SS&P 2022 Benefits Open Enrollment Step 1 of 10 10% This form will allow you to select your 2022 benefits. Please refer to your Open Enrollment brochure or contact beth@omahatrack.com for rate details. Before completing the wizard, you will need the names and social security numbers of any dependents and/or beneficiaries you are adding. Employee Name* First Last I have reviewed my 2022 benefit brochure and materials. I would like to do one of the following: Make no changes for 2022 Review my 2022 elections Are you making any changes to you dependents or beneficiaries for 2022?* Yes No This includes spouses, children and/or additional life insurance beneficiaries. Your do not need to list your spouse or children again if they are also beneficiaries.Name* First Last AddressLeave blank if same as employeeRelationship*SpouseDependent ChildBeneficiaryDate of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN*Do you have an additional dependent or beneficiary to add?* Yes No Name* First Last AddressLeave blank if same as employeeRelationship*SpouseDependent ChildBeneficiaryDate of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN*Do you have an additional dependent or beneficiary to add?* Yes No Name First Last Do you have an additional dependent or beneficiary to remove?* Yes No Name First Last AddressLeave blank if same as employeeRelationship*SpouseDependent ChildBeneficiaryDate of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN*Contact Sara at sara@omahatrack.com if you need to add more dependents and/or beneficiaries. UnitedHealthcare High Deductible Medical PlanUnitedHealthcare High Deductible Medical Plan Our high-deductible medical plan is insured through United Healthcare and coupled with a self-funded health reimbursement account (HRA) also administered by United Healthcare. The HRA reduces the in-network deductible to an out-of-pocket maximum of $2,500 for employee only coverage, and $5,000 for employee with dependent(s) coverage. All HRA expenses are funded by Omaha Track. To view detailed plan documents and resources, click here. Make your selections for coverage below. Be sure to indicate which family members you want to enroll by checking the checkbox next to their name. If there is a family member you want covered that is not listed below, return to the Family Members screen to add them. If you choose to waive coverage for yourself and/or any of your listed dependents, you must select the reason and provide the requested details below.Coverage Level*Select One. Includes Dental at no additional cost to employee. Waive Employee-Only: $46.00 per paycheck Employee + Child(ren): $126.00 per paycheck Employee + Spouse: $241.50 per paycheck Family: $330.00 per paycheck Optum Health Savings Account (HSA) Employees who participate in the Aetna High-Deductible Medical Plan have the opportunity to contribute to a health savings account (HSA) offered through Optum. An HSA is an individually-owned, tax-advantaged account that is used to pay for routine medical expenses either now or in the future. Unused funds and interest are carried over, without limit, from year to year. You own the HSA and it is yours to keep – even if you change jobs, health plans, or retire. Omaha Track encourages employees to establish an HSA by providing a one-time initial employer contribution, as well as a dollar-for-dollar match up to a designated annual maximum. Employee-Only Coverage: Employer contribution of $100 when you open your account, plus earn up to $300 through employer match each year. Employee + Dependent(s) Coverage: Employer contribution of $150 when you open your account, plus earn up to $600 through employer match each year. For a full list of qualified expenses, click here.I would like to update or change my HSA contribution.* Yes No 2021 HSA contribution limit (employer + employee) Self-only: $3,650 Family: $7,300 HSA catch-up contributions (age 55 or older) $1,000 (This can be changed any time by emailing beth@omahatrack.com)Amount per Paycheck* DentalAmeritas Dental Plan (with Medical) Enrollment will be the same as Medical Employees who elect medical coverage with Omaha Track are provided dental coverage through Ameritas at no additional cost. All dependents covered under the medical plan are automatically covered on the dental plan. In-network coverage includes: Type 1 & 2 services covered at 100%, Type 3 services covered at 60%, a $25 deductible per person for Type 2 & 3 services, and a $1,500 annual maximum per person. Our plan includes adult and child orthodontics ($1,000 lifetime maximum per covered person), Dental Rewards, and Lasik Advantage. To view detailed plan documents and resources, click here.Ameritas Dental Plan (Waived Medical) Employees who waive medical are eligible to elect dental only coverage with Ameritas. In-network coverage includes: Type 1 & 2 services covered at 100%, Type 3 services covered at 60%, a $25 deductible per person for Type 2 & 3 services, and a $1,500 annual maximum per person. Our plan includes adult and child orthodontics ($1,000 lifetime maximum per covered person), Dental Rewards, and Lasik Advantage. To view detailed plan documents and resources, click here.Dental Coverage Level* Waive Employee-Only: $1.68 per paycheck Employee + Child(ren): $7.94 per paycheck Employee + Spouse: $8.12 per paycheck Family: $14.38 per paycheck Select One. Ameritas/VSP Vision Plan Our vision plan with Ameritas offers coverage through VSP’s Choice Network. In-network deductibles are: $10 exam, $25 eye glass lenses or frames, and up to $60 for contact exams. Coverage includes: annual eye exam covered in full, lenses covered in full, elective contacts up to $130 per year, and exam/lens/frames every 12/12/24 months. To view detailed plan documents and resources, click here. Make your selections for coverage below. Be sure to indicate which family members you want to enroll by checking the checkbox next to their name. If there is a family member you want covered that is not listed below, return to the Family Members screen to add them. Vision Coverage Level* Waive Employee-Only: $0.92 per paycheck Employee + Child(ren): $4.38 per paycheck Employee + Spouse: $4.72 per paycheck Family: $8.20 per paycheck Select One. Lincoln Financial Group Accident Plan If you are accidentally injured, accident insurance from Lincoln Financial Group can help you take care of out-of-pocket expenses and medical costs beyond what your health insurance covers. Premiums are deducted pre-tax and benefits are paid directly to you tax-free. • If you have a covered accidental injury, LFG will send you a check.You decide how to spend it.• Cash benefits cover a full range of injury expenses and treatments,including emergency room visits, surgeries, fractures, lacerations,and more.• Coverage provided for multiple covered injuries from a singleaccident.• Benefits are focused on the family, safety and accident prevention.• No exclusions for pre-existing injuries.• No medical questions are required to receive coverage.• Dependent children are eligible to age 26 regardless of student status. For additional plan information, click here. Accident Coverage Level* Waive Employee-Only: $5.72 per paycheck Employee + Child(ren): $9.36 per paycheck Employee + Spouse: $10.04 per paycheck Family: $13.62 per paycheck Select One. Lincoln Financial Group Critical Illness Plans With the rising cost of healthcare, getting seriously ill could have a big impact on your finances. If you are diagnosed with a critical illness, this insurance plan can help you pay for expenses that aren't covered by your health insurance plan. Critical illness coverage pays you a lump-sum cash benefit to help pay for treatment or bills. Premiums are deducted pre-tax and benefits are paid directly to you tax-free. Our critical illness plan through Lincoln Financial Group offers two plan options. Plan 1 provides a $10,000 basic benefit, with covered dependents receiving 50% of your benefit amount. Plan 2 provides a $20,000 basic benefit, with covered dependents receiving 50% of your benefit amount. For additional plan information, click here. Guarantee issue of benefits will only apply to first time eligible employees. Those who previously waived coverage and would now like to elect this benefit must complete the appropriate evidence of insurability form and submit it to Lincoln Financial Group for review and approval before coverage will begin. Critical illness is an issue-age benefit, meaning that your rates will not increase as you age. Tobacco rates are in place for this plan. LFG's definition of tobacco usage evaluates whether anyone to be insured (employee or spouse) used tobacco in the past 12 months, including smokeless tobacco and electronic cigarettes. You must designate your beneficiary(ies) for this policy below. Please be sure to specify the percentage of the benefit you want paid to each beneficiary; these percentages should total 100%. Primary means the person(s) you choose to receive your life insurance benefits. Secondary means the person(s) you choose to receive your life insurance benefit only if all primary beneficiaries are disqualified or die before you.Critical Illness Coverage Level* Waive Employee-Only Employee + Child(ren) Employee + Spouse Family Select One. See Benefit Brochure for premium amounts.Tobacco User* Yes No Lincoln Financial Group Voluntary Life Plan Voluntary life insurance through Lincoln Financial Group is an optional benefit offered by Omaha Track where the employee pays the premium. Premiums are based on age and the amount of insurance purchased. If your employment ends, you may apply for an individual life insurance policy with LFG without having to provide evidence of insurability. You have the opportunity to purchase voluntary life insurance up to five (5) times your annual salary not to exceed $500,000 in increments of $10,000. During your initial enrollment period, the first $150,000 of coverage is guaranteed issue and does not require Evidence of Ensurability (EOI) or good health. Those who elected coverage during their initial benefit enrollment can increase their coverage by $10,000 or $20,000 without evidence of insurability. Those who waived coverage during their initial benefit enrollment will need to provide evidence of insurability to obtain coverage now. If your elected coverage exceeds the guarantee issue, you must provide evidence of insurability. To view detailed plan documents and resources, click here. If your selection requires an Evidence of Insurability (EOI) form, you will receive the form via email within 7-10 business days. If your slection requires EOI and the form is not completed, all future elections will require EOI. You must designate your beneficiary(ies) for this policy below. Please be sure to specify the percentage of the benefit you want paid to each beneficiary; these percentages should total 100%. Primary means the person(s) you choose to receive your life insurance benefits. Secondary means the person(s) you choose to receive your life insurance benefit only if all primary beneficiaries are disqualified or die before you. When you designate minors as beneficiaries, it is important to understand that insurance benefits may not be released to a minor child. They may, however, be paid to a court appointed guardian of the child’s estate. The regulations governing minor beneficiaries vary by state.I would like to be contacted to change my voluntary life and/or AD&D insurance elections.*YesNo I would like to be contacted to review or update my beneficiaries or I have other questions.*YesNoContact Number*Signature*I have reviewed my 2022 elections and confirm my elections as submitted.
