............................................................................................. 19-20 Long Term Care..................................................................................................................................... 21 Specified Illness..............................................................................................................................22-24 Legal Insurance ............................................................................................................................. 25-26 Spending Accounts ......................................................................................................................27-29
The Path2College 529 Savings Plan .........................................................................................................30
Employee Checklist.......................................................................................................................................... 31
HIPAA Privacy Notice...............................................................................................................................32-33
Benefit Phone Directory................................................................................................................................ 34
Terms and Conditions.............................................................................................................................. 35-36

1-877-3GBreez

1
www.gabreeze.ga.gov

2013
Welcome
The State of Georgia Flexible Benefits Program
Are you planning or expecting the birth or adoption of a child? Getting married soon? Are you caring for an aging parent? Is it time to start thinking about supplementing your retirement? These are just some of life's changes that could affect the health care and financial needs of you and your family.
This 2013 You Decide! booklet gives you an opportunity to review and understand your benefits package. It summarizes benefits available to employees and their dependents eligible to participate in the Flexible Benefits Program, along with certain procedures to be followed to obtain these benefits.
There are some plan enhancements for the 2013 Plan Year, so review all information carefully. It is up to you to understand all the options available and make the choices that best suit your needs. Making the right decisions about your options can make a real difference toward building a rewarding future for you and your family.

2
1-877-3GBreez

www.gabreeze.ga.gov

2013

General Eligibility and Enrollment Information

Enrollment and Eligibility
You are eligible to participate in the Flexible Benefits Program if:
You are a full-time regular employee who works at least 30 hours a week and are expected to work for at least nine months. Employees who work in a sheltered workshop or work transition program, contingent employees, temporary employees, and student employees are not eligible.
You are a public schoolteacher, working at least 17.5 hours, and employed in a professionally certified capacity, working half time or more and not considered a "temporary" or "emergency" employee.
You are an employee of a local school system holding a non-certificated position. You must be eligible to participate in the Teacher's Retirement System (TRS) or its local equivalent, and you must work a minimum of 20 hours a week (or 60% of the time necessary to carry out the duties of the position, if that's more than 20 hours).
You are an employee of a local school system working at least 15 hours (or 60% of the time necessary to carry out the duties of your position, if that's more than 15 hours) and you are eligible to participate in the Public School Employees' Retirement System (PSERS), as defined by Paragraph 20 of Section 47-4-2 of the Georgia Code.
You are an employee of a county or regional library and work at least 17.5 hours per week.
Others deemed eligible by Federal or Georgia law.
If you aren't sure whether you're eligible, contact your personnel/payroll office.

Dependents Eligible For Coverage Eligible dependents include: Your legal spouse Your dependent child/ren who are under
age 26, Your dependent child/ren who are age
26 or over, and who are incapable of self-sustaining employment by reason of mental incapacity or physical disability Dependent child/ren are defined as you or your spouses' natural or legally adopted child/ren. To verify eligibility of newly added dependents, you must provide supporting documentation (i.e., birth certificate, marriage certificate), if requested.
Benefit Salary Your Benefit Salary includes your base salary and salary supplements that are regular, non-temporary, and not more than the amount on which retirement contributions are calculated - is reflected on GaBreeze and remains constant for the entire Plan year. It is calculated on your date of hire or the Benefit Calculation Date. Any adjustments to the Benefit Salary, with the exception of errors (as determined by the Plan Administrator) shall be reflected on the following Benefit Calculation Date, to be effective for the following Plan Year. Promotions, demotions, adjustments due to certifications are not deemed to be errors. Benefit Salary is the pay used to calculate your pay-based coverage - employee life, AD&D, and disability.

1-877-3GBreez

3
www.gabreeze.ga.gov

2013Continued
General Eligibility and Enrollment Information

Pre-Tax Premiums Help You Stretch Your Dollars The Flexible Benefits Program allows you to save on taxes while you pay for your benefits. Pre-tax premiums reduce your taxable pay...and your taxes. That's because premiums for most of your insurance options, health benefit options, and spending account contributions are taken out of your paycheck before federal and state income taxes and Social Security (FICA) taxes are withheld.
This means your taxable pay is lower...and so are your taxes. It also means you have more in your paycheck - or more to spend on benefits than you would if you paid the same premiums with after-tax dollars.
Important Information If You Are A New Employee
New Hire Electronic Enrollment You will receive an enrollment worksheet mailed to your home address to prepare you to enroll. You can select your benefits using the employee web site (GaBreeze. ga.gov) located on the Team Georgia Connection/Flex web site (www.team. georgia.gov/flex) or calling the GaBreeze Benefits Center at 1-877-342-7389.
Dental For new employees hired after January 1, 2013, there is a 6 month waiting period for Major services under the Select Plan and a 6 month waiting period for Major and Ortho services under the Select Plus plan. The DHMO Option does not have waiting periods or late enrollment penalties, but you must

use a DHMO network provider and live/ work in the metro Atlanta area. Spending Accounts Your paycheck reductions for the spending accounts will start the 15th of your first full calendar month of employment. Your total contributions to each account are prorated by the number of months you participate in these options up to the maximum monthly amount allowed for each account. Once you enroll, you may submit claims for services incurred on or after the first of the month after you have completed one full calendar month of employment.
Long-Term Care You have a one-time opportunity to sign up for long-term care insurance without providing medical underwriting.
Employee Life, Spouse Life and Child Life You have a one-time opportunity to choose some levels of employee and spouse life insurance coverage without providing medical underwriting. Please see Employee, Spouse, and Child Life section for specific limits.
Employee Specified Illness and Spouse Specified Illness You have a one-time opportunity to sign up for the Specified Illness guaranteed levels up to $30,000 without providing medical underwriting. Coverage for children is included with the Employee benefit.

4
1-877-3GBreez

www.gabreeze.ga.gov

2013 Continued
General Eligibility and Enrollment Information

Important Information If You Are A New Employee (cont'd)

You have a one-time opportunity to sign up for the Spousal Specified Illness guaranteed level up to $10,000 without providing medical underwriting
Disability There is a one-time opportunity to sign up for long-term disability coverage without providing medical underwriting during your new hire eligibility period. If you do not sign up now, you will need to complete an Evidence of Insurability Form.
Other Coverage There are no medical underwriting requirements at any time for legal insurance, AD&D, spending accounts, or vision benefits.
Be sure to consider your options carefully when you first enroll. If you decline or drop some of your State coverages and want to pick them up again another year, you may have to prove insurability through medical underwriting to be covered again, or have longer waiting periods to receive full benefits.
After You Enroll For Coverage
When Coverage Begins Coverage for new options selected during the Plan Year 2013 Annual Enrollment will begin on January 1, 2013 as long as you have met all contractual and administrative requirements.
1-877-3GBreez

Your new premiums for your health benefit plan and spending account reductions begin December 15; other premiums begin December 31 (for semi-monthly pay periods). These dates may not apply if your department has a different pay schedule. Please check with your personnel/payroll office for more information. See specific plan descriptions for information about when your coverage begins.
If you are a new employee, your benefit selection(s) and any necessary forms must be completed no later than 30 days after your hire date. Your coverage will begin on the first day of the month after you have completed a full calendar month of continuous employment.
Confirming Your Choices You are responsible for the benefit selections entered on the GaBreeze web site or calling the GaBreeze Benefits Center. It is very important that you confirm your selections prior to the end of the enrollment period and ensure that you print your Confirmation page. The choices confirmed at the end of the enrollment period are the valid choices for the entire Plan Year. The Confirmation Statement does not guarantee your coverage in some benefit coverages that require additional information. If you have not completed and submitted the additional forms/information required by your selected plan, the choices shown on your Confirmation Statement may not be valid.
Compare your paycheck statements with your Confirmation Statement. It is your responsibility to notify your personnel/ payroll office immediately if there is an
5
www.gabreeze.ga.gov

2013Continued
General Eligibility and Enrollment Information

error. Deductions should match the confirmed choices. Any changes to your benefit selections must be in accordance with IRS 125 and Employee Benefit Plan Council rules and regulations and approved by plan administrators.
To Change Your Decisions at Annual Enrollment Every Annual Enrollment you can change your benefit decisions, based on which benefits are available and right for you. Remember, this is an annual agreement to allow the State to purchase some benefits for you through pre-tax premiums. You will not be able to change these benefit decisions until the next Annual Enrollment unless you have a qualifying change in status as described in the Terms and Conditions.
To Change Your Decisions Outside Annual Enrollment
Qualifying Change in Status Event In general, the Internal Revenue Service prohibits you from changing any coverage elections, or enrolling in or canceling any coverage under the Flexible Benefits Program outside of Annual Enrollment. However, the rules of the Internal Revenue Service and the Employee Benefit Plan Council do permit you to change coverage or enroll or cancel coverage in certain limited circumstances, if the change corresponds to a qualifying change in status event.
The Employee Benefit Plan Council has the responsibility to interpret these rules and make the final decision as to whether you may enroll or change any coverage outside
6
1-877-3GBreez

of the Annual Enrollment period. Your request for enrollment or a change in any other coverage under the Flexible Benefits Program must be entered on the GaBreeze web site or by calling the GaBreeze Benefits Center within 30 days after the qualifying event. There will be no refund of premiums paid into the Plan, when a timely change is not made.
Note: For a list of possible change in status events that might permit you to change one or more coverages under the Flexible Benefits Program, please refer to the Terms and Conditions in this booklet.
Generally, any changes will go into effect the first of the month following the request when the payroll deduction is changed to reflect your new choices. For some benefits, however, when you change coverage based on the acquisition of dependents, the coverage effective date for the new coverage may be retroactive to the date of the acquisition of the dependent in some circumstances, or may be the first of the month following the request to change coverage.
Continuation of Benefits During Unpaid Leave, Retirement or End of Employment
Unpaid Leave
When you go on leave without pay, you will receive a bill for coverage from GaBreeze while on an unpaid leave of absence. If you do not continue paying premiums for coverage, your benefits will be cancelled and you may be subject to penalties and wait periods, if allowed to re-enroll. You may be required to wait until the next
www.gabreeze.ga.gov

2013Continued
General Eligibility and Enrollment Information

Annual Enrollment period to re-enroll. Be sure to review each Plan Description for each option. Exceptions: FLMA and Military Leave.
Retirement
It is the responsibility of each employee to contact the vendor directly within the required timeframe, to continue coverage unless you are retiring. If you retire and are currently enrolled in dental, your coverage will continue automatically. If you wish to cancel your dental coverage, you will need to contact the GaBreeze Benefits Center. For vision and HCSA, you may continue through COBRA.

End Employment
If you leave active State employment and then return during the same plan year and within a 30-day period, your previous choices will remain in effect unless you report a qualifying change in status event.
If you leave active State employment and return in the same plan year outside a 30-day period, you will be treated as a new hire.

"

1-877-3GBreez

" The enrollment process is easy.
7
www.gabreeze.ga.gov

Can I take Insurance Coverage with me when I leave?

Benefits
Dental Coverage Select & Select Plus DHMO Option
Vision Coverage Health Care Spending Accounts Dependent (Child) Care Spending Account Employee/Spouse/ Child Life Insurance AD&D Insurance Specified Illness Disability/Coverage
Short-Term Long-Term Legal Insurance
Long-Term Care Insurance

Retiree Coverage Available Through Retirement Plan Benefit Deductions

Coverage Can Be Continued
Through COBRA

Coverage Can Be Direct
Billed By Carrier Or Converted To An Individual
Policy

You Must Decide And
Complete Carrier Forms
Within

COBRA - 60

days

Convert 30

Yes

Yes

No

days

- Prepaid

Yes

Yes

Yes

Option

No

Yes

No

Yes

No

(Through end of

No

the plan year)

60 days 60 days

No

No

No

----

No

No

Yes

30 days

No

No

Yes

30 days

No

No

Yes

30 days

No

No

No

----

No

No

Yes

30 days

No

No

Yes

30 days

(Through end

of the plan

year)

No

No

Yes

30 days

8
1-877-3GBreez

www.gabreeze.ga.gov

2013

Dental

Dental Plans
We offer a wide variety of dental plan choices including two new plans, Select and Select Plus, from Delta Dental which replace the Regular and PPO plans previously provided by United Concordia. Each plan has different payment schedules and providers. Closely review these plans to determine which one best fits the needs of you and your family. Use the comparison chart in this guide to learn about the plans. Due to availability, your best option may depend on where you live or work, and you should check the availability of dentists carefully. The three dental plans are listed below according to the dentist network availability in geographic areas:

covered services they provide you, so you'll usually pay the least when you visit a PPO network dentist. This also ensures Delta Dental PPO dentists won't balance bill you the difference between the contracted amount and their usual fee. If you visit a non-Delta Dental dentist, they can balance bill you the difference between the amount of benefits payable by Delta Dental and the dentist charge for that service. Note: Orthodontia services for adults and dependent children are available through the Select Plus Plan only.
Important Information for Select and Select Plus Options

Delta Dental Select and Delta Dental Select Plus For all employees throughout Georgia;
Dental Health Maintenance Organization (DHMO, formerly Prepaid) Specifically for employees who live or work in metropolitan Atlanta area.
Your Choices
Select and Select Plus Options with Delta Dental You may go to any dentist If you visit a Delta Dental PPO network
dentist, they accept reduced fees for

Six (6) Month Wait Period
All New Hires are subject to the Six (6) Month Wait Period for Type III and Orthodontia services (for adults and children under the Select Plus Plan).
Based on the employee's enrolled effective date, newly eligible dependents may not be required to meet the six (6) Month Wait Period.
This Annual Enrollment only: Current employees not enrolled in dental may select one of Delta Dental options without being required to meet the six (6) Month Wait Period.

"

" With such a large network of dental providers, I found my dentist online and am pleased with their services.
1-877-3GBreez

9
www.gabreeze.ga.gov

2013Continued
Dental

Dental HMO (DHMO) Plan:
CIGNA Dental Care (DHMO) plan makes it easy and affordable for you to take care of your dental health.
No deductibles No annual dollar maximums No claim forms to file No ID cards required to receive care No age limit on sealants No referrals required to visit a network
orthodontist or for children under 7 to visit a network pediatric dentist
The CIGNA DHMO is available to employees who live or work in the metropolitan Atlanta area. With the CIGNA DHMO, you'll know exactly what you pay ("copays") for covered services even for specialty care with a referral approved for payment. Just choose a general dentist from the CIGNA DHMO network at enrollment and visit that dentist for all your dental care needs. Most Preventive services such as exams, x-rays and cleanings, are covered by a $0 or low copay (frequency limits may apply). Dental treatments such as fillings, crowns and root canals are covered reduced, fixed copays for covered services.

Keep in mind, there is no out-of-network coverage with a DHMO plan; but finding a network dentist near you is easy when you use the "Provider Directory" at www. cigna.com. Your covered family members can each choose their own general dentists. After you enroll, you can change your general dentist anytime - online or by phone.
Did you know research supports a relationship between gum (periodontal) disease and complications for diabetes, heart disease and stroke, pre-term birth, and other health issues? That's why CIGNA created the CIGNA Dental Oral Health Integration Program. Under this program, eligible State of Georgia Flexible Benefits Program participants enrolled in a CIGNA plan can enjoy enhanced preventive dental coverage.
For additional information about CIGNA, please visit www.cigna.com.

10
1-877-3GBreez

www.gabreeze.ga.gov

Option 1

Delta Dental Options Comparison Chart

Eligibility

Primary enrollee, spouse and eligible dependent children to age 26

Deductibles*
Deductibles waived for D & P

Dental Select: In-Network - $50 per person / $150 per family each calendar year Dental SelectPlus: $50 per person / $150 per family each calendar year Out of Network: $50 per person / $150 per family each calendar year
Yes

Maximums*
D & P counts toward maximum?

$500 per person each calendar year Dental Select Plan $2,000 per person each calendar year Dental SelectPlus Plan
No

Dental Select Plan

Dental SelectPlus Plan

Benefits and Covered Services **

PPO Dentists***

Premier

Non-Delta PPO

Dentists*** Dental

Dentists***

Dentists***

Premier Non-Delta Dentists*** Dental
Dentists***

Diagnostic & Preventive Services (D&P)
Exams, cleanings, x-rays, sealants

100%

100%

100%

100%

100%

100%

Basic Services Fillings, simple tooth extractions

80%

80%

80%

90%

90%

90%

Endodontics (root canals)
Covered Under Basic Services

80%

80%

80%

90%

90%

90%

Periodontics (gum treatment)
Covered under Basic Services

80%

80%

80%

90%

90%

90%

Oral Surgery Covered Under Basic Services

80%

80%

80%

90%

90%

90%

Major Services Crowns, inlays, onlays and cast restorations, bridges, dentures & TMJ, surgical periodontics

50%

50%

50%

60%

60%

60%

Orthodontic Benefits Adults and dependent children

Not Covered

Not Covered

Not Covered

50%

50%

50%

Orthodontic Maximums Not

Lifetime

Covered

Not Covered

Not Covered

$2,000

$2,000 $2,000

*** If you switch plans during the calendar year your Deductible and Annual Maximum may be adjusted accordingly. *** Limitations or waiting periods may apply for some benefits; some services may be excluded from your plan.
Reimbursement is based on Delta Dental contract allowances and not necessarily each dentists's actual fees. *** Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists
and 80th percentile for non-Delta Dental dentists.

1-877-3GBreez

11
www.gabreeze.ga.gov

2013
Cigna Dental

CIGNA DHMO Comparison Chart

Benefits & Covered Services

In Network

Type I Diagnostic & Preventive Services Oral Exams, Cleanings, x-rays,

100% Reduced, fixed, preset charges for all covered services. See your patient Charge Schedule for Specific Charges

Type II Basic Services Fillings, Root canals, Extractions, Scaling and root planning Repairs to dentures, bridges and crowns Sealants Type III Major Crowns, Dentures, Bridgework, Surgical periodontal Orthodontic Benefits Cephalometric x-rays, Treatment study, Bands, appliances
Annual Deductible Maximum Benefits Waiting Period for Benefits

100% Reduced, fixed, preset charges for all covered services. See your patient Charge Schedule for Specific Charges (amalgam (silver) fillings only)
60% Reduced, fixed, preset charges for all covered services. See your patient Charge Schedule for Specific Charges 50% for employee dependents under 19 (and eligible dependents) Reduced, fixed, preset charges for all covered services. See your patient Charge Schedule for Specific Charges NONE No Maximum No Waiting period

12
1-877-3GBreez

www.gabreeze.ga.gov

2013

Vision

Vision Plans with Spectera Vision coverage is available with two plan
options Select and Select Plus. Both plans offer these features: covered exams and materials; statewide access to a network of panel providers; no claims to file for "in-network" benefits; and benefits for "out-of-network" providers.
The Spectera Vision Care participating provider network includes private practice optometrists, ophthalmologists and retail chains.
Your Options
Select Option The Select Plan covers standard single
vision and standard lined multi focal lenses for glasses. Cosmetic lens options such as tinting, UV coating, progressive lenses, etc., are not covered, but are provided to Spectera Vision's members at a savings below normal retail charges. Certain standard contact lenses, including daily wear, and up to 4 boxes of standard single vision disposable contacts are covered in full for your co-payments. Under the Select Plan, if you purchase contacts that are not among Spectera Vision's "covered in full" selection, you will receive an annual $105 allowance toward the purchase of contact lenses, and professional fees (i.e., fit and follow-up). To receive the full $105 allowance under the Select Plan, you must receive your exam, fitting and evaluation at a single visit to the same network provider. The allowance will only apply to one purchase per plan year. You must submit all receipts at the same time. Any balance remaining and not used during the plan
13
1-877-3GBreez

year when the purchase occurred will be forfeited.
Select Plus Option In addition to the coverage in the Select
Plan, the Select Plus Plan does offer cosmetic lens options for Tints, UV, Polycarbonate and Basic Progressive lenses. To receive the full $200 allowance under the Select plus Plan, you must receive your exam, fitting and evaluation at a single visit to the same network provider. The allowance will only apply to one purchase per plan year. You must submit all receipts at the same time. Any balance remaining and not used during the plan year when the purchase occurred will be forfeited.
Important Information for Select Plan Benefits are provided every 12 months
for exams, lenses and/or contacts and every 24 months for frames measured from the last date of service. The out of network allowance for contact lenses will be $105. Note: Benefit service limitations are calculated on a rolling calendar year. Example: if you receive exam services in March, you will be eligible to receive another exam in March of the following year.
Important Information for Select Plus Plan Benefits are provided every 12 months for
exams, lenses and/or contacts and every 12 months for frames measured from the last date of service. The out of network allowance for contact lenses will be $200. Note: Benefit service limitations are calculated on a rolling calendar year. Example: if you receive exam services in March, you will be eligible to receive another exam in March of the following year.
www.gabreeze.ga.gov

Select Plan Option

Service

In-Network Benefits

Out-of-Network Benefits

Routine Eye Exam

100% after $10 copay

Reimburses up to $40

Every 12 months

Lenses Standard

Every 12 months Single vision, or Lined Bifocal, or Lined Trifocal, or Lenticular Frames Every 24 months after a $20 materials copay*
Contact Lenses Every 12 months in place of eyeglasses
Medically Necessary Not Medically Necessary

100% after $20 copay
100% after $20 copay
100% after $20 copay
100% after $20 copay
Retail Providers (Examples: Eye Glass World, For Eyes and Wal-Mart)
Up to $130 retail allowance toward any frame package
Frames below $130 provided at no additional cost
Private Doctors Office $130 retail allowance towards any
frame. You pay the difference. Group of select frames or frames
below $130 provided at no additional cost
After $20 copay. Covered in full contact lenses in lieu of eyeglasses. At in-network providers includes fitting/evaluation fee, contacts and two follow up visits. If you chose disposable contacts, you receive up to four boxes. Non-covered contacts receive $105 allowance.
Covered after $20 materials copay
Covered after $20 material copay for covered lenses selected from OptumHealth's list. Up to four boxes of covered disposable contact lenses are included when using a network provider. All other contacts available through a $105 allowance that includes fitting, follow-up & materials. Please note to receive the full $105 credit, you must receive your exam, fitting evaluation and all contact materials at the same provider at the same time. (At Wal-Mart $70 of the $105 allowance is allocated to materials and $35 to professional fees).

Reimburses up to $60 Reimburses up to $80 Reimburses up to $80 Reimburses up to $45 of retail
Reimburses up to $105 Reimburses up to $210 Up to $105 max that includes fit, followup & materials

Refractive Eye Surgery Access to discounted provider locations throughout the United States. To find a participating laser eye surgeon, visit our web site at www.myspectera.com

Discount only: The in-network benefit is a discount off the full retail price.

No benefits

Remember if you use in-network providers, you are responsible only for your portion of the cost. If you decide to use a non-network provider, you pay everything and file a claim to receive payment according to the out of network payment schedule. * Must qualify as medically necessary as described in the enrollment booklet.

1-877-3GBreez

14
www.gabreeze.ga.gov

Select Plus Plan Option

Service Routine Eye Exam Every 12 months Lenses Standard Every 12 months Single vision, or Lined Bifocal, or Lined Trifocal, or Lenticular
Frames Every 12 months after a $20 materials copay*
Contact Lenses Every 12 months in place of eyeglasses
Medically Necessary Not Medically Necessary

In-Network Benefits 100% after $10 copay

Out-of-Network Benefits Reimburses up to $40

Lens Options covered are: Tints, UV, Polycarbonate and Basic Progressives lenses.
100% after $25 copay
100% after $25 copay
100% after $25 copay
100% after $25 copay
Retail Providers (Examples: Eye Glass World, For Eyes and Wal-Mart)
Up to $150 retail allowance toward any frame package
Frames below $150 provided at no additional cost
Private Doctors Office $150 retail allowance towards any
frame. You pay the difference. Group of select frames or frames
below $150 provided at no additional cost
After $25 copay. Covered in full contact leses in lieu of eyeglasses. At in-network providers includes fitting/evaluation fee, contacts and two follow up visits. If you chose disposable contacts, you receive up to eight boxes. Non-covered contacts receive $200 allowance.
Covered after $25 materials copay
Covered after $25 material copay for covered lenses selected from OptumHealth's list. Up to eight boxes of covered disposable contact lenses are included when using a network provider. All other contacts available through a $200 allowance that includes fitting, follow-up & materials. Please note to receive the full $200 credit, you must receive your exam, fitting evaluation and all contact materials at the same provider at the same time. (At Wal-Mart $70 of the $200 allowance is allocated to materials and $130 to professional fees).

OON Lens options are not covered. Reimburses up to $40 Reimburses up to $60 Reimburses up to $80 Reimburses up to $80 Reimburses up to $45 of retail
Reimburses up to $210 Up to $200 max that includes fit, followup & materials

Refractive Eye Surgery Access to discounted provider locations throughout the United States. To find a participating laser eye surgeon, visit our web site at www.myspectera.com.

Discount only: The in-network benefit is a discount off the full retail price.

No benefits

Remember if you use in-network providers, you are responsible only for your portion of the cost. If you decide to use a non-network provider, you pay everything and file a claim to receive payment according to the out of network payment schedule. ** Must qualify as medically necessary as described in the enrollment booklet.

15
1-877-3GBreez

www.gabreeze.ga.gov

2013

Employee, Spouse, and Child Life Insurance and AD&D

Employee Life Insurance With Minnesota Life If you want life insurance protection or you want to supplement the protection you already have, you may choose group term life coverage under the Flexible Benefits Program. The life insurance amount you choose is paid to your beneficiaries, if you die while this coverage is in effect. Your beneficiaries are the persons you name to receive your life insurance benefits.
Available Coverage Amounts one times your pay (maximum coverage
is $300,000) two times your pay three times your pay four times your pay five times your pay six times your pay seven times your pay eight times your pay nine times your pay
If you are a newly eligible employee, you may elect Employee Life Insurance at one (1) times your Benefit Salary up to $300,000 or Two (2) through Nine (9) times your Benefit Salary up to and including $200,000. If you apply for an amount of insurance in excess of $200,000, you will be subject to medical underwriting. The coverage maximum is $1,000,000. If you are age 65 or older, the amount of your life coverage is reduced.
Spouse Life Insurance With Minnesota Life If you choose employee life insurance for yourself, you may also choose spouse life insurance coverage for your spouse. Spouse life insurance premiums are based on the coverage level and employee age. Premiums for spouse coverage are aftertax. However, if you are age 65 or older,
1-877-3GBreez

the amount of your spouse life coverage is reduced.
Available Coverage Amounts
Spouse Life - $ 6,000 - $ 12,000 - $ 30,000 - $ 60,000 - $100,000 - $150,000 - $200,000 - $250,000
Spouse Life coverage cannot exceed 100% of your amount of Employee Life coverage.
You are the beneficiary of spouse life insurance coverage and will receive the insurance benefit in the event of your spouse's death.
If you are a newly eligible employee, you may elect $30,000 or less of spouse life coverage without medical underwriting.

Child Life Insurance With Minnesota Life If you choose life insurance for yourself, you may also choose child life insurance coverage for your child(ren). Child life insurance premiums are after-tax.

Available Coverage Amounts Child Life - $ 3,000 - $ 6,000
- $ 15,000

- $ 10,000 - $ 20,000

Your children are eligible for coverage if they are under age 26.

Child life coverage can be elected without medical underwriting.

Important Notes about Child Life: The child coverage begins at live birth.
Coverage from live birth to 6 months is the lesser of the elected amount or $6,000. From 6 months of age to age 26, the full amount elected applies.

16
www.gabreeze.ga.gov

2013Continued
Employee, Spouse, and Child Life Insurance and AD&D

Child Life coverage cannot exceed 100% of your amount of Employee Life coverage.
You are the beneficiary of child life insurance coverage and will receive the insurance benefit in the event of the child's death.
Accidental Death and Dismemberment Insurance With Minnesota Life The Flexible Benefits Program offers accidental death and dismemberment (AD&D) insurance to be paid to you or your beneficiary if your death or injury is the result of a covered accident. In case of the permanent and total disability benefit under AD&D, you are eligible for the benefit if your injury prevents you from working at any job for which you are qualified by education, training, or experience.
Available Coverage Amounts one times your pay two times your pay three times your pay four times your pay five times your pay six times your pay seven times your pay eight times your pay nine times your pay

Important Notes about Employee, Spouse, Child Life and AD&D Insurance The life and AD&D insurance amounts
you choose will be based on your Benefit Salary as of October 1, 2012. This amount is rounded up to the next higher $1,000, after you multiply your coverage and the premium has been adjusted for your October 1, 2012 pay and age. If your coverage selection requires medical underwriting, you will need to complete the Minnesota Life Evidence of Insurability Form along with any other required information. An approval by Minnesota Life, the insurance carrier, must be made before coverage can be in effect. Be sure to designate your beneficiaries by accessing the GaBreeze web site or calling GaBreeze Benefits Center. Also, you can change and update your beneficiaries at any time. For information regarding conversion and portability of your Employee Life, Spouse Life, and Child Life insurance, contact Minnesota Life Insurance toll-free at 1-800-660-2519.

The coverage maximum is $1,000,000. If you are age 75 or older, the value of your coverage is reduced.

17
1-877-3GBreez

www.gabreeze.ga.gov

2013

"

"I wanted to make sure my family would be financially secure and that's why I decided to increase my life insurance.

1-877-3GBreez

18
www.gabreeze.ga.gov

2013

SHORT AND LONG TERM DISABILITY

To help provide income protection against the unexpected, the Flexible Benefits Program allows you to choose: Short-Term Disability insurance and/or Long-Term Disability insurance.
Short-Term Disability With The Standard
If you choose short-term disability (STD) coverage, this plan will work with other income benefits to replace 60% of your Benefit Salary (in effect during the Plan Year the disability began) up to $800 per week. If you receive other benefits, (such as Social Security, workers' compensation, other disability plans and/or programs including the State retirement systems) that total 60% of your Benefit Salary, the shortterm disability plan will not pay for this disability.

Your STD benefits can continue until you recover, return to work, or receive benefits for a maximum of 150 calendar days or a maximum of 173 calendar days, depending on the coverage level you have chosen. The calendar-day maximums are reduced by any days of paid sick leave, donated leave or Special Injury Leave that you use which exceeds the applicable wait period.
When changing from the 30-day Benefit Waiting Period to the 7-day Benefit Waiting Period, a Pre-Existing clause is applicable. If you have a condition for which you should have sought medical care or which originated prior to the 7-day Benefit Waiting Period effective date, you will be subject to the rules of the 30-day Benefit Waiting Period until you are on the plan for 12 consecutive months. The Pre-Existing clause does not apply to accidental injuries.

Your Options Seven (7) Day Benefit Waiting Period Thirty (30) Day Benefit Waiting Period
How STD Works In general: A late enrollment penalty may apply for
late entrants to the STD plan (employees who do not elect STD when first eligible). Your STD benefits are calculated on the Benefit Salary that is in effect during the Plan Year your disability began, less other income benefits. For example, if your first day of disability is December 3, 2012, your disability benefit will be calculated from the 2012 Benefit Salary, not your 2013 Benefit Salary.

What Is A Late Enrollment Penalty For Late Entrants? A current employee choosing coverage for the first time or re-enrolling after discontinuing coverage is considered a late entrant. For STD late entrants, who become disabled due to Physical Disease, Pregnancy, or Mental Disorder, during the 12-month period after the date your STD insurance becomes effective, benefits will not begin until after you have been disabled for 60 days until you are on the plan for 12 consecutive months. For STD late entrants whose disabilities begin after this 12 month period, benefits will start after the benefit waiting period (7 or 30 continuous calendar days) is satisfied for STD.

19
1-877-3GBreez

www.gabreeze.ga.gov

2013Continued
Short and Long Term Disability

Enrolling For Short-Term Disability Coverage Your premiums will be based on your coverage level and Benefit Salary. Since you pay for this coverage with after-tax premiums, you won't pay taxes on the benefits you receive.
Note: Employees should check with your agency concerning leave usage policies when disabled. Agency policy may impact your eligibility to receive Short-Term Disability benefits.

Effective January 1, 2013, LTD benefits end when you are no longer disabled or reach age 67, except benefits for disabilities caused by mental disorders, or other limited conditions, which are limited to two years. If you become disabled after reaching age 60, however, your benefits could continue for a limited period after age 67.
Note: For claims initiated prior to January 1, 2013, benefits will end when you are no longer disabled or reach age 65.

Long-Term Disability With The Standard
Long-Term Disability Protection The Flexible Benefits Program's LongTerm Disability (LTD) coverage works with other benefits you are eligible to receive, including Social Security, workers' compensation, other disability plans and programs, including the State retirement systems. The plan assures that your combined disability benefits from all these sources will equal 60% of your Benefit Salary up to $5,000 a month.
How Long LTD Benefits May Be Payable These benefits will begin after you have been disabled for 180 calendar days and are reduced by any sick leave you use.

Enrolling For Long-Term Disability Coverage Your cost for long-term disability coverage is based on your age, your FICA Status, Benefit Salary, and whether or not you are eligible for disability coverage through any State of Georgia retirement plan, and/or through Social Security.
LTD premiums are paid with pre-tax dollars. These benefits are considered taxable income and you are responsible for paying taxes to the Internal Revenue Service (IRS).
If you have any questions about eligibility or how the short-term and long-term disability insurance plans work, call 1-888-641-7186.

"

" When I had to take a leave of absence, because of disability, I didn't have to worry about my finances.
1-877-3GBreez

20
www.gabreeze.ga.gov

2013

Long Term Care

Long-Term Care With Unum Long-Term Care refers to a wide range of personal care, health and social services for people of all ages who suffer a chronic disease or long-lasting disability. These services can be provided in a nursing facility, an adult day care center or at home, and can involve some nursing care. The cost for this kind of care is very high. Home care can be as much as $20,000 per year, and nursing home care can range in cost from $20,000 to $60,000 annually. Generally, you pay these expenses out of your own pocket, because medical insurance and Medicare do not cover longterm care.
Your Long-Term Care Options You can choose from one of three daily benefit levels and the corresponding monthly premium that is right for your needs and budget. The amount of the benefit depends on two factors: where the long-term care is provided - either in a nursing facility, or home/day/assisted living facility - and the daily dollar level of the coverage you have selected. With any of these daily benefit options, benefits are paid on a monthly basis. The monthly benefit is equal to 100% of your elected daily benefit amount for care provided in a state-licensed nursing home facility, and 60% of your elected daily benefit amount for care provided in an assisted living facility or at home. If you wish, you can add on a reduced paid-up option and/or an inflation protection option.
Who Can Be Covered This plan is offered to you, your spouse, your parents or your parents-in-law. "Parents" are biological (natural), adoptive, or step-parents of eligible employees or

spouses. Your spouse, parents and parentsin-law will have to complete a medical underwriting process and be approved to be accepted for LTC coverage. Your family members' premiums will be billed directly by the insurance company. Your payroll deduction will be for your individual coverage only.
When Benefits Are Paid Benefits begin after a 90-day waiting period in which you or a covered family member has an eligible physical or cognitive disability. You qualify for benefits if the disability creates a need for you to receive continual help from another person to carry out any three of the six activities of daily living. Benefits from long-term care insurance are not taxed when you receive them.
About Your Premiums and Enrolling You pay for your LTC coverage through the convenience of payroll deduction with after-tax dollars. Premium costs are based on your age as of the Benefit Calculation Date (October 1). Your family members' premiums are based on their age as of the date they apply for coverage. Their premiums will be sent directly to Unum, not deducted from payroll.
If you are a newly eligible employee, you may select LTC with no medical underwriting requirements. If you are a current employee, enrolled and want to increase your benefit level, add options, re-enrolling after discontinuing coverage or enrolling for the first time, medical underwriting will be required. For more information about long-term care coverage, call Unum at 1-888-SOG-FLEX (1- 888-764-3539).

21
1-877-3GBreez

www.gabreeze.ga.gov

2013

Specified Illness

Specified Illness Plan With Continental American Insurance Company

With the group specified illness plan, our goal is to help you and your family cope with and recover from the financial stress of surviving a critical illness or condition.

Employee coverage levels: $ 5,000 $ 10,000 $30,000 $40,000

$20,000 $50,000

Lump-sum benefits paid directly to the insured following the diagnosis of each covered specified illness after you are hospital confined for the specified illness. (See the chart below for information on covered specified illnesses.)
Rates cannot be individually increased due to change in age, health or individual claim.
No medical underwriting required for up to $30,000 in coverage, and simplified medical underwriting process with only a few health questions.
The plan is portable* - take your coverage with you if you leave your job.
Available to employees age 18-69. Benefits for participants reduced 50% at
age 70.

Spouse coverage levels: $5,000 benefit $10,000 benefit No medical underwriting required Employee must have coverage for the
spouse to have coverage Rates are based on employee age

Child coverage: Children covered at no additional cost All children are covered at 25% of
employee benefit amount Children ages 0 25, if a dependent Child coverage automatically included in
existing employee coverage
1-877-3GBreez

Covered Cricital Illnesses*

Illnesses Covered under the Percentage of Face

Plan

Amount

Heart Attack

100%

Stroke

100%

Major Organ Transplant

100%

Renal Failure (End Stage) 100%

Internal Cancer

100%

Coma

100%

Severe Burns

100%

Paralysis

100%

Loss of Sight, Hearing or Speech

100%

Alzheimer's Disease

25%

Carcinoma in situ

25%

Coronary artery

25%

First Occurrence Benefit After receipt of written proof of loss, an insured may receive up to 100% of the benefit selected upon the first diagnosis of each covered critical illness.
Additional Occurrence Benefit If an insured collects full benefits for a Critical Illness under the plan and later has one of the remaining covered illnesses, then we will pay the full benefit amount for any additional illness. Occurrences must be separated by at least 6 months.
Re-Occurrence Benefit If an insured receives full benefit for a covered condition and is later diagnosed with the same condition, we will pay the full benefit again. The two dates of diagnosis must be separated by at least 12 months or 12 months treatment free for Internal Cancer.
22
www.gabreeze.ga.gov

2013Continued
Specified Illness

Health Screening Benefits An insured may receive a maximum of $100 for any one covered screening test per calendar year. We will pay this benefit regardless of the results of the test. Payment of this benefit will not reduce the amount payable for the diagnosis of a critical illness. There is no limit to the number of years the insured can receive the health screening benefit; it will be paid as long as the policy remains in force. This benefit is payable for the covered employee. The covered health screening tests include: Stress test on a bicycle or treadmill Fasting blood glucose test, blood test for
triglycerides or serum cholesterol test to determine level of HDL and LDL Bone marrow testing Breast ultrasound CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) CEA (blood test for colon cancer) Chest x-ray Colonoscopy Flexible sigmoidoscopy Hemocult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum protein electrophoresis (blood test for myeloma) Thermography

*Certain stipulations apply to portability. **A partial benefit (25%) is payable for
carcinoma in situ and coronary artery bypass surgery. Payment of the partial benefit for carcinoma in situ will reduce the benefit for internal cancer. Payment of the partial benefit for coronary artery bypass surgery will reduce the benefit for a heart attack.
NEW FOR 2013!
Critical Illness Select Plus Plan Includes Accident Benefits for you and your family in the event of an on or off the job accidental injury.
Did you know? The Number of emergency department visits for unintentional injuries in 2008 was: 28.4 million. (Injury Facts, Center of Disease and Control) Indemnity benefits paid as the result of an
accidental injury. 24-Hour Coverage

"

" You can't predict if you're going to need coverage for Specified Illness, but you can plan ahead in case you do.

23
1-877-3GBreez

www.gabreeze.ga.gov

2013Continued
Specified Illness
Over 50 accident indemnity benefits included
No medical underwriting required. Rates cannot be individually increased
due to change in age, health or individual claim. The plan is portable* - take your coverage with you if you leave your job. Available to employees and spouses age 18-69.
PLAN BENEFITS SUMMARY Please refer to your certificate of coverage for definitions, limitations and exclusions.
Benefits Include: Medical Fees (Physician Charges, X-Rays,
Emergency Room Services and Supplies) Hospital Fees (Hospital Admission, Daily
Hospital Confinement and Intensive Care) Accidental Injuries (Fractures/
Dislocations, Lacerations, Tendons/ Ligaments, Ruptured Disk, Torn Knee Cartilage, Burns, Eye Injuries) Accident Follow-up Benefits (Physical Therapy, In-patient Rehab, Follow-up treatments) Additional Benefits (Family Lodging, Transportation, Gunshot Wound, Paralysis, Prosthesis)
For a complete list of benefits and descriptions, please refer to the Critical Illness Select Plus PDF Brochure or your certificate of coverage.
24
1-877-3GBreez

www.gabreeze.ga.gov

2013

Legal Insurance

Legal Insurance Plan with Hyatt Legal Plan
Whether you're buying a new home, drawing up a will or just need some legal advice, the Hyatt Legal Plan can give you easy access to experienced, local network attorneys.
Now you have a resource at your fingertips for important everyday legal services. What's more, you'll also have someone to turn to for unexpected legal matters. You can now enroll in a great voluntary benefit legal plan offered through Hyatt Legal Plans.

Administrative and Incompetency Hearings
Civil Litigation Defense Consumer Protection Matters Debt Collection Defense Identity Theft Defense Bankruptcy Enforcement or Modification of Support
Orders Eviction and Tenant Defense Guardianship/Conservatorship Adoption Immigration Assistance Tax Audits Divorce (As defined by the SPD) Real Estate Matters for Second
Residence or Vacation Home Name Changes Juvenile Court Defense

Your Legal Benefit Options Select Plan

Don't miss your chance to enroll in this important and worthwhile benefit it can pay for itself the first time you use it.

The Select option provides benefits for the following services:
Powers of Attorney Office Advice and Consultation Wills and Codicils Living Wills Traffic Matters (no DUI) Document Preparation & Review Real Estate Matters for Primary
Residence Elder Law Matters

Access to Over 11,000 Attorneys
The Hyatt Legal Plan provides members with access to a national network of more than 12,000 Plan Attorneys. If you prefer, you may use your own attorney and be reimbursed according to a set fee schedule. If you find yourself in need of legal assistance while traveling within the U.S., call our Client Service Center. You will be referred to an attorney in the area.

Select Plus Plan

What Are the Exclusions?

The Select Plus option offers the same services as the Select Plan with some additional services. A few of the differences are:
1-877-3GBreez

The legal plan excludes appeals; class actions and appeals; matters which Hyatt Legal Plans deems frivolous, nonmeritorious or unethical; farm and business
25
www.gabreeze.ga.gov

2013Continued
Legal Insurance

matters, and any employment-related matters. For a complete list of exclusions, contact your local human resources representative for a copy of the plan document.
What if I have More Questions?
Call 1-800-821-6400 Monday through Friday from 8 a.m. to 7 p.m. (Eastern Time). A Client Service Representative will help you understand coverage, find a plan attorney in the location most convenient to you, offer information about using an outof-network attorney, and answer any other questions.

For more information, visit the website www.legalplans.com. Click on "Thinking About Enrolling?" and enter a password:
Select Plan 7600001 - Employee Only 7610001 - Employee w/Dependents
Select Plus Plan 7620001 - Employee Only 7630001 - Employee w/Dependents

"

26
1-877-3GBreez

" With the legal insurance, I now can afford a lawyer. www.gabreeze.ga.gov

2013

Spending Accounts with SHPS

Spending Accounts will be co-branding with ADP
What's New?
Your FSA is administered by SHPS HR Solutions, now a part of the ADP family. Please be aware you will begin to see the ADP name on HCSA and DCSA materials in the near future. The customer service phone number, fax number, mailing address and website address will remain the same.
The annual maximum amount a person can place into their Health Care Spending Account has been reduced to $2,460* in compliance with the Patient Protection and Affordable Care Act (PPACA).
For the 2013 Plan Year, the spending accounts being offered are:

Health Care Spending Account

Dependent (Child) Spending Account

Annual Maximum $2,460

$4,992

Annual Minimum $ 120

$ 120

* Note: a monthly administration fee of $3.20 is included in the total contribution amount.

Some of the eligible expenses include: Deductibles and co-payments not paid by
any health or dental insurance in which you or your family members participate; Costs for procedures not covered or not covered fully by a health, dental or vision plan; Specialized equipment for disabled persons; Preventative care screenings; Contact lens and glasses; Laser eye surgery; Prescription and over-the-counter medicine; Mental health services; Physical therapy; and Certain other IRS approved expenses.
A few examples of expenses that are not eligible include: Cosmetic procedures/drugs Electrolysis Hair transplants Herbal supplements Insurance premiums Nicotine patches and gum Nutritional supplements Teeth whitening/bonding Vitamins

The IRS rules and the rules of the Employee Benefit Plan Council designate eligible expenses and the Employee Benefit Plan Council has the responsibility to interpret these rules and make all decisions as to an expense's eligibility.
Health Care Spending Account (HCSA) The Health Care Spending Account (HCSA) helps you save tax dollars on the healthrelated treatment you and your family receive.
1-877-3GBreez

The Debit Card

When you enroll in a Health Care

Spending Account, you'll receive

a VISA Spending Account Card

for purchases of eligible healthcare

expenses. You will automatically receive

the Card, along with information about

the card and how it can be used. You

may request up to 4 additional cards

with your spouse or dependent's name

on it, for a fee of $5.00 per card. If your

card is lost or stolen, you may request

another card for a fee of $15.00. For

additional cards, call ADP at

1-800-893-0763.

27

www.gabreeze.ga.gov

2013Continued
Spending Accounts

Keeping Receipts Remember, you must keep your receipts since some transactions may require validation by ADP.
2 Month Grace Period Employees have an additional 2 months to spend the money in their Health Care Spending Account. This means qualified expenses may be reimbursed for services provided through March 15. Employees will have until April 30 to send their claims to ADP for reimbursement. Remember, if a claim is mailed, the envelope must be postmarked by April 30th. The fastest way to get claims to ADP is to fax them at 1-866-643-2219.
To best take advantage of this grace period, plan only for expenses you expect to have for the 12 month period. If you do not use all of the money you contributed, you can then use it in the grace period.
Important Note: The IRS does not allow participation in Health Care Spending Accounts and Health Savings Accounts.
Dependent (Child) Care Spending Account (DCSA)
The Dependent (Child) Care Spending Account provides you with the opportunity to use tax-free dollars to pay for the care of your children under age 13 or other IRS eligible dependents while you and your spouse work or go to school full time.
Childcare services may include your cost to send a child to preschool, after school,
28
1-877-3GBreez

or nursery school. Also, expenses for dependents of any age who are unable to care for themselves because of a physical or mental handicap are eligible. A person qualifying for this type of care must spend at least eight hours a day in your home. Elderly dependent care may include your cost to send a dependent parent to an elderly daycare facility or to have someone to care for them in your home. If you are married, both you and your spouse must be working or a full-time student during the time the care is received. Your income tax return (long and short forms) will require you to include your dependent care provider's name and tax number or Social Security number.
Dependent (Child) Care Spending Account Exclusions List
These are a few examples of dependent care expenses that are not eligible for reimbursement: Activity and book fees Cleaning and cooking services not
provided by the care provider Field trips Food, clothing, and entertainment Kindergarten Overnight camps Sports lessons Transportation to and from the child
care provider Tuition to private school
NOTE: You should carefully review your options and consult a qualified tax advisor for assistance in determining using the Dependent Care Tax Credit or using the Dependent Care Spending Account.
www.gabreeze.ga.gov

2013Continued
Spending Accounts

Dependent (Child) Care Spending Account Limits
You may not be able to deposit the full $4,992 if any of the following situations apply to you:
If your spouse works for the State or another employer who offers a similar plan, the total of your family's contributions to a dependent (child) care spending account cannot exceed $4,992.
If either you or your spouse earns less than $5,000 a year, you can deposit as much as the smaller of your two incomes.
If your spouse is either a full-time student or incapable of self-care, you may deposit up to $3,000 for one dependent, or $4,992 for two or more dependents.
If you are married but file a separate federal income tax return, you may deposit a maximum of $2,500 to your dependent (child) care spending account.
If you are hired after January 1 or have a qualified change in status during the plan year (see Terms and Conditions), you may contribute up to $416 per month for the remainder of the plan year.
Important Information About Spending Accounts
Deductions for spending accounts are made every pay period.
Your spending account enrollment is binding

for the plan year. You may be able to make limited changes if you have a qualified status change. You cannot carry over expenses that you have incurred in one plan year into the next plan year for reimbursement. Claims should only be submitted after services have been provided. You may submit claims at any time for any amount, but payment will not be made until your claims total $25 or more. Reimbursement may be by check or by direct deposit to your bank account. You receive a bi-monthly statement showing how much you have in each account. You cannot transfer money from one account to another. Reimbursements are issued on a daily basis. Spending account claims for the 2012 Plan Year (January 1 - December 31, 2012) must be faxed or mailed with correct documentation and postmarked on or before April 30, 2013. Spending account claims for the 2013 Plan Year (January 1 - December 31, 2013) must be faxed or mailed with correct documentation and postmarked by April 30, 2014. Under IRS rules, any money left in your accounts and not claimed for the previous plan year's expenses by the claim filing deadline is forfeited. It is retained by the plan and used for administrative expenses.
Contact GaBreeze Benefits Center at 1-877-3GBREEZ (1-877-342-7339) for more information or log onto the web site at www.GaBreeze.ga.gov.

"

"I use my Health Care Spending Account to pay health care deductibles.

1-877-3GBreez

29
www.gabreeze.ga.gov

Offered by the Georgia Higher Education Savings Plan

Start your child on the path to a brighter future. There are a number of paths to choose from to pay for a child's education. Choose the right one, and virtually any college dream can be within reach. And college can lead to a brighter future. Even if your child receives a HOPE Scholarship or other forms of financial aid, saving for college now is a key step to avoiding loans and providing flexibility down the road.
Now, thanks to a program offered by the State of Georgia -- the Path2College 529 Plan, formerly referred to as the Georgia Higher Education Savings Plan (GHESP) -- you have a smart and flexible way to help save for future higher education expenses.
With a Path2College 529 Plan account, you don't pay Georgia or federal taxes on earnings as your account grows. Then, when it's time to pay for college, the money you withdraw for qualified higher education expenses is also Georgia and federal tax-free. In addition, Georgia offers a state income tax deduction for up to $2,000 in contributions for each beneficiary.
With the Path2College 529 Plan, you can choose from seven investment options designed to meet your savings goals. There are no start-up or application fees, no maintenance fees, and no sales charges or broker commissions. You pay only a low annual management fee of less than one percent.

Start your child on the path to a brighter future.
It's easy to enroll. Don't worry about a big up-front financial commitment. You can open an account for as little as $25 per contribution. And the Path2College 529 Plan offers an Automatic Contribution Plan that drafts your checking or savings account, or you can sign-up for the payroll deduction program and contribute as little as $15 per pay period. Once you start, it's easy to stay on track!
You can obtain enrollment, ACP, and payroll deduction information by contacting the state office of the Path2College 529 Plan at (404) 463-0000 or outside metro-Atlanta at (866) 529-9529 or by email at GA529@otfs. ga.gov. You can also obtain the necessary payroll forms by visiting www.otfs.georgia. gov. Click on College Savings Plan Forms and review the Employee Payroll Checklist for New Accounts (if you do not currently have an account), or the Employee Payroll Checklist for Existing Accounts (if you already have an account). Visit www.path2college529.com for more information.
Please Note: Please note: Payroll contributions are made using after-tax dollars; therefore, you are not subject to the limits and restrictions for flexible benefits during the Annual Enrollment period. Your payroll deduction can be started, stopped, increased or decreased at anytime during the year by contacting us at the numbers above.

1-877-3GBreez

30
www.gabreeze.ga.gov

2013

EMPLOYEE CHECKLIST

Employee Checklist

Check with personnel/payroll office for deadlines.
Review the enrollment booklet, providing you with valuable information for each option descriptions of required supplemental for medical underwriting requirements, and Terms & Conditions.
Check on the website (GaBreeze. ga.gov) to confirm if additional forms are required, such as medical underwriting forms.
Review your Confirmation Page thoroughly and immediately report discrepancies to GaBreeze Benefits Center. Follow-up to assure corrections were made.
Compare your pay stub(s) against options selected. Contact your personnel/payroll office with discrepancies.
Report any incorrect information to your personnel/payroll office.
Other Important Information
For questions about claims or benefits for the State Health Benefit Plan, see Benefit Phone Directory for phone numbers. For general questions about the Flexible Benefits Program, call GaBreeze 1-877-3427339.

The Flexible Benefits Program attempts to be as consistent as possible with State Health Benefit Plan rules and regulations. This is not always possible due to the variations in benefit offerings.
This booklet summarizes the benefits you can choose through the State of Georgia Flexible Benefits Program. A more detailed explanation of benefit provisions is provided in each benefit Summary Plan Description. Every attempt has been made to ensure that the information in this booklet is accurate.
The State of Georgia Flexible Benefits Program is governed by legal documentation and insurance contracts. However, in the event there are any conflicts between this booklet and the official plan descriptions and contracts, the terms of the official plan descriptions and contracts will prevail.
The Flexible Benefits Program is governed by the current tax law and is subject to and operated in accordance with the regulations of the Internal Revenue Service (IRS). If changes in the Program are necessary to comply with the law or IRS regulations, you will be notified.

31
1-877-3GBreez

www.gabreeze.ga.gov

2013

Privacy And Security Notice

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that covered entities, including state agencies that deal with Protected Health Information (PHI), provide you with this notice. This notice pertains to those programs specifically administered by the Department of Administrative Services (DOAS) in which DOAS may maintain various types of PHI about you. DOAS understands that information about you and your family is very personal. As such, DOAS is committed to protecting and securing your information.
This notice tells you how DOAS uses and discloses information about you and discusses your rights in keeping this information private and secure. Please review this notice carefully.
Overview What is HIPAA? HIPAA, the Health Insurance Portability and Accountability Act of 1996, is a federal law regarding the confidentiality and security of Protected Health Information (PHI). It imposes restrictions on how your health information can be used and shared and confirms rights for individuals concerning their own health information.
What is PHI? PHI, Protected Health Information, is individually identifiable health information that is maintained or transmitted by a covered entity. It is information related to a person's health, provision of care, or payment. Examples of items containing PHI include: a bill for health services, an explanation of benefits statement, receipts for reimbursement from a health flexible spending account or any list showing the

amount of benefits paid with a breakdown by social security number. This also includes your employer (state agency, school system, authority, etc.) transmitting information about you to DOAS. This information may include your name, address, birth date, social security number, employee identification number and certain health information.
How DOAS Uses and Discloses Protected Health Information When services are contracted, DOAS may disclose some or all of your information to the company to perform the job DOAS has contracted with them to do. DOAS requires the company to safeguard your information in accordance with federal and state law.
Privacy and Security Law Requirements DOAS is required by law to: Maintain the privacy of your information. Protect electronic PHI by implementing
reasonable and appropriate physical administrative and technical safeguards. Provide this notice of DOAS' legal duties and privacy and security practices regarding the information that DOAS has about you. Abide by the terms of this notice. Refrain from using or disclosing any information about you without your written permission, except for the reasons given in this notice. You may revoke your permission at any time, in writing. That revocation will not apply to information that DOAS disclosed prior to receiving your written request. If you are unable to give your permission due to an emergency, DOAS may release information, if it is in your best interest. DOAS must notify you as soon as possible after releasing the information.

1-877-3GBreez

32
www.gabreeze.ga.gov

2013Continued
Privacy And Security Notice

Your Health Information Rights You have the following rights regarding the health information maintained by DOAS about you: You have the right to see and obtain a
copy of your health information. This right would not extend to information needed for a legal action relating to DOAS. You have the right to ask DOAS to change health information that is incorrect or incomplete. DOAS may deny your request under certain circumstances or request additional documentation. You have the right to request a list of the disclosures that DOAS has made of your health information beginning in April 2003. You have the right to request a restriction on certain uses or disclosures of your health information. DOAS is not required to agree with your request. You have the right to request that DOAS communicate with you about your health in a way or at a location that will help you keep your information confidential. You may request another copy of this notice from DOAS, or you may obtain a copy from the DOAS web site, www. doas.ga.gov (under "Privacy").

DOAS does not discriminate on the basis of disability in the admission or access to, or treatment of employment in its programs or activities. If you have a disability and need additional accommodations to participate in any DOAS programs, please contact the DOAS at the numbers listed. For TDD relay service only: 1-800-2550056 (text-telephone) or 1-800-255-0135 (voice).
If you believe your privacy or security rights have been violated: You may file a complaint in writing to
the DOAS Privacy Unit at: Department of Administrative Services Attn: Privacy Officer 2 MLK Jr. Drive, SE Suite 502, West Tower Atlanta, GA 30334
You can file a complaint with the Secretary of Health and Human Services by writing to: Secretary of Health and Human Services, 200 Independence Ave. SW, Washington, DC 20201. For additional information, call 1-877696-6775.
You may file a grievance with the United States Office for Civil Rights by calling 1-866-OCR-PRIV (1-866-627-7748) or 1-886-788-4989 TTY.

For More Information and To Report a Problem If you have questions and would like additional information about Protected Health Information (PHI) you may contact Gabreeze at 1 877 342-7339 Monday thru Friday 8:00 a.m. to 5:00 p.m. You may also visit DOAS web site, www.doas.ga.gov.

There will be no retaliation for filing a complaint or grievance.
If DOAS changes its privacy or security practices significantly, DOAS will post the new notice on its web site at www.doas. ga.gov (Under "Privacy"). This notice, effective April 14, 2003, was amended April 20, 2005.

33
1-877-3GBreez

www.gabreeze.ga.gov

2013

Benefit Phone Directory

Flexible Benefits Program

GaBreeze Benefits Center Website: GaBreeze.ga.gov

1-877-342-7339

Employee, Spouse, Child Life Insurance and Accidental Death and Dismemberment Life conversion and Portability information

1-800-660-2519

Dental Insurance CIGNA - www.cigna.com Delta Select and Select Plus www.deltadentalins.com

1-800-642-5810 1-866-496-2384

Vision Coverage www.myspectera.com

1-800-638-3120

Disability Insurance

1-888-641-7186

Long-Term Care Insurance

1-888-227-4165 or 1-800-227-4165

Legal Insurance www.legalplans.com

1-800-821-6400

Spending Accounts Hearing Impaired https://myspendingaccount.shps.com

1-800-893-0763 1-800-952-0452

Specified Illness Insurance Portability Information

1-800-433-3036 1-800-433-3036

State Health Benefit Plans

SHBP Eligibility

1-800-610-1863

404-656-6322

United Healthcare of Georgia Health Reimbursement Arrangement (HRA) High Deductible Health Plan (HDHP) Health Maintenance Organization (HMO) Retirees

1-800-396-6515 1-877-246-4189 1-877-246-4189 1-877-755-5343

CIGNA Healthcare Active Employees Retirees

1-800-633-8519 1-800-942-6724

1-877-3GBreez

34
www.gabreeze.ga.gov

2013

Terms and Conditions

The Flexible Benefits Program is offered by the Employee Benefit Plan Council, the Board of Community Health and participating departments and authorities. The Flexible Benefits Program is governed by the Internal Revenue Code, section 125, and rules issued by the Employee Benefit Plan Council and the Board of Community Health. The Flexible Benefits Program provides you with a method to have your employer purchase benefits with money that would have been paid to you. You do not receive the premium amounts and contributions for the pre-tax options you select as taxable income (and therefore do not pay taxes on that amount); you do receive the benefits as an employer paid benefit. The Option Statement, either paper or electronic, is a binding salary agreement. Failure to comply with all contractual and administrative requirements will result in any excess salary reductions being retained by the Plan. The following statements apply to the benefit options listed on the Option Statement and on the Annual Enrollment web site.
1) Your participation in the Flexible Benefits Program is voluntary. You are not required to choose any of the options. If you do not wish to participate in these benefits, mark `no coverage' in each benefit category, sign and date the paper Option Statement, and return it to your personnel or payroll office. If you choose your benefits through web enrollment, click `no coverage' in each benefit category and complete the confirmation process.
2) Some coverage levels available to you and the premium amount for each coverage level may be calculated using your retirement salary, your age, your eligibility for disability retirement benefits, and FICA status on your date of hire or the Benefit Calculation Date, whichever is deemed appropriate by the Plan Administrator. Any adjustments to the Benefit Salary, with the exception of errors (as determined by the Plan Administrator) shall be reflected on the following Benefit Calculation Date, to be effective for the following Plan Year. Promotions, demotions, adjustments due to certifications are not deemed to be errors. Any errors in these items should be reported to your personnel or payroll office immediately.
3) The calculation of tax savings does not take into consideration any other income earned by employee or family members, income reduction program such as Deferred Compensation or Tax Sheltered Annuities, or any changes you may make in coverages for the upcoming year.
4) By selecting coverages and indicating contributions to Spending Accounts, you are agreeing that your agency may reduce your taxable income by the amount necessary to purchase those coverages and make those contributions. Except in certain circumstances, the amount of income reduction may not be changed until the next enrollment period.
1-877-3GBreez

5) For dependent and/or spousal coverage, it is your responsibility to notify the Flexible Benefits Program if the person ceases to be eligible to participate in the Plan. There will be no refund of premiums paid into the Plan, when a timely change is not made.
6) After this enrollment period you may become a participant or make changes in some coverages only under limited conditions in accordance with the rules of the IRS code, the Employee Benefit Plan Council, and the Board of Community Health. The Employee Benefit Plan Council and the Board of Community Health have the responsibility to interpret these rules and make the final decision as to whether you may enroll or change any coverage outside of the enrollment period. Your request for enrollment or a change outside of the enrollment period will only be considered if you submit the proper documentation within the timeframe allotted. To submit a request for enrollment or change to coverage under the State Health Benefit Plan, you must complete and submit a Membership or Discontinuation Form to your employer's Benefits Coordinator within 30 days. Your request for enrollment or a change in any other coverage under the Flexible Benefits Program must be done by calling GaBreeze Benefit Center or on the website within 30 days. A list of events that might permit you to enroll or change one or more coverages under the Flexible Benefits Program:
a) You gain or lose a spouse; or b) You gain (no time limit if due to judgment, decree or order) or lose an eligible dependent; or c) Your spouse or dependent becomes eligible for or loses coverage under another employer's plan, COBRA or a governmental plan; or d) An event causes your dependent to gain or lose eligibility for coverage under your employer's plan; or e) Your change of residence causes you or your spouse or dependents to gain or lose eligibility for coverage under your plan or another employer's plan; or f) The cost of your dependent care increases or decreases significantly and your dependent provider is not related to you, your spouse, or your dependent; or g) Your spouse's employer increases, decreases or ceases coverage, or conducts open enrollment; or h) You, your spouse or your dependent gain or lose eligibility for Medicare or Medicaid.
7) This salary agreement will be terminated if you change the agreement during the next enrollment period. If you do not change the agreement, your benefit choices will rollover in the next Plan year or default to a specified coverage.
8) If you are eligible to participate in the Plan, you terminate and are rehired within 30 days during the same Plan Year, you must maintain the same options.
35
www.gabreeze.ga.gov

2013Continued
Terms and Conditions

9) Options and coverage levels under the State Health Benefit Plan are set forth in the State Health Benefit Plan Document. Options and coverage under the Flexible Spending Accounts are set forth in the Flexible Benefit Plan Document. For all other benefits under the Flexible Benefits Program, the options and coverage levels offered conform to policies provided by the insurance company making the offer. By selecting an option and coverage level you agree to abide by the terms and conditions of that policy.
10) Contributions to Spending Accounts are voluntary. You should not participate in Spending Accounts until you thoroughly read the sections of the Enrollment Booklet related to Spending Accounts. By choosing to contribute money to one or more Spending Accounts you are agreeing to abide by the Rules of the Employee Benefit Plan Council related to Spending Accounts. In particular, you are agreeing to the following provisions:
a) Money contributed for one type of Spending Account cannot be used to pay claims payable from another type of Spending Account.
b) In general, the amount contributed for a Dependent Care Account cannot be greater than the earned salary of you or your spouse, whichever is less.
c) If you are married filing separately, the amount contributed for a Dependent Care Account cannot be greater than $2,500.
d) The validity of a claim against a Spending Account is determined in accordance with the Plan, Internal Revenue Code, and IRS regulations as interpreted by the Administrator subject to the appeal provisions of the Plan.
e) Any money not reimbursable to you will be forfeited to the Flexible Benefits Program. Forfeited money will not be returned or paid to the employee but will be used to reduce the costs associated with providing this benefit.
f) For the Spending Accounts, eligible expenses will be reimbursed in accordance with the Rules of the Employee Benefit Plan Council and the IRS code.
g) For the Dependent Care Spending Account, you will not be reimbursed for more than the Plan has received from your department on your behalf.
h) If you decide to activate and use the Spending Account debit card, you agree to abide by all requirements as indicated in the cardholder agreement received with the card.
11) By selecting the Specified Illness Benefit, you are agreeing to the following:
a) I am asserting that to the best of my knowledge and belief, the answers to the questions on the application are true and complete. They are offered to Continental American Insurance Company as the basis for any insurance issued. It is understood and agreed that coverage will not become effective unless I am actively at work on the date of enrollment and the effective date of coverage.
1-877-3GBreez

b) I understand and agree that no benefits are payable for loss starting or occurring within 12 months of the effective date of coverage which is caused by, contributed to by, due to or resulting from a Pre-existing condition, unless I have gone 12 months without medical care, treatment or supplies for the Pre-existing condition.
c) I realize that any false statement or misrepresentation may result in loss of coverage under the certificate. I understand that no insurance will be in effect until approved by Continental American Insurance Company and the necessary premium is paid. Any person who, with intent to defraud or knowing that he is facilitating fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
d) I authorize my employer to deduct the appropriate amount from my earnings and to deduct and pay Continental American Insurance Company the premium required thereafter each month for my insurance.
12) Other terms and conditions: a) If you choose not to participate or choose not to
continue coverages, your ability to enroll at a later date will be subject to contractual provisions, which may include medical proof of insurability or limited coverages.
b) If you failed to enroll in options requiring medical underwriting when first eligible and you choose new or increased levels of coverage, you must complete the medical underwriting process and be approved.
c) If you choose coverage under the Life Insurance options and the Accidental Death and Dismemberment options, the same Beneficiary Election Form will be used. If a beneficiary is not named, the beneficiary will follow the order stated in the policy. d) If you select more than $50,000 under the Life Insurance option, you may choose to pay the premium with after-tax dollars to imputed income; this will eliminate any tax savings on the life insurance premium.
13) In the event of an administrative error with respect to the Flexible Benefits Program, decisions will be made in accordance with the Internal Revenue Code, the Rules of the State Health Benefit Plan, and the Rules of the Employee Benefit Plan Council for the Flexible Benefits Program.
36
www.gabreeze.ga.gov