Page 26 - Success Academy | 21-22 Benefits Summary

Glossary
Coinsurance Copay
Deductible
EE Eligible Dependent
In-Network Providers Out-of-Network Providers Out-of-Pocket Maximum
Plan Year Portable Qualifying Life Event
Percentage of insurance covered by employee after deductible is met
A fixed amount you pay for a covered health care service, usually when you receive the service
Amount you pay before the insurer begins to pay for eligible medical and prescription expenses. For the HSA Plan, if you have family coverage, you must satisfy the family deductible before the plan begins to cover your expenses.
Employee
Your spouse to whom you are legally married, your same/opposite sex domestic partner (defined by state), your dependent child(ren). Medical and Vision: Children, up to when they turn age 26. Dental: Children, up to when they turn age 26. Your unmarried children of any age who are permanently and totally disabled for whom you provide financial support All dependents require documentation
Providers that have agreed to accept our insurance carriers rates Providers that have not partnered with our insurance carriers
The most you’ll need to pay during a plan year. This provides financial protection from catastrophic medical and pharmacy expenses.
July 1, 2021 – June 30, 2022
Ability to take the benefit with you if you were to leave Success Academy
An event that allows you to make changes to your benefits within 30 days of the event. These events include:
• Marriage, divorce, or legal separation
• Birth or adoption of a child or placement of a child for adoption
• Death of a dependent, child no longer eligible due to reaching limiting age
• Change in employment status, including loss or gain of employment, for your spouse or a dependent that results in a change in eligibility, change in work schedule, including switching between full-time and part-time status, by you, your spouse, or a dependent that results in a change in eligibility, change in residence or work site for you, your spouse or a dependent that results in a change in eligibility
Note: A change in day care provider is a Qualifying Life Event for Dependent Day Care only.
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