State of Arkansas
Employee Benefits Information
2022023
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Benefit Books Provided by ARSEBA
Co
ver – Arkansas State Capitol Rotunda, Shutterstock
Arkansas State Employees
New Hire Benefit Guide
Contents
Eligibility Information……………………………………………………………………….……………….….……….….page 2
Health Plan Summaries…………………………………………………………………………….………….……….…..page 3
Health Insurance Election Form…………………………………………………………………………………………page 5
Spousal Affidavit………………………………………………………………………………………………………………..page 7
My ARFamily Benefits…………….………………………………………………………………………….………………page 9
Delta Dental Plan Comparisons..……………….……………………………………………………….…………….page 10
Delta Dental Application…………………………………………………………………………………….…………….page 11
Humana Vision Benefit Information…………………………………………………………………………………page 13
Humana Vision Application……………………………………………………………….……….………...………….page 15
Colonial Life Group State Paid and Expanded Basic Term Life Insurance….………..….………….page 17
Employee Assistance Program……………………………………………………….……….………..……….…….page 19
Health Savings Accounts/Flexible Spending Accounts Quick Facts……….…….…………..………..page 20
Flexible Spending Account (FSA) Election Form……………….………………….…….……….….………..page 21
Health Savings Account (HSA) Election Form……………………………………………………………………page 23
Arkansas Diamond Plan – Voya………………………………………………………….……….….……….……….page 25
Arkansas Diamond Plan – Voya Opt Out Form…………………………………….……….….……….……….page 27
Colonial Life – Accident, Critical Illness and Life Insurance…………………….….……………..………page 29
Aflac – Hospital Indemnity Insurance………………………………………..…………..………..……….……..page 30
Manhattan Life – Short Term Disability and Cancer Insurance…………………………………..…….page 31
Unum – Group Long Term Disability Insurance…………………………………….….……………..….……page 32
Arkansas State Employees Association information and application………………………………..page 35
Benefit Contact Information…………………………………………………………….………………….........…..page 37
1
Benefits are a valuable part of any compensation package. State employees are offered a wide variety of
benefits. These benefits are available through payroll deduction and are available on a pre-tax basis when
appropriate.
This benefit book is to outline the benefits that are subsidized by the state as well as the voluntary benefits
that are wholly employee paid.
Eligibility – You are eligible to participate in the benefits program if you receive a regular paycheck, meaning
you are not a seasonal or contract employee and working 1,000 or more hours each year. An extra help
employee whose agency has agreed to pay the State match for their coverage and is willing to be
responsible for all costs for participating in the Plan.
Dependents Eligible for Coverage – In most cases, eligible dependents include:
• Your legal spouse. Spouses eligible for coverage through his or her employer are not eligible for
coverage.
• Your dependent child(ren) who are under age 26
• Dependent child(ren) are defined as your or your spouse’s natural or legally adopted child(ren)
• To verify eligibility of newly added dependents, you may be requested to provide supporting
documentation (i.e. birth certificates, marriage certificate).
When your dependents no longer meet eligibility requirements, their coverage ends the last day of the
month they become ineligible. You may be responsible for any cost for services received while your
dependent was incorrectly listed as eligible.
Coverage Effective Date – Coverage is effective the first day of the month following the date of application
and following your qualifying event. Note: The qualifying event is not the date of eligibility.
Qualifying Events – For qualifying events, active members have 60 days from the date of the qualifying
event to enroll/drop a spouse and/or dependent to the plan. Please note, retirees have only 30 days. List
of approved qualifying events:
• Marriage, divorce, legal separation
• Birth or adoption of a child
• Death of a spouse or child
• You or one of your covered dependents gain or lose other benefits coverage due to a change in
employment status
• Loss of eligibility for group health coverage or health insurance coverage
Pre-tax Premiums – Most products available to the state employees are available on a pre-tax basis. Pre-
tax premiums increase your take-home pay because your insurance premiums will be deducted from your
salary before taxes are calculated. For products such as health, dental, and vision insurance, you will
automatically be in a pre-tax status unless you stipulate otherwise.
2
PREMIUM CLASSIC BASIC
In-Network Out-of-Network In-Network Out-of-Network In-Network
Individual Deductible $500 $2,000 $2,500 $4,000 $6,450
Family Deductible $1,000 $4,000 $2,800/$5,000 $8,000 $12,900
Individual Medical Out-Of Pocket Max $3,000 N/A $6,450 N/A $6,450
Family Medical Out-Of Pocket Max $6,000 N/A $12,900 N/A $12,900
You Pay You Pay You Pay
Covered Services In Network Out of Network In Network Out of Network In-Network
Physician’s Ofce Visit $25 copay 40% after deductible 20% after deductible 40% after deductible 0% after deductible
Specialist’s Ofce Visit $50 copay 40% after deductible 20% after deductible 40% after deductible 0% after deductible
Other Physician Services 20% after deductible 40% after deductible 20% after deductible 40% after deductible 0% after deductible
Advanced Imaging (Radiology) 20% after deductible 40% after deductible 20% after deductible 40% after deductible 0% after deductible
Emergency Room Visit & Observation $250 copay 0% 20% after deductible 40% after deductible 0% after deductible
In-patient Hospital Services 20% after deductible 40% after deductible 20% after deductible 40% after deductible 0% after deductible
Outpatient Hospital Services 20% after deductible 40% after deductible 20% after deductible 40% after deductible 0% after deductible
Diagnostic Services 20% after deductible 40% after deductible 20% after deductible 40% after deductible 0% after deductible
Urgent Care Center $100 copay 0% 20% after deductible 40% after deductible 0% after deductible
Physical Exams/Preventative Care 0% 40% after deductible 0% 40% after deductible 0%
Immunizations 0% 0% 0% 0% 0%
Well Baby/ Child Care visits 0% 40% after deductible 0% 40% after deductible 0%
Vision Screening $50 copay $50 copay $50 copay $50 copay $50 copay
Hearing Screening $50 copay $50 copay $50 copay $50 copay $50 copay
Insulin Pump 20% after deductible 40% after deductible 20% after deductible 40% after deductible 0% after deductible
Glucometers 20% after deductible 40% after deductible 20% after deductible 40% after deductible 0% after deductible
• Members must meet their plan’s deductible amount before coinsurance begins for covered services.
• The family deductible is the deductible amount for any tier above Employee Only coverage (Employee + Spouse, Employee + Children, Family).
• Copays do not count towards the satisfaction of your deductible amount.
• The out-of-pocket maximum includes the deductible, copays and coinsurance amounts you have paid towards covered in-network services.
• Employees on the Premium plan can have the $250 ER copay waived if they are referred to the ER by the 24/7 Nurse Hotline (1-866-458-0408). The 24/7 Nurse Hotline is not
intended for use during a medical emergency.
• The plan will pay 100 percent for individuals on family coverage when they reach the individual out-of-pocket maximum amount.
• No out-of-network coverage for Basic Coverage.
Prescription Drugs PREMIUM CLASSIC BASIC
Tier 1 - Generic $15 copay 20% after deductible 0% after deductible
Tier 2 - Preferred $40 copay 20% after deductible 0% after deductible
Tier 3 - Non-Preferred $80 copay 20% after deductible 0% after deductible
Tier 4 - Specialty $100 copay 20% after deductible 0% after deductible
Reference Priced Drugs
Plan pays certain amount per unit; the member
is responsible for the remaining cost.
Not covered Not covered
Individual RX Out of Pocket Max $3,100 N/A N/A
Family RX Out of Pocket Max $6,200 N/A N/A
* Employees on the Classic or Basic plans must meet their plan medical deductible amounts prior to starting 20% coinsurance for covered drugs.
Below is a snapshot of benefits covered by the ARBenefits plan for each of our
2023 Arkansas State Employee
plan levels. A full schedule of benefits for each
plan level is available at ww
w.transform.ar.gov.
Questions? Contact EBD Member Services at 1-877-815-1017 or e-mail
[email protected].gov.
3
ARKANSAS STATE ACTIVE EMPLOYEES MONTHLY PREMIUMS
2023 Plan Year Rates - Effective January 1, 2023 - December 31, 2023
Premium
Employee Only
$547.78 $375.78 $172.00 $86.00
Employee & Spouse
$1,369.45 $875.23 $494.22 $247.11
Employee & Child(ren)
$1,040.78 $731.04 $309.74 $154.87
Employee & Family
$1,862.45 $1,231.93 $630.52 $315.26
Classic
Employee Only
$476.23 $377.53 $98.70 $49.35
Employee & Spouse
$1,190.58 $870.34 $320.24 $160.12
Employee & Child(ren)
$904.84 $724.66 $180.18 $90.09
Employee & Family
$1,619.18 $1,218.92 $400.26 $200.13
Basic
Employee Only
$420.32 $420.32 $0.00 $0.00
Employee & Spouse
$1,050.80 $870.58 $180.22 $90.11
Employee & Child(ren)
$798.60 $722.24 $76.36 $38.18
Employee & Family
$1,429.08 $1,214.48 $214.60 $107.30
The Basic plan meets the minimum essential coverage required under A.C.A.
State Contribution is funded by legislation
Plan Contribution is funded by ASE Trust Fund as Claims Reserve Allocation
Base Monthly
Premium
State & Plan
Contribution
Total Monthly
Employee Cost
Per-Payroll
Deduction
(24 payroll)
4
p
Rev. 09/02/2020 6000-f
-13
5
Instruction Page
ALL PORTIONS OF THE ELECTION FORM MUST BE COMPLETED OR IT WILL BE SENT BACK FOR
COMPLETION PRIOR TO PROCESSING.
Social Security Numbers are required for enrollment.
If
you do not provide a Social Security Number for
yourself or your dependents, health insurance coverage cannot be provided. Exception: A newborn's Social
Security number will be accepted after enrollment but must be sent in once it is received.
You must drop all of your ineligible dependents. When your dependents no longer meet
eligibility requirements, their coverage ends the last day of the month they became ineligible. You may be
responsible for any cost for services received while your dependent was incorrectly listed as eligible.
If
you experience a qualifying event that allows you to cancel your health insurance, you can only enroll
again during the next annual open enrollment period or if you have a qualifying status change event.
Qualifying status change events include marriage, birth and loss of group coverage.
You should receive plan information and ID cards in a timely manner from ARBenefits.
If
you do not, call
ARBenefits at 1-877-815-1017 (When you hear the recording, Just Press One).
Your elections will remain in effect for the remainder of the calendar year unless you experience a
qualifying status change event, as defined by the ARBenefits Summary Plan Description.
Your effective date of coverage will be the first of the month following date of application and following your
qualifying event. Note: The qualifying event is not the date of eligibility.
Pre-tax premiums increase your take-home pay because your insurance premiums will be deducted from
your salary before taxes are calculated. You will automatically be in a pre-tax status unless you otherwise
notify your payroll clerk.
Members who turn age 65 or become eligible for Medicare must send in a copy of their Medicare card to
ARBenefits.
Supporting documentation is required for proof of dependent eligibility. For changes being made due to a
qualifying event, documented proof a qualifying event has occurred is also required such as a Certificate of
Credible Coverage (COCC). More information available in the ARBenefits Summary Plan Description.
Adding a spouse:
∗
Copy of marriage license
∗
Completed ARBenefits Spousal Affidavit available at www.
transform.ar.gov/employee-benefits
Adding a dependent child:
∗
Newborns - Birth certificate or hospital birth announcement that includes child's parents and date of birth (up to 6 months of age)
∗
Child - Copy of child's birth certificate
∗
Step-child - Copy of marriage license to the step-child's parent and a copy of the child's birth certificate
∗
Legal Guardianship - Court-approved guardianship papers (with signature
&
seal)
Completed election forms can be submitted to EBD by fax, mail, or online through the ARBenefits Member
Portal at www.transform.ar.gov/employee-benefits/arbenefits.
For assistance, contact ARBenefits at 1-877-815-1017 Monday through Friday, from 8:00 a.m. to 4:30 p.m.
CST. Learn more about plans, costs and provider at www.transform.ar.gov/employee-benefits
Rev.
09/02/2020
6000-f-13
6
By signing this affidavit, I certify that the information provided above is accurate. I understand that any misrepresentation in the
information I provided above will permit the Plan to terminate my coverage. If applicable, I authorize the release of the information noted
above, and agree to its use in the application process for ARBenefits plan coverage.
Employee Signature:
Date:
Spouse Signature:
Date:
Affidavit of Spousal Health Care Coverage
This Affidavit must be completed for consideration to cover a spouse.
Employee Name:
Employee SSN:
Spouse Name:
Spouse SSN:
To be completed by employee electing to enroll a spouse in coverage.
Pursuant to Arkansas Code §21-5-407(4), any spouse who is offered coverage for Medical Benefits under any other
employer-sponsored health plan is NOT eligible to be covered under the Plan.
1. Is your spouse currently employed?
☐ Yes (If yes, please proceed to question #2)
☐ No (If no, sign and return this form along with your election form and a copy of your Marriage License.)
2. Is your spouse currently employed by an Arkansas state agency or public school district?
☐ Yes (If yes, sign and return this form along with your election form and a copy of your Marriage License.)
☐ No (If no, proceed to question #3)
3. Does your spouse’s employer offer health insurance coverage?
☐ Yes ☐ No
4. Is your spouse covered by his/her employer sponsored health plan?
* If No, please submit information from your spouse’s employer as to why your spouse is not covered.
☐ Yes
☐ No
5. Does your spouse’s employer sponsored coverage meet the Affordable Care Act (ACA) minimum guidelines?
* If No, please provide information from your spouse’s employer stating that coverage does not meet ACA guidelines.
☐ Yes
☐ No
For any questions or concerns, contact EBD Member Services at 1-877-815-1017x1
7
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8
State of Arkansas
In Network Out of Network In Network Out of Network
Calendar Year Maximum
(Preventative, Basic and Major Expenses)
Calendar Year Deductible
Per Individual
Per Family
Preventative and Diagnostic Services 100% 80% 100% 80%
No Deductible No Deductible No Deductible No Deductible
Oral exams and Cleanings 1 Per Year 1 Per Year 2 Per Year 2 Per Year
X-Rays(Bitewing, Panoramic, Full Mouth)
Bitewings- as required, Full
mouth - 1 in 60 consecutive
months
Bitewings- as required, Full
mouth - 1 in 60 consecutive
months
Bitewings- as required, Full
mouth - 1 in 60 consecutive
months
Bitewings- as required, Full
mouth - 1 in 60 consecutive
months
Fluoride Application
1 per year for dep children to
age (19)
1 per year for dep children to
age (19)
1 per year for dep children to
age (19)
1 per year for dep children to
age (19)
Sealants
dep children to age (16) dep children to age (16) dep children to age (16) dep children to age (16)
Basic and Major Services- Deductible applies
Space Maintainers 80% 60% 80% 60%
Minor emergency treatment 80% 60% 80% 60%
Simple Extractions 80% 60% 80% 60%
Fillings 60% 50% 80% 60%
Crowns 60% 50% 60% 50%
Prosthodontics(Dentures and Bridges) 60% 50% 60% 50%
Surgical Periodontics 60% 50% 60% 50%
Oral Surgery Not covered Not covered 60% 50%
Non-Surgical Periodontics Not covered Not covered 60% 50%
Periodontal Maintenance Not covered Not covered 60% 50%
Endodontics(Root Canal) Not covered Not covered 60% 50%
Riders
Child Orthodontia (through age eighteen (18)) Not covered Not covered 60% 50%
Lifetime Orthodontia Maximum Not covered Not covered
Other Items
Waiting Periods
Monthly Rates Guaranteed for 1
Year from 1/1/2023-12/31/2023
Employee 20.60$ 30.72$
Employee + Spouse 41.06$ 61.22$
Employee + Children 40.12$ 59.78$
Family 66.48$ 99.08$
$ 10.12
$ 20.16
$ 19.66
Monthly Rate Difference
Carryover Benefit
Carryover Benefit Maximum: $1,000
Carryover Benefit Maximum: $2,000
Orthodontia coverage
$75
$1,000
$ 32.60
Fillings at 60% versus 80%
6 Month on Major & Orthodontic Services
1 Exam &Cleaning versus 2
Oral Surgery coverage
Non-Surgical Periodontal
Endodontics coverage
Periodontal Maintenance
6 Month on Major services
Plan Differences
$1,000
$25
$2,000
Annual Maximum
Delta Dental PPO Plus Premier (9 out of 10 dentist
in Arkansas)
For m ore infor m ation please cont act: Ar kansas State Em ployees Benefit Advisor s
Phone: ( 501) 224-5234 or ( 888) 224-5233 E- m ail: ser vice@ar seba.com
Websit e: w ww.arseba.com
For provider search please visit www.deltadentalar.com
Carryover Benefit Added
2018*
Carryover Benefit: $250
Claims Threshold: $499
Carryover Benefit: $500
Claims Threshold: $999
Base Plan
Premium Plan
$25
$75
Delta Dental PPO (4 out of 10 dentist in Arkansas)
Network Access
10
Note: For new hires, the effective date will be first of the month following the signature date provided on this form
.
DENTAL ENROLLMENT/CHANGE FORM
1. COVERAGE CHANGES *Please check the box(es) next to the reason for your change .
Type of coverage selected & plan option (choose one)
Open enrollment
New Hire
Agency Change
Term Coverage
Status Change
Address Change
Reason(s) for Status Change:
Marriage*
Divorce*
Birth or adoption of child*
Loss of spouse’s coverage*
No longer dependent child*
Death of dependent*
Name Change
Other
*Date of event above:
Base Dental Premium Dental
Employee $20.60 Employee $30.72
Employee/Spouse $41.06 Employee/Spouse $61.22
Employee/Child(ren) $40.12
Employee/Child(ren) $59.78
Employee/Family $66.48 Employee/Family $99.08
Monthly Rates effective January 1, 2023 – December 31, 2023
2. LIST ALL MEMBERS TO BE ENROLLED OR AFFECTED BY CHANGE
Add Remove Last Name First Name
MI
Spouse or
Dependent
Gender
M/F
Birthdate
(MM/DD/YY)
.3. AUTHORIZATION
I authorize dentists, dental office personnel, and other health care professionals and entities to disclose to Delta Dental of Arkansas, its agents and employees (including,
without limitation, its claims and customer servic e personnel) a ll information necessary to determ ine (1) eligibi lity for cover age and (2) covered benefits. This
authorization is made for each individual to be enrolled or aff ected by this change. The authorization is valid for 30 months from the date this form is signed for the
purpose of collecting informat ion in connection w ith enrollment, coverage reinstatement, or requests t o change benefits. The a uthorization is valid for the term of
coverage for the purpose of collecting information in connection with claims for benefits. The applicant or the applicant’s authorized representative is entitled to receive
a copy of the authorization form.
.4 CERTIFICATION
I
certify that the information supplied by me on this form is accurate to
the best of my knowledge. Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
I authorize payroll deductions.
Signature:
Date:
DAR-ENR-12
Arkansas State Employees Benefit Advisors
1301 West 7th Street, Little Rock, AR 72201
Questions? Call (501) 224-5234 or (888) 224-5233
AGENCY NAME: .
For internal use only:
Delta Dental Group Number:__________
Effective Date:________ (MM)_________(DD)_________(YY)
LAST NAME: FIRST: MI:
SSN: PERSONNEL NUMBER:
STREET ADDRESS:
CITY: STATE: ZIP:
PHONE: ( )
EMAIL:
DATE OF HIRE: ______(MM)______(DD)______(YY) GENDER: MALE FEMALE
DATE OF BIRTH: ______(MM)______(DD)______(YY) MARITAL STATUS: SINGLE MARRIED
Auditor of State
Non-AASIS
3571-0AR10000, 3571-1AR10000
11
Fax Form to ARSEBA
(501) 663-1445
(employee ID)
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12
Humana.com
ARHK7WLEN
Vision care services
If you use an
IN-NETWORK provider
(Member cost)
If you use an
OUT-OF-NETWORK provider
(Reimbursement)
Exam with dilation as necessary $5 Up to $30
• Retinal imaging
1
Up to $39 Not covered
Contact lens exam options
2
• Standard contact lens fit and follow-up Up to $55 Not covered
• Premium contact lens fit and follow-up 10% off retail Not covered
Frames
3
$150 allowance
20% off balance over$150
$65 allowance
Standard plastic lenses
4
• Single vision $15 Up to $25
• Bifocal $15 Up to $40
• Trifocal $15 Up to $60
• Lenticular $15 Up to $100
Covered lens options
4
• UV coating $15 Not covered
• Tint (solid and gradient) $15 Not covered
• Standard scratch-resistance $15 Not covered
• Standard polycarbonate - adults $40 Not covered
• Standard polycarbonate - children <19 $40 Not covered
• Standard anti-reflective coating $45 Not covered
• Premium anti-reflective coating Premium anti-reflective coatings as
follows:
Premium anti-reflective coatings
as follows:
- Tier 1 $57 Not covered
- Tier 2 $68 Not covered
- Tier 3 80% of charge Not covered
• Standard progressive (add-on to bifocal) $15 Up to $40
• Premium progressive Premium progressives as follows: Premium progressives as follows:
- Tier 1 $110 Not covered
- Tier 2 $120 Not covered
- Tier 3 $135 Not covered
- Tier 4 $90 copay, 80% of charge less $120
allowance
Not covered
• Photochromatic / plastic transitions $75 Not covered
• Polarized 20% off retail Not covered
Contact lenses
5
(applies to materials only)
• Conventional $150 allowance,
15% off balance over $150
$104 allowance
• Disposable $150 allowance $104 allowance
• Medically necessary $0 $200 allowance
ARKANSAS
Humana Vision 130
State of Arkansas
13
H
u
mana.com
ARHK7WLEN
Vision care services
If you use an
IN-NETWORK provider
(Member cost)
If you use an
OUT-OF-NETWORK provider
(Reimbursement)
Frequency
• Examination Once every 12 months Once every 12 months
• Lenses or contact lenses Once every 12 months Once every 12 months
• Frame Once every 24 months Once every 24 months
Diabetic Eye Care: care and testing
for diabetic members
• Examination
- Up to (2) services per year
$0 Up to $77
• Retinal Imaging
- Up to (2) services per year
$0 Up to $50
• Extended Ophthalmoscopy
- Up to (2) services per year
$0 Up to $15
• Gonioscopy
- Up to (2) services per year
$0 Up to $15
• Scanning Laser
- Up to (2) services per year
$0 Up to $33
Optional benefits
• Polycarbonate Lenses for Children <19 Provides for standard polycarbonate lens with $0 copay. Not available in
AK, CT, ID, & OH.
1
Member costs may exceed $39 with certain providers. Members may contact their participating provider to
determine what costs or discounts are available.
2
Standard contact lens exam fit and follow up costs and premium contact lens exam discounts up to 10% may vary
by participating provider. Members may contact their participating provider to determine what costs or discounts are
available.
3
Discounts available on all frames except when prohibited by the manufacturer.
4
Lens option costs may vary by provider. Members may contact their participating provider to determine if listed costs
are available.
5
Plan covers contact lenses or frames, but not both.
Additional plan discounts
• Member may receive a 20% discount on items not covered by the plan at network Providers. Members may contact
their participating provider to determine what costs or discounts are available. Discount does not apply to EyeMed
Provider’s professional services, or contact lenses. Plan discounts cannot be combined with any other discounts or
promotional offers. Services or materials provided by any other group benefit plan providing vision care may not be
covered. Certain brand name Vision Materials may not be eligible for a discount if the manufacturer imposes a no-
discount practice. Frame, Lens, & Lens Option discounts apply only when purchasing a complete pair of eyeglasses. If
purchased separately, members receive 20% off the retail price.
• Members may also receive 15% off retail price or 5% off promotional price for LASIK or PRK from the US Laser
Network, owned and operated by LCA Vision. Since LASIK or PRK vision correction is an elective procedure, performed
by specialty trained providers, this discount may not always be available from a provider in your immediate location.
Humana Vision 130
Please note that limitations and exclusions can be found in your policy or by contacting ARSEBA.
Provider Search Tool: Humana Vision Insight Network Provider Search
14
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Arkansas State Employees Benefit Advisors
1301 West 7th Street
Little Rock, Arkansas 72201
(501) 224-5234, Toll Free (888) 224-5233
VisionCareEnrollment/ChangeForm
State of Arkansas
FAX COMPLETED FORM TO ARSEBA: (501) 63-
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Vision 0314
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15
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16
GTL WITH AD&D FOR ARKANSAS STATE EMPLOYEES-NH
Group Term Life Insurance with Accidental Death &
Dismemberment (AD&D) Insurance for Active Employees
There are two convenient options to enroll:
1. Enroll with a telephonic Colonial Life benefits counselor.
Ask benefits questions and complete your enrollment by calling:
833-703-1967, Employer Code: 8038317
| Monday-Friday | 7 a.m. to 7 p.m. CT
Benefit confirmation forms can be emailed to you at the conclusion
of the enrollment.
2. Self-enroll online.
Access the enrollment site URL: Harmony.benselect.com/SoA
Use the following login information:
n Log In: MEMBER ID (This is also your Health ID number.)
n Personal Identification Number: The last four digits of your
Social Security number and the last two digits of your birth year
(six digits total)
During your online enrollment, you will be prompted to accept or decline
each coverage type, premiums will be displayed for your selections and
the appropriate health questions will be displayed, when applicable.
Benefit confirmation forms can be printed or saved at the conclusion of
the enrollment.
Enrollment opportunities:
1. During annual enrollment
2. 60-day new hire eligibility period
3. Within 60 days of a qualifying event,
such as marriage, birth or adoption
How secure is your family’s financial future without you?
If something happened to you, would your family be able to maintain their way of life? How would they cover ongoing
living expenses? Colonial Life’s group term life insurance can help provide financial security for your family.
Employees who are eligible for ARBenefits health insurance are also eligible for Group Term Life with AD&D insurance. Employees
should allow a minimum o
f 7 business days from their new hire date before accessing the enrollment site or the telephonic enrollment.
This will allow time for employees’ eligibility data to be uploaded into the enrollment platform.
17
Coverage options Who pays Benefit amount(s)
Basic group term life with
AD&D insurance
Employer $10,000
Your employer is providing this benefit, and you will be
automatically enrolled.
Expanded basic group term life
with AD&D insurance
Employee $1,000 increments up to $40,000
Health questions are not asked during the 2023 Plan Year Open
Enrollment and new hire enrollment.
Supplemental employee group
term life with AD&D insurance
Employee $1,000 increments up to $250,000
Health questions are not asked during the 2023 Plan Year Open
Enrollment and new hire enrollment for benefit amounts up to $100,000.
Any benefit amount over $100,000 is subject to evidence of insurability.
*Supplemental spouse group
term life with AD&D insurance
Employee $1,000 increments up to $50,000
Health questions are not asked during the 2023 Plan Year Open Enrollment
and new hire enrollment for spouse benefit amounts up to $10,000. Any
benefit amount over $10,000 is subject to evidence of insurability.
*Supplemental dependent child(ren)
group term life with AD&D insurance
Employee $1,000 increments up to $50,000
Health questions are not asked during the 2023 Plan Year Open Enrollment
and new hire enrollment for spouse and coverage up to $10,000. Any
benefit amount over $10,000 is subject to evidence of insurability.
Your basic and optional coverages
EXCLUSIONS AND LIMITATIONS
Losses Not Covered Under Your Life Insurance Benefit:
Your life insurance benefit does not cover any losses where death is caused by, contributed to by, or results from suicide
occurring within 24 months aer a covered person’s initial eective date of insurance or aer the date any increases or
additional insurance becomes eective, whether sane or insane.
This applies to any amounts of insurance for which you pay all or part of the premium.
This applies to any amount subject to evidence of insurability requirements and we approve the evidence of insurability form
and the amount you applied for at that time.
You will be given credit for any period of time applied toward the satisfaction of the suicide provision, if any, under your
Employer’s prior group life insurance plan.
Losses Not Covered Under the AD&D Insurance Benefit:
Your AD&D benefit does not cover any losses that are caused by, contributed to by, or resulting from:
• an attempt to commit or commission of suicide or intentional self-inflicted injury while sane or insane;
• active participation in a riot;
• an attempt to commit or commission of a felony or engaging in an illegal occupation;
• voluntary use of any drugs, poisonous substance, intoxicant or narcotic, except any drugs taken as prescribed by a
physician and taken as prescribed. Accidental exposure to any poisonous substance will not be excluded;
• the presence of that percentage of alcohol in the covered person’s blood which raises a presumption that the covered
person was under the influence of alcohol. The blood-alcohol level which raises this presumption is governed by the
laws of the state in which the accident occurred;
• disease of the body, mental infirmity or diagnostic, medical or surgical treatment;
• being exposed to war or any act of war, declared or undeclared, or serving in the armed forces of any country or authority.
Losses as a result of acts of terrorism or nuclear release committed by individuals or groups will not be excluded from
coverage unless the covered person who suered the loss committed the act of terrorism or nuclear release; or
• investigational or experimental procedures, surgery, or drugs, including complications arising from having experimental
or investigative procedures, surgeries, or drugs.
Termination
Coverage terminates:
• if the group policy ends;
• the date you no longer meet eligibility requirements;
• the end of the grace period if we do not receive the required premium for your insurance; or
• the date the next premium is due aer you ask us to end your coverage.
If you are no longer eligible for coverage as an active employee, you may be eligible to port your group term life and AD&D
coverage, or you may convert your group term life and AD&D coverage to an individual life insurance policy. Premiums may
be higher than those paid by active employees.
Evidence of Insurability means a statement of medical history which we will use to determine if an applicant is approved for
coverage. Blood profiles and medical examinations, if applicable, will be provided at our expense. Evidence of Insurability is
required for any amount of life insurance over the maximum guaranteed issue amount.
Premium will vary based on plan options and face amount selected.
The eective date of your coverage will be delayed if you are not a member of an eligible class on the coverage eective date.
The coverage will be eective on the date that you return to status as a member of an eligible class. If the certificate covers
your spouse and/or dependent children, their coverage will be eective on the date that you return to status as a member of
an eligible class.
Applicable to policy number GTL1.0-P-AR-SOA and certificate number GTL1.0-C-AR-SOA. This is not an insurance contract
and only the actual policy provisions will control.
7-22 | NS-578442-3
Under
written by Colonial Life & Accident Insurance Company, Columbia, SC
©2022 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a
registered trademark and marketing brand of Colonial Life & Accident Insurance Company.
Supplemental group term life
with AD&D insurance
Age Employee
Under 25
$0.10
25-29
$0.10
30-34
$0.13
35-39
$0.14
40-44
$0.22
45-49
$0.36
50-54
$0.57
55-59
$0.83
60-64
$1.24
65-69
$2.42
70-74
$ 3.94
75+
$ 7.85
Supplemental spouse group term
life with AD&D insurance
All eligible ages
$0.75
Supplemental dependent
child(ren) group term life with
AD&D insurance
All eligible ages $0.12
Expanded basic group term life
with AD&D insurance
$0.27 per $1,000
A person may only be insured once under
this plan. Married employees eligible
for ARBenefits life insurance may not be
insured both as an employee and as a
spouse, and a child may only be insured
by one employee.
* Employee must elect supplemental group term life with AD&D insurance on themselves in order to elect supplemental group term life with AD&D insurance for the spouse or dependent
child(ren). Eective 1/1/2020, the spouse and/or child supplemental group term life with AD&D benefit amount must be either equal to or lower than the employee’s supplemental group
term life with AD&D benefit amount.
GTL WITH AD&D FOR ARKANSAS STATE EMPLOYEES-NH
2023 Rates (per $1,000)
Monthly co
st of coverage
18
EMPLOYEE ASSISTANCE PROGRAM - EAP
When life’s a little much,
reach out and get in touch.
Let’s be real: life can be tough. When your responsibilities start to feel overwhelming
and showing up each day with a smile on your face seems difficult, it’s important to
reach out for help. You can lean on your free and confidential Employee Assistance
Program (EAP) for support.
We’ve got your back.
A free benefit from your workplace, the EAP can help you or anyone in your household:
• Be more present and productive at work
• Receive support when you don’t feel ilke yourself
• Get help with responsibilities that are distracting or stressful
• Grow personal and career skills
• Be a caring, loving friend or family member
• Receive care after a traumatic event or diagnosis
• Make healthy lifestyle choices
• Improve and inspire daily life
We’re here for you, always.
Life happens, regardless of the day or time. That’s why we make ourselves available
24/7, even on holidays. So whenever you need to reach out, we’re here for you.
SERVICES
Counseling
• In-person
• Telephone
• Text messaging
• In-the-moment
• Video
Consultation on
• Finances
• Legal needs
• Managing
employees
• Life
Crisis support
Coaching
Adult and child
care resources
Personal and
professional training
Digital behavioral
health tools
Services are free and your employer will not know you reached out.
ndbh.com
877-300-9103
Support Line
Call anytime
877-300-9103
Mobile app
Search for New
Directions EAP
Web
Visit ndbh.com
for resources
19
Health Savings
Account (HSA)
Flexible Spending
Account (FSA)
Eligibility Must be enrolled in
an ARBenets High-
Deductible Health Plan
(Classic or Basic).
No eligibility requirements.
You can have an FSA on
any plan level, and even if
you do not have ARBenets
coverage.
Annual contribution
limits
2023 Limits:
Individual: $3,850
Family: $7,750
Persons aged 55 and
older may contribute
an additional $1,000
annually above those
limits.
2023 Limits:
Health and Limited: $3,050
Dependent Care: $5,000
Changing contribution
amount
Employees can adjust
their contribution
amount anytime during
the year.
Contributions can only
be adjusted at open
enrollment, or with a
qualifying change in
employment or family
status.
Re-Enrollment Employees do not have
to re-enroll their HSA
every year.
Employees must submit
an election form every year
during open enrollment to
establish their FSA.
Rollover of funds Unused funds roll over
year-to-year.
Employees can rollover up
to $610 year-to-year. Any
amount unused over $610
will be forfeited after the
annual run-out period.
When can I use funds? You must have the funds
in your account in order
to use them.
The amount you elect to
contribute is available for
you to use at the start of
the year with the exception
of Dependent Care FSA.
Connection to employer You can take your HSA
with you as you change
employers. You own your
account.
You will lose your FSA funds
when you term employment
with the State.
State contribution The State of Arkansas
contributes $25 for
individuals and $50 for
families per month with
an HSA.
The state contribution
counts towards your
annual maximum
contribution limit.
No state contribution
FSA/HSA
Flexible Spending Accounts (FSA)
and Health Savings Accounts (HSA)
are a benet available to state of
Arkansas employees as a way to
set aside pre-tax money for medical
expenses not covered by insurance.
Three types of FSAs are available:
Health Care, Limited-Purpose and
Dependent Care.
Healthcare FSAs provide tax
savings on your out-of-pocket
health expenses. A Limited Purpose
FSA allows you to pay for dental
and vision expenses until your
deductible.
While employees cannot contribute
to a Health Care FSA and an HSA
at the same time, employees with
an HSA can establish a Limited-
Purpose FSA. Limited-Purpose FSAs
can be used for dental and vision
expenses only.
Employees can use their account
funds on expenses such as: dental
work, eye glasses and contact
lenses, prescription drugs, and
physical therapy just to name a few.
A Dependent Care FSA is a pre-tax
benet that allows you to pay for
eligible dependent care services
such as preschool, before/after
school programs, child and elder
day care. Once your account is
funded, you can use the balance
to be reimbursed for eligible
expenses.
If you have questions regarding FSA/
HSA, you can contact EBD Member
Services at 1-877-815-1017 x1 and
by e-mail at
20
Form Instructions: Please complete all entries on this form. Please print, sign and date this form, and submit to your Human
Resources Benefits Department.
Enrollee Personal Information
First Name: Last Name: Change Effective Date:
Employer Name: Employee ID:
Permanent Address: City: State: Zip Code:
Day Time Phone Number: Email Address:
Social Security Number:
__ __ __ / __ __ / __ __ __ __
Date of Birth:
(Month/Day/Year)
__ __ /__ __ /__ __ __ __
Marital Status:
o Single o Married o Divorced o Widowed
Enrollment Status:
o New enrollment o Re-enrollment
Flexible Spending Account (FSA) Elections
Health Care FSA o Select Full Coverage FSA o Select Limited Purpose FSA o Decline Health Care FSA
I. Annual Employee Contribution* II. Contribution per pay
period (I divided by 24)
Dependent Care FSA o Select Dependent Care FSA o Decline Dependent Care FSA
I. Annual Employee Contribution* II. Contribution per pay
period (I divided by 24)
*For calendar year 2023, Health Care FSA pretax contribution limits are $3,050, and Dependent Care FSA (DCFSA) pretax contribution limits are $5,000.
Authorization and Certication
I understand that:
• I am authorizing my employer to reduce my compensation by the amount specified. This election will expire at the end of the plan
year, and I must make a new election each year.
• I am not permitted to change my elections during the plan year unless the change is due to and in accordance with certain recognized
IRS regulations for change in status events.
• I must report any administrative errors to my payroll administrator or human resources department within 10 days of my first payroll
deduction of the plan year.
• Funds left in my Dependent Care Account at the close of the plan year will be forfeited. Funds left in my Health Flexible Spending
Account may be forfeited, per plan rules. See plan documents for more details.
I will receive an Optum Financial Payment Card to access funds in my account. I certify that:
• The card will only be used for eligible medical and/ or dependent care expenses.
• Claims I pay with the card have not been reimbursed and I will not seek reimbursement from any other plan covering health or
dependent care benefits. I understand that supporting documentation may be requested.
Employee Signature: Date:
Flexible Spending Account Enrollment Form
FSAs, HRAs and RRAs are administered by Optum Financial, Inc., or ConnectYourCare, LLC (collectively, “Optum Financial”).
© 2022 Optum, Inc. All rights reserved. 209985C-062022
21
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22
Health Savings Account (HSA)
Enrollment Form
HSAs are individual accounts offered or administered through ConnectYourCare, LLC, an IRS-Designated Non-Bank Custodian of HSAs and subsidiary of Optum Financial, Inc. Neither Optum
Financial, Inc. nor ConnectYourCare, LLC is a bank or an FDIC insured institution.
© 2022 Optum, Inc. All rights reserved. 210317A-062022
Follow these easy steps:
1. Complete all entries on this Enrollment Form. Please print.
2. Sign and date this form.
3. Submit it to your Human Resources Department.
Personal Information
Employee Name:
(last name, first name)
Social Security Number:
Street Address:
(cannot be PO Box)
City, State, Zip Code:
Mailing Address:
(if different)
City, State, Zip Code:
Day Time Phone Number:
Email Address:
Date of Birth (MM/DD/YYYY):
Enrollment Status __ New Enrollment __ Re-enrollment
Marital Status: __ Single __ Married __ Divorced __ Widowed
Health Savings Account Qualification
Your health savings account is your financial asset even if you change employers or health plans. To open a health
savings account you
must meet three criteria:
1)
You must be covered by a qualifying high deductible plan.
2)
You cannot be covered by another health plan, including Medicare or Flexible Spending Account. (You may be
covered by a Limited Purpose
Flexible Spending Account).
3)
You cannot be claimed as a dependent on another individual's tax return.
Health Savings Account
__ Select HSA __ Decline HSA
Monthly Employer Contribution:
I. Annual Employee Contribution
(Not to Exceed Contribution Maximums*)
II. Number remaining pay periods
III. Contribution per pay period (I divided by II)
Authorization and Certification
I accept the terms of the ConnectYourCare HSA enrollment form. I understand that:
•
I am authorizing my employer to reduce my compensation by the amount specified. I understand the HSA election I have
made will remain in place from year-to-year until I notify my employer of a change to my HSA election.
•
I must report any administrative errors to my payroll administrator or HR department within 10 days of my first payroll
deduction of the plan year.
I will receive Payment Card to access funds in my account. I certify that:
•
The card will only be used for eligible medical expenses.
•
Claims I pay with the card have not been reimbursed and I will not seek reimbursement from any other plan covering
health or dependent care benefits. I understand that supporting documentation may be requested.
Employee Signature
Date
For Employer Use
Date of Hire (MM/DD/YYYY):
Benefits Effective Date:
(MM/DD/YYYY)
Individual $25.00 Family $50.00
23
Health Savings Account (HSA)
Enrollment Form
HSAs are individual accounts offered or administered through ConnectYourCare, LLC, an IRS-Designated Non-Bank Custodian of HSAs and subsidiary of Optum Financial, Inc. Neither
Optum Financial, Inc. nor ConnectYourCare, LLC is a bank or an FDIC insured institution.
© 2022 Optum, Inc. All rights reserved. 210317A-062022
PER THE USA PATRIOT ACT:
To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to
obtain, verify and record information that identifies each person who opens an account. When you open the account, we will ask for
your name, street address, date of birth and other information that will allow us to identify you. We may also ask to see your driver’s
license or other identifying documents.
*The total combined amount of both employer and employee contributions cannot exceed IRS maximum contributions limits.
IRS regulations are indexed annually for inflation. If you want to contribute the total annual amount for a tax year in which you were only HSA eligible for a portion
of that year, you must remain HSA eligible through the end of the next tax year or face tax penalties.
24
AR DIAMOND PLAN
CHOICE | COMPOUNDING | CONSOLIDATION | CONTROL
Diamond
Deferred Compensation Plan
Arkansas
Let’s talk about the future
5013019900 | 8662713327 | MYPLAN.VOYA.COM
Have you thought about how to begin building the income you’ll need for the future?
While your pension and Social Security oer you a good start, they may not be enough to fund the lifestyle you want in
retirement. The AR Diamond Plan – your employer’s 457 Plan – is here to help you generate the income you may need
by oering you an easy, tax-deferred way to save. The AR Diamond Plan provides you with additional flexibility to save
and invest for your future. To help you get started in the Plan, you’ll be automatically enrolled into the AR Diamond Plan
on your first day of employment. You’ll be enrolled saving 3% each pay period on a pre-tax basis, and be invested in
a Retirement Target Date Fund based on your birth year, assuming a retirement date of age 65, unless you choose to
decline enrollment by logging in to the AR Diamond Plan website at myplan.voya.com or by calling the Plan Information
Line at 800-905-1833 before your first payroll is processed.
Once you’re enrolled, you can choose to not participate (or opt out) in the Plan at any time. If you opt out within the first
90 days after your first payroll is processed, you can request a refund of any contributions made into the Plan. If you
choose to opt out on day 91 and beyond, normal qualifying 457 distribution rules will apply.
What’s in it for you – key benefits of the
AR Diamond Plan
• Pre-tax savings – you may pay less in taxes today
• Roth savings – you pay taxes today but not in
retirement*
• Tax-deferred investing – your employer’s savings plan
grows tax deferred. Contributions and any earnings are
tax-deferred and will be taxed as ordinary income when
distributed.
• A choice of investments – so you can create a
portfolio that’s right for you
• Qualifying withdrawals – should you need to take a
withdrawal before retirement
• 24/7 account access – by smartphone or computer
• Automatic enrollment – easy enrollment starting
at a 3% pre-tax contribution rate
To learn more about the Plan, go to myplan.voya.com.
Your contributions
You can save up to the annual IRS contribution
limit on a pre-tax basis, after-tax with Roth contributions
or a combination of both. If you are age 50 or older in
any given year or within three years of your Normal
Retirement Age, you can make additional catch-up
contributions. You can change your contribution rate at
any time. Please refer to www.voya.com/IRSlimits for
current limitations.
About Voya Financial®
At Voya (NYSE: VOYA) we’re dedicated to helping people
feel more confident about the future. For more than 40
years, we’ve helped millions of people like you prepare
for it through employer-sponsored retirement plans and
other financial solutions.
As the plan record keeper for the AR Diamond Plan, we
will manage the daily servicing of your Plan and provide
you with plan information, transaction processing, account
statements, saving and investing education and more.
* For Roth contributions and earnings to be eligible for tax-free withdrawals, your initial
Roth deposit must have been in your account for at least five years and you must be
at least age 59½ (or in the event of your disability or your death)
25
Diamond
Deferred Compensation Plan
Arkansas
5013019900 | 8662713327 | MYPLAN.VOYA.COM
This material is intended to provide educational information on the subjects covered. It is general in nature and the strategies suggested may not be suitable for everyone. It is not
intended to provide specific tax, legal or other professional advice. You should seek advice from your tax and legal advisors regarding your individual situation.
Plan administrative services are provided by Voya Institutional Plan Services, LLC, a member of the Voya family of companies. Representatives who provide investment services
to the Arkansas Diamond Deferred Compensation Plans or to Plan Participants are Registered Representatives of Stephens Inc. There is no aliation between the Arkansas
Diamond Deferred Compensation Plans, any of the Voya family of companies and/or Stephens Inc.
177267 3044756.G.P-2 WLT 250000476
Ready to make a move for your future?
If you are a new employee of the State of Arkansas, you will receive
a Personal Identification Number (PIN) by mail.
If you misplace your password or previously opted not to enroll,
it’s easy to request a new password.
• Go to the Plan website at myplan.voya.com and click on
“Forgot Password?” or
• Call the Plan Information Line at 800-905-1833. Customer Service
Associates are here to help Monday through Friday, 7:00 AM to
7:00 PM CT (excluding New York Stock Exchange holidays).
A new password will be mailed to your home address within seven
business days.
Want to meet with a Plan Advisor
to learn more about the Plan?
Your local Arkansas Diamond Plan Advisors are available to
meet with you one-on-one at your convenience. Call 501-301-9900
(or 866-271-3327) during standard business hours except on New York
Stock Exchange holidays to schedule a time.
• Cheryl Daughenbaugh (Central AR)
• Nancy Lewis (Southern AR)
• Brete Garland (Northern AR)
See how your savings
translate into estimated
monthly retirement income
with myOrangeMoney®,
an interactive educational
experience
. You’ll find it on the
Plan website and Voya Retire
mobile app.
**
**iPhone® is a trademark of Apple Inc., registered in the U.S.
and other countries. App Store is a service mark of Apple Inc.
Android is a trademark of Google Inc. Amazon and Kindle are
trademarks of Amazon.com, Inc. or its aliates.
26
Auto Enrollment Opt Out Form REV 9
.11.2014 | 2
Arkansas Diamond Deferred Compensation
Plan
Auto Enrollment Opt Out
Form
As a new employee, you will be automatically enrolled into the Arkansas Diamond Deferred
Compensation Plan, with a 3% automatic deduction. If you do not wish to participate, you have 90 days
from your first deduction to opt out.
Complete this form to opt out of the Arkansas Diamond Deferred Compensation Plan. You must return
this form to your payroll department on your first day of employment. If you choose to not complete the
form on your first day of employment, you may opt out of the plan by logging into the Arkansas Diamond
Deferred Compensation Plan website at
https://myplan.voyaplans.com
o
r by calling 1.800.905.1833
EMPLOYEE OPT OUT ACKNOWLEDGEMENT AND SIGNATURE
I understand by checking the below box I have indicated my election to not participate in the Arkansas
Diamond Deferred Compensation Plan at this time. I understand that I may choose to begin a deferral
percentage in the future by logging into the AR Diamond Deferred Compensation Plan website at
https://myplan.voyaplans.com
or by calling 1.800.905.1833
I decline participation in the AR Diamond Deferred Compensation 457 Plan.
I have read the Auto Enrollment Guide provided to me. I hereby confirm my election to not
participate in the Arkansas Diamond Deferred Compensation Plan and understand that I can re-enroll in
the Plan at any time.
_______________________________________ ____________________________________
Please Print Your Name Social Security Number
_______________________________________ ____________________________________
Signature Date
HIR/Payroll: Please note this form is to be used only on day one (1) of employment. If the employee chooses to not
complete the form on their first day of employment, then decides to opt out of the plan and/or request a refund,
the employee must opt out and/or request a refund by logging into the Plan website at
https://myplan.voyaplans.com
or by calling 1.800.905.1833
Questions? Call the Arkansas Diamond Local Office: 501.301.9900 or toll free at 1.866.271.3327
27
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28
New hire enrollment
THE FOLLOWING VOLUNTARY
BENEFITS WILL BE OFFERED
DURING ENROLLMENT:
Accident insurance provides a benet
for a range of accidental injuries.
Group specied disease insurance
provides a benet to help you manage
the nancial impacts of a critical illness.
Term life insurance offers a predictable
way to provide more life coverage at more
affordable prices during high-need years.
Whole life insurance provides a benet to
help protect your family’s way of life in the
event of your death.
These benets are being offered for a
limited time with no medical underwriting
to qualify for coverage. Eligibility
requirements apply.
State of Arkansas is pleased to have Arkansas State Employees Benet Advisors assist with
your enrollment. During the enrollment, each of you are encouraged to attend a quick, private
1-to-1 session with a benets counselor. In that session, you’ll discuss all of your current benets
as well as new and updated benet options. Your benets counselor will answer any questions
you may have and offer you simple, straightforward advice as you sort through your choices.
Contact your oce HIR to nd out when a benet counselor will be at your oce!
The policies, their names or their provisions may vary or be unavailable in some states. The policies have exclusions and limitations which may affect
any b
enets payable. For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.
Policy forms marketed by the company vary by product and are too numerous to list in the advertisement, but a list can be provided upon request.
Colonial Life Insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.
©2022 Colonial Life & Accident Insurance Company. All rights reserved.
Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 9-22 | NS-15196-4
ColonialLife.com
IF YOU ARE UNABLE TO ATTEND A 1-TO-1
BENEFITS COUNSELING SESSION, CONTACT
THE ENROLLMENT CALL CENTER TO APPLY
Phone: 833-703-1967
Employer Code:1395219
Time: 8 a.m. – 5 p.m. CT
Here’s how it works:
1. Gather any information you may need to apply,
such as dep
endents’ names, birth dates, ages,
Social Security numbers and addresses.
2. You can speak with a benets counselor to answer
any questions you may have or leave a message for
a callback. A benets counselor can complete your
enrollment over the telephone.
3. You will receive an Election Form conrming
your voluntary benet elections via secure email.
For more details contact:Arkansas State Employees Benet Advisors
888-224-5233 | 501-224-5234 | www.arseba.com
29
Health insurance wasn’t designed to cover everything.
That’s why there’s Aac. Aac can help take care of
what health insurance doesn’t cover, so you and your
employees can focus on caring for everything else.
Aac supplemental benets
Our product portfolio is as broad as your needs, with individual and group plans that help cover the
expected – and unexpected – that’s sure to come life’s way.
Open enrollment planning
isn’t complete until
you have Aflac
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30
SHORT-TERM DISABILITY
The ManhattanLife Central Care Group
Disability Income Insurance Policy provides
a monthly disability benefit payable to an
insured employee in the event of a total
disability resulting from an off-the-job,
covered accident or sickness.
Benefit coverage for up to 65% of salary,
excluding bonuses and overtime.
MONTHLY BENEFIT AMOUNT
• $500 - $6,000
ELIMINATION PERIOD
(Refers to the number of consecutive days you
must be Totally Disabled before the policy begins
to pay the Monthly Benefit for Total Disability)
• 0/7 or 0/14 (Accident/Sickness)
BENEFIT DURATION
• Total Disability - 6 months
This is not a policy of workers’
compensation insurance. The employer
does not become a subscriber to the
Workers’ Compensation System by
purchasing this policy, and if the employer
is a non-subscriber, the employer loses
those benefits that would otherwise
accrue under the Workers’ Compensation
Laws. The employer must comply with the
Workers’ Compensation Law as it pertains
to the non-subscribers and the required
notifications that must be filed and posted.
State of Arkansas
State of Arkansas is now making the following
ManhattanLife Assurance products available to its employees.
CANCER CARE PLUS
“Limited Cancer and Dread Disease Policy”
Portable And Renewable For Life! *
BENEFIT PACKAGE OPTIONS
LOW
PLAN
HIGH
PLAN
CANCER SCREENING TEST - Payable for one annual
cancer screening test. Not payable if received through any
free-testing program or for any other cancer screening test
for which a charge is not made. Payment based on benefit
amount selected.
Pays $50
per calendar
year
Pays $100
per calendar
year.
FIRST OCCURRENCE BENEFIT (RIDER) - Payable when
a covered person is diagnosed with cancer for the first time.
Payable only once for each covered person and not payable
for skin cancer. Not available for ages 65 and above.
Pays $2,500.
Pays
$10,000.
DAILY HOSPITAL CONFINEMENT BENEFIT - Payable
when a covered person is confined to the hospital for the
treatment of cancer or a dread disease. Payment is based
on the daily benefit amount selected. Payable for the first 70
days of each period of confinement.
Pays $150
per day.
Pays $150
per day.
SURGICAL BENEFIT - Payable for surgeries performed in or
out of the hospital to treat cancer or a specified dread disease.
Benefits for surgical procedures are calculated as a percentage
of the per-surgery maximum benefit amount selected.
Pays max
per surgery
$3,000.
Pays max
per surgery
$4,000.
RADIATION, CHEMOTHERAPY AND
IMMUN
OTHERAPY* - We will pay the actual charges
for Teleradiotherapy, Radio-Active Isotopes Therapy,
Chemotherapy, Chemotherapy Enhancer Drugs, and Anti-
Nausea and Immunotherapy drugs, as indicated in the policy,
for the treatment of cancer or a specified dread disease.
Benefits are based on the maximum monthly benefit amount
selected. Actual Charges means the amount(s) actually
paid by or on behalf of the Covered Person and accepted
by the provider as full payment for the covered services
provided. This benefit is not payable if treatment is received
in a government or charity hospital.
*Note - Immunotherapy must be FDA approved
Pays actual
charges,
max $5,000
per month.
Pays actual
charges,
max $5,000
per month.
This plan covers an additional 27 dread diseases.
* Subject to company’s right to change premium.
For more information about enrolling, policy benefits, limitations and exclusions, please visit:
Arkansas State Employees Benefits Advisors
(888)
224-5233 or email ser[email protected]
POLICY FORM NUMBERS: CP4000 AR 4/04, DIMSTR and DICER
T
OPEN ENROLLMENT DISCLAIMER: Not all products offered are guaranteed to issue and may include a pre-existing condition waiting period; please
consult your agent representative for policy underwriting parameters.
Coverage is subject to policy exclusions and limitations that may affect benefits payable. This is not a complete disclosure of plan qualifications and
limitations. See your ManhattanLife benefits counselor for complete details.
Underwritten by ManhattanLife Insurance Company of America, 107777 Northwest Freeway, Houston, Texas 77092
CENTRAL CARE
DISABILITY INCOME
31
Unum
| Long Term Disability Insurance 410275
EN-1978 FOR EMPLOYEES (3-22)
Arkansas State Employees
How does it work?
This coverage provides a monthly benefit if you have
a covered illness or injury and you can’t work for a few
months — or even longer.
You’re generally considered disabled if you’re unable to do
important parts of your job — and your income suffers as
a result.
Why is this coverage so valuable?
You can use the money however you choose. It can help
you pay for your rent or mortgage, groceries, out-of-pocket
medical expenses and more.
Long Term Disability
Insurance
Consider your expenses
Utilities $
Housing $
Groceries $
Transportation $
Child care/Elder care $
Medical/Personal care $
Education $
Insurance $
Long Term Disability Insurance can replace
part of your income if a disability keeps you
out of work for a long period of time
What else is included?
Survivor Benefit
If you die while you’ve been disabled and receiving benefits
for at least 180 days, your family could get a benefit equal to 3
months of your gross disability payment.
Waiver of premium
If you’re disabled and receiving benefit payments, Unum
waives your cost until you return to work.
Work-life balance Employee Assistance Program
Get access to professional help for a range of personal and
work-related issues, including counselor referrals, financial
planning and legal support.
Worldwide emergency travel assistance
One phone call gets you and your family immediate help
anywhere in the world, as long as you’re traveling 100 or more
miles from home. However, a spouse traveling on business
for his or her employer is not covered.
For questions contact Arkansas State Employees Benefit
Advisors at 501-224-5234
32
Unum | Long Term Disability Insurance 410275
EN-1978 FOR EMPLOYEES (3-22)
Billed amount may vary slightly. Your rate is based on your age and will increase as you move to the next age band.
If you didn’t get coverage when you were first eligible, you’ll
have to answer health questions now. If you‘re newly eligible,
you may not have to answer health questions. If you already
have coverage, you can increase it up to the maximum
available. You may have to answer health questions. New
coverage may be subject to pre-existing condition limitations.
Elimination period (EP)
Your elimination period is 180 days. This is the number of
days that must pass after a covered accident or illness before
you can begin to receive benefits.
Benefit duration (BD)
This is the maximum length of time you can receive benefits
while you’re disabled. You can receive benefits up to the
Social Security (SS) normal retirement age, for 5 years or for 5
years.
How much coverage can I get?
You*
You are eligible for coverage if you are an active
employee in the United States working a minimum
of 20 hours per week
.
Choose to cover 60%, 60% or 50% of your monthly
income, up to a maximum payment of $5,000.
The monthly benefit may be reduced or offset by
other sources of income.
*See the Legal Disclosures for more information.
Calculate your cost
• Follow the instructions
on the worksheet at right
to determine your cost
per paycheck.
• For step 2, enter the
amount that is less: 1)
your annual earnings or
2) the maximum covered
annual earnings listed on
the rate chart, based on
your age and coverage
percentage amount you
want.
(Choose the age you will
be when your coverage
becomes effective. See your
plan administrator for your
plan effective date.)
Rates
Option 1 Option 2
Percent of monthly income ›
60%
EP: 180 days
BD: SS retirement age
60%
EP: 180 days
BD: for 5 years
Age: 15-24 $0.240 $0.170
25-29 $0.390 $0.230
30-34 $0.750 $0.410
35-39 $1.260 $0.600
40-44 $1.800 $0.850
45-49 $2.350 $1.220
50-54 $2.770 $1.510
55-59 $3.040 $2.310
60-64 $3.270 $3.900
65-69 $2.460 $3.620
70+ $1.890 $1.940
Rates
Option 1 Option 2 Option 3
Percent of monthly income ›
60%
EP: 180 days
BD: SS retirement age
60%
EP: 180 days
BD: for 5 years
50%
EP: 180 days
BD: for 5 years
Age: 15-24 $0.240 $0.170 $0.140
25-29 $0.390 $0.230 $0.190
30-34 $0.750 $0.410 $0.310
35-39 $1.260 $0.600 $0.470
40-44 $1.800 $0.850 $0.610
45-49 $2.350 $1.220 $0.850
50-54 $2.770 $1.510 $1.120
55-59 $3.040 $2.310 $1.750
60-64 $3.270 $3.900 $2.710
65-69 $2.460 $3.620 $2.600
70+ $1.890 $1.940 $1.420
Disability worksheet
1
Enter your annual earnings and calculate your maximum monthly benefit available.
$________ ÷ 12 = $_______ x _____% = $__________
Your annual
earnings
Your
monthly
earnings
(The % plan that you want) Max monthly benefit available (if the amount exceeds
the plan max of $5,000, enter $5,000)
2
Calculate your cost per paycheck
$________÷ 100 = $_______ x
$______ = $_______ ÷ 12 = $__________
Your annual
earnings
Rate for the
option you
choose
Number of paychecks
per year
Total cost per paycheck
33
Unum | Long Term Disability Insurance 410275
EN-1978 FOR EMPLOYEES (3-22)
Exclusions and limitations
Active employee
You are considered in active employment, if on the day you apply for coverage, you are being paid regularly
by your employer for the required minimum hours each week and you are performing the material and
substantial duties of your regular occupation.
Delayed effective date of coverage
Insurance coverage will be delayed if you are not an active employee because of an injury, sickness,
temporary layoff, or leave of absence on the date that insurance would otherwise become effective.
Benefit duration (BD)
The duration of your benefit payments is based on your age when your disability occurs. Your Long Term
Disability benefits are payable while you continue to meet the definition of disability. Please refer to your
plan document for the duration of benefits under this policy.
Definition of disability
You are considered disabled when Unum determines that:
• You are limited from performing the material and substantial duties of your regular occupation due to
sickness or injury; and
• You have a 20% or more loss of indexed monthly earnings due to the same sickness or injury
After 24 months, you are considered disabled when Unum determines that due to the same sickness or
injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by
education, training or experience.
You must be under the regular care of a physician in order to be considered disabled.
The loss of a professional or occupational license or certification does not, in itself, constitute disability.
“Substantial and material acts” means the important tasks, functions and operations that are generally
required by employers from those engaged in your usual occupation and that cannot be reasonably omitted
or modified.
Unless the policy specifies otherwise, as part of the disability claims evaluation process, Unum will evaluate
your occupation based on how it is normally performed in the national economy, not how work is performed
for a specific employer, at a specific location or in a specific region.
Deductible sources of income
Your disability benefit may be reduced by deductible sources of income and any earnings you have while you
are disabled, including such items as group disability benefits or other amounts you receive or are entitled
to receive:
• Workers’ compensation or similar occupational benefit laws, including a temporary disability benefit
under a workers’ compensation law
• State compulsory benefit laws
• Automobile liability insurance policy
• No fault motor vehicle plan
• Third-party settlements
• Other group insurance plans
• A group plan sponsored by your employer
• Governmental retirement system
• Salary continuation or sick leave plans, if applicable
• Retirement payments
• Social Security or similar governmental programs
Exclusions and limitations
Benefits will not be paid for disabilities caused by, contributed to by, or resulting from:
• Intentionally self-inflicted injuries;
• Active participation in a riot;
• War, declared or undeclared or any act of war;
• Commission of a crime for which you have been convicted;
• Loss of professional license, occupational license or certification;
The loss of a professional or occupational license does not, in itself, constitute disability.
Unum will not pay a benefit for any period of disability during which you are incarcerated.
The lifetime cumulative maximum benefit for all disabilities due to mental illness is 24 months. Disabilities
based primarily on self-reported symptoms are limited to 24 months. Only 24 months of benefits will be paid
for any combination of such disabilities even if the disabilities are not continuous and/or are not related.
Payments can continue beyond 24 months only if you are confined to a hospital or institution as a result of
the disability.
Termination of coverage
Your coverage under the policy ends on the earliest of the following:
• The date the policy or plan is cancelled
• The date you no longer are in an eligible group
• The date your eligible group is no longer covered
• The last day of the period for which you made any required contributions
• The last day you are in active employment except as provided under the covered layoff or leave of absence
provision.
Unum will provide coverage for a payable claim that occurs while you are covered under the policy or plan.
Unum’s LTD contracts standardly include a provision called the Social Security Claimant Advocacy Program.
With this feature, claimants can receive expert advice and assistance from us regarding their Social Security
Disability claim during the application and appeal process. Social Security advocacy services are provided by
GENEX Services, LLC or Brown & Brown Absence Services Group. Referral to one of our advocacy partners is
determined by Unum.
Worldwide emergency travel assistance services are provided by Assist America, Inc. Work-life balance
employee assistance program services are provided by HealthAdvocate. Services are available with select
Unum insurance offerings. Terms and availability of service are subject to change and prior notification
requirements. Service providers do not provide legal advice; please consult your attorney for guidance.
Services are not valid after coverage terminates. Please contact your Unum representative for details.
This information is not intended to be a complete description of the insurance coverage available. The policy
or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which
may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form
C.FP-1 et al. or contact your Unum representative.
Underwritten by:
Unum Life Insurance Company of America, Portland, Maine
© 2022 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum
Group and its insuring subsidiaries.
34
The Arkansas State Employees Association is a non-profit
association that works with the State Legislature and
Governor’s office for the betterment of Arkansas State
Employees, as well as ensuring an efficient and effective
state government. It also offers its members optional,
additional benefits and opportunities.*
• Scholarships - Each year ASEA awards scholarships. Members and their dependents are eligible to apply.
• Retail Discounts - Our extensive network of retail discount partners can save you money.
• Representation - ASEA represents Arkansas state employees on all your issues year around.
• Pay, Health Insurance, Retirement Plan, and Benefits - What matters to you most is our priority.
• Benevolent Fund - Our fund assists members’ survivors with up to $1,000 paid upon death.
• Member's Only Website - Only members have access to our reporting and discount codes.
• ASEA Newsletter - As a member you can receive a subscription to our newsletter (print or digital available).
3 WAYS TO JOIN:
Online at aseaar.org • Mail form to: P.O. Box 1588, Little Rock, AR 72203 • Fax form to: 501-378-0113
An ASEA membership offers many unique benefits to save you time and money.
For only $2.17 a pay period, members receive:
I prefer to pay dues on annual basis and enclose check for $52.00.
I pre
fer to have my newsleer emailed to me.
*ASEA membership is not a requirement.
IRS regulaons require ASEA to nofy its members regarding a reasonable esmate of the poron of their annual dues
that are allocable to lobbying and polical expenses and will be nondeducble for individual tax reporng. Currently,
up to 5% of membership dues received may be used for lobbying and polical expenses.
35
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36
Contact information for Benefits
Benefit
Contact
Phone
Address
Health Insurance Employee Benefits Division (EBD)
Transform.ar.gov/employee-benefits/
e-mail: [email protected]
(877) 815-1017
Press 1, then 2
501 Woodlane St.,
Ste 500
Little Rock, AR 72201
Dental and Vision
Insurance
ARSEBA – Arkansas State Employees Benefit
Advisors
www.arseba.com
e-mail: [email protected]
(501) 224-5234
(888) 224-5233
(501) 663-1445
Fax
1301 West 7
th
Street
Little Rock, AR 72201
Health Savings
Account/Flexible
Spending Account
Optum Financial
https://www.myoptumfinancial.com/arbenefits
(833) 229-4431
Group Term Life
Insurance
Colonial Life
Transform.ar.gov/employee-benefits/
(855) 868-6009
PO Box 1365
Columbia, SC 29202
Deferred
Compensation
Arkansas Diamond Plan – Voya
https://myplan.voya.com
(501) 301-9900
(866) 271-3327
Other Voluntary
Insurance:
Accident
Cancer
Critical Illness
Hospital Indemnity
Life Insurance
(Individual Term,
Universal and
Whole)
Short Term
Disability
Long Term Disability
Identity Guard
ARSEBA – Arkansas State Employees Benefit
Advisors
www.arseba.com
e-mail: [email protected]
(501) 224-5234
(888) 224-5233
(501) 663-1445
Fax
1301 West 7
th
Street
Little Rock, AR 72201
AR State Employees
Association
ASEA - www.aseaar.org (501) 378-0187
(800) 950-8139
PO Box 1588
Little Rock, AR 72203
Employee
Assistance Program
- EAP
New Directions
www.ndbh.com
(877) 300-9103
Additional information and forms including Notice of Privacy Practices and HIPAA
information can be found at:
https://www.transform.ar.gov/employee-benefits
37
State of Arkansas
Employee Benefits Information
2023
