Coordination with Other Paid Time Off- Self Insured Only Does employer require EE to either exhaust or have choice to utilize Sick Days or EIB (Extended Illness Bank) during the EP? If Yes: Elimination Period must be based on the “greater of” Sick Days or 14 days, for example. Upon EP satisfaction: For ASO, ATP (non check cutting clients) Employer may apply offsets as desired. For checking cutting clients, offsets will be determined by the client. Day Hospital – Confinement Are Accident and Sickness Elimination Periods waived for hospital confinement? (Yes/No) First Day Hospital – Outpatient (Note: Benefit basis only) Are Accident and Sickness benefits payable from first day outpatient, provided the employee is disabled on the day following the Elimination Period? (Yes/No) Benefit Duration Indicate the total number of weeks of the Benefit Duration. (ie. Number of weeks benefits are payable) Benefit Duration Look Back Period Example: If EE has a disability within a rolling calendar year from current disability, we must deduct the previous disability from their current disability. Example: Disability eff 5/1/13. Matrix checks to see if EE went out of work from 5/1/12 up until 5/1/13. If yes, Matrix deducts the # of days that EE was previously on disability from current disability that began 5/1/13. If the lookback reveals that the EE was on disability from 7/1/12 thru 7/30/12, Matrix would deduct 30 days from current disability that began 5/1/13. Note: Applies to ASO STD Only For most a Benefit Duration Look Back Period is not applicable. However, if the plan contains this provision, indicate the look back period of time and if it is in days, weeks or years. For example, 26 weeks. If there is a look back period, a history file must be provided.
Exclusions Note: Applies to ASO Only RSL has standard exclusions that differ from ASO and cannot be changed. Example of standard Exclusion language: Intentionally self-inflicted illness or injury; the commission or attempted commission of a felony or engagement in an illegal occupation; an act of war; not under the regular and continuous care of a physician; incarceration in any federal, state or municipal penal institution, jail, medical facility, hospital or in any other place because of a criminal conviction; employment of an employer other than the Policyholder, loss of a professional or occupation license or certification; an occupational injury or sickness and elective surgery Weekly Benefit Percentage Enter the benefit amount, for example: 60% of pay Maximum Weekly Benefit Enter the maximum benefit amount. Minimum Weekly Benefit the minimum benefit amount. Late Entrant Sample = N/A or EOI only if Voluntary STD. Plan Options are (Yes/No) Offsets Note: Fully Insured STD standard offsets are Individual Disability Income (IDI), Formal Salary Continuance, Wages Example of standard Offsets: Workers’ compensation for lost time, disability, Social Security, federal or state disability benefits, No fault auto insurance. Is offset on $ for $ or greater than 100%? Redirects Only available on Writing policies. Define the redirects (premium for Medical, Dental, etc.) available to be deducted from the benefits. Claims to set up the customer as the recipient of the redirects. Rate Per $10 of Weekly Covered Benefit Note: On Fully Insured Voluntary STD there is no composite Rate. Employer paid rate