2 0 1 2
L u n a
I n n o v a t i o n s
Benefits Enrollment Guide
MEDICAL AND PRESCRIPTION DRUGS
Medical Insurance will be renewing with Anthem Blue Cross and Blue Shield again
this year. There will still be 3 medical offerings, 2 Health Reimbursement Account
Plans and 1 High Deductible Health Plan paired with the health savings account.
A Health Savings Account is owned by the employee. The employee can make tax
free deposits into the Health Savings Account. This money set aside in the Health
Savings Account is used to pay eligible medical expenses and you can take it with
you if you were to cease employment with Luna Innovations.
With a Health Reimbursement Account (HRA), Luna Innovations puts a set amount of
money into an account for you depending on which plan you choose. You can use
this money to pay the underlying medical plan deductible. This money does not roll
over from year to year. If you were to leave Luna, the funds in the HRA account
would stay with Luna.
HRA 809
The $2,000 (individual)/$4,000 (family) deductible will be shared by you and
Luna.
Individual Example:
$2,000 deductible – Luna will pay the first $1,500 and you will be responsible for the
remaining $500
Family Example
$4,000 deductible – Luna will pay the first $3,000 and you will be responsible for the
remaining $1,000
HRA 808
The $5,000 (individual)/$10,000 (family) deductible will be shared by you and
Luna.
Individual Example:
$5,000 deductible – Luna will pay the first $1,000 and you will be responsible for the
remaining $4,000
Family Example:
$10,000 deductible – Luna will pay the first $2,000 and you will be responsible for
the remaining $8,000
ANTHEM MEDICAL
AND PRESCRIPTION DRUGS
Please see a brief summary of the plan offerings listed below:
Services
Plan 809 (HRA)
Plan 808 (HRA)
Plan GHSA448
$2,000/$4,000
$5,000/$10,000
$3,000/$6,000
Paid at 100%
Paid at 100%
Paid at 100%
$2,000/$4,000
$5,000/$10,000
$3,000/$6,000
$6,000/$12,000
$1,500/$3,000
$1,000/$2,000
Primary Care
Physician
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Specialist
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Outpatient
Facility/Outpatient
Hospital
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Inpatient Hospital
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Inpatient
Behavioral Health
Care & Substance
Abuse
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Outpatient
Behavioral Health
Care & Substance
Abuse
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Urgent Care
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Emergency Care
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Subject to deductible
$0 afterwards
Routine Wellness
Checkup
Deductible
-Individual
-Family**
Out of Pocket
Maximum
-Individual
-Family
HRA Contribution
to offset
deductible
2
-
Individual
-
Family
$3,000/$6,000
$4,000/$8,000
N/A
Services
Plan 809 (HRA)
Plan 808 (HRA)
Plan GHSA 448
$2,000/$4,000
$5,000/$10,000
$3,000/$6,000
Dependent Age
End of the month the dependent attains age 26
Prescription Drugs
After above
deductible
After above
deductible
After above
deductible
Retail/Mail Order
Retail/Mail Order
Retail/Mail Order
$10/$10
$10/$10
$10/$10
$30/$60
$30/$60
$30/$60
$50 or 20%/$150 or
20%
$50 or 20%/$150 or
20%
$50 or 20%/$150 or
20%
-Generic
-Preferred Brand
-Non-Preferred
Brand
*In-Network Only Benefits are shown in this example
**Please note that the family deductible could be met by one member or a
combination of members enrolled in the plan.
Employee Bi-Monthly Cost (24 Pay Periods)
Employee
Employee &
Employee &
Employee &
Spouse
Employee &
Child
Only
Children
Family
HRA 809
$24.04
$214.82
$73.03
$197.50
$357.12
HRA 808
$0
$159.19
$49.37
$144.11
$269.35
GHSA 448
$0
$106.98
$22.04
$89.96
$192.36
ANTHEM Blue View Vision
Below is a summary of the vision benefits that are included in the medical plans
above. In addition to the services listed below there are valuable discounts on
additional eyewear and accessories.
Services
Blue View Vision 130/$25 12/24 Rider
Annual Routine Eye Exam
$15 copay
Eyeglass Frames – Every two years you may
select any eyeglass frame and receive the
following allowance toward the purchase
price
$130 allowance then 20% off remaining balance
Lens options (once every year)
-Standard plastic single vision lenses (1 pair)
-Standard plastic bifocal lenses (1 pair)
-Standard plastic trifocal lenses (1 pair)
Eyeglass lens upgrades
3
$25 copay, then covered in full
Member cost for upgrades
-UV coating
-$15
-Tint (solid and gradient)
-Standard Polycarbonate
-Transitions lenses
-Progressive lenses
-Standard
-$15
-$40
-$75
-Progressive lenses
-$65
-Premium Tier 1
-Premium Tier 2
-Premium Tier 3
-$91
-$97
-$103
-Standard Anti-Reflective Coating
-$45
-Premium Tier 1 Anti-Reflective Coating
-$57
Premium Tier 2 Anti-Reflective Coating
-$68
-Other add-ons and service
-20% off of retail price
Contact lenses
Contact lenses
-Elective conventional lenses
-$130 allowance then 15% off balance
-Elective disposable lenses
-$130 allowance
-Non-elective contact lenses
-Covered in full
DENTAL
Luna Innovations will continue to offer Dental Insurance through Delta Dental of VA.
Delta Dental Premier Plan
Services
Amount You Pay
Preventive Services (100%
coverage)
Exams, cleanings, x-rays (Bitewings and Full mouth), Space
Maintainers, Sealants, Healthy Smile, Healthy You* ,
Preventive benefits are not deducted from your annual
maximum
Deductible
Applies to basic and major services only – $50 per person,
$150 per family
Basic Services
Fillings, Oral Surgery, Endodontics, Periodontics
(20% after deductible)
Major Services (50% after
deductible)
Crowns, Dentures,Implants
Annual Maximum
The plan pays a maximum of $1,500 per year per covered
person
Orthodontics (50% after
deductible)
Covers dependent children up to age 19
Orthodontics Lifetime
Maximum
$1,000 (Exempt from the deductible)
Dependent Status
To the end of the month the dependent attains age 26
*Allows for one additional cleaning per year for members with diabetes, pregnant
members and those with certain heart conditions.
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Dental Employee Bi-Monthly Cost (24 pay periods)
Employee
Employee &
Employee &
Employee &
Employee &
Only
Child
Children
Spouse
Family
$1.10
$21.18
$21.18
$17.27
$37.36
BASIC LIFE INSURANCE
Luna Innovations provides it’s innovators with Basic Life and Accidental Death and
Dismemberment Insurance. Aetna life insurance will be administering this benefit this
year. The coverage that is provided is 2 times annual earnings to a maximum of
$500,000. Luna also provides dependent coverage in the amount of $2,000 for spouse
and $1,000 for children.
VOLUNTARY LIFE INSURANCE
Innovators who want to supplement their group life insurance benefits may purchase
additional coverage through Aetna. When you enroll yourself and/or your dependents in
this benefit, you pay the full cost through payroll deductions. You are able to purchase
life amounts in increments of $10,000 to a lesser of 5 times annual salary or $500,000.
The guarantee issue amount is the lesser of 3 times salary or $150,000. The guarantee
issue only applies when you are first eligible for coverage. If you do not apply within 31
days of first becoming eligible, you would need to submit for medical evidence of
insurability.
Your spouse can purchase coverage in $5,000 increments to the lesser of 50% of your
coverage or $250,000. Spouse guarantee issue is $20,000.
You also have the option to purchase life insurance on your dependent children until
they attain age 19, 25 if a full time student. You can purchase coverage in increments
of $2,000 to a $10,000 maximum.
All innovators have the option to increase coverage at open enrollment in $40,000
increments up to the guarantee issue without evidence of insurability. This option is
only available if you enrolled when first eligible.
Cost is based upon age and amount chosen. Please refer to the Aetna enrollment form for a detailed over view of the cost.
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DISABILITY INCOME BENEFITS
All Luna Innovations Innovators are provided with Short and Long Term Disability
Benefits through Aetna. In the event you become disabled due to injury or sickness,
disability income benefits are provided as a source of income. Disability benefits
received are treated as taxable income to innovators.
Benefits Begin
Benefits Payable
Percentage of Income
Replaced
Maximum Benefit
Short-Term Disability
Long-Term Disability
Day 8
After 90 days
12 weeks
Social Security Normal
Retirement Age
60%
60%
$1,000 per week
$10,000 per month
EMPLOYEE ASSITANCE PROGRAM
All employees have access to a counselor through Anthem’s employee assistance
program. This program offers 24/7 access for numerous issues. This program offers 4
face to face sessions per issue.
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FLEXIBLE SPENDING ACCOUNT
Want to enjoy additional tax relief—Enroll in
Luna Innovations Flexible Spending Account
and Premium Only Plan

Save up to 25 percent! Money put into the plan and used for
qualified expenses goes in tax free.


Dependent and health care expenses are eligible.


Get reimbursed for eligible out-of-pocket medical expenses such as
medical copays, Rx copays, glasses, contacts or contact solution,
dental or orthodontia services.
Pay Medical/Dental Premiums with pre-tax dollars
OTC medications are no longer an eligible expense unless you have
a prescription from your provider.
Take advantage of the opportunity to enroll during open
enrollment or within 30 days of a qualifying event.
Flexible Spending Account/Premium Only Calculator
On the next page is an example of how you can calculate your own medical and
dependent care expenses as well as the portion of premium you are paying. Once
you have estimated what your total medical, dental, vision, dependent care
expenses, and portion of premium that you are paying will be, add all of those
amounts up. Look to the chart on the right that is the tax estimate table. Multiply
total expenses by your tax bracket percentage to get your annual tax savings. Then
divide by your monthly paycheck to see the increase in spendable income!!!
Please note that if you have a Health Savings Account or will be
implementing one this year, you are not eligible to use the medical flex
account.
The maximum amount that employees can set aside in a medical account is
$2,300. The maximum amount for the dependent care account is $5,000 or
$2,500 if married and filing separately.
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Medical
Vision
Dental
Dependent Care
Expenses
Deductibles
$
Exams
$
Routine Exam
$
Children
$
Copays
$
Eye Surgery
$
Fillings/Crowns
$
Adults
$
Prescriptions
$
Lenses/Frames
$
Orthodontics
$
Over the
Counter Drugs
$
Contacts/Solutions
$
Other
$
Other
$
Other
$
Total
$
Total
$
$
Total
$
Total
$
Estimated Annual Expenses & Tax Savings
Total Medical + Vision + Dental Expenses
Total Dependent Care Expenses
Total Medical/Dental Premium
Total Expenses
Tax Bracket Percentage (see right)
Annual Tax Savings
Number of Pay Periods
Estimated Savings Amount Per Paycheck
$____
+____
+____
$____
X____
$____
/ ____
$____
T a x E s t i m a te T a b l e
Annual Household Earnings
Estimated Tax Rate
< $30,000
$30,000 - $40,000
25%
29%
$40,000 - $70,000
31%
> $70,000
33%
*Based on Social Security, federal, and state income
taxes. Rates are estimates based on national
averages and may not reflect your actual tax rate.
The information in this Enrollment Guide is presented for illustrative purposes and is based on information
provided by the employer and the insurance carriers. The text contained in this Guide was taken from various
summary plan descriptions and benefit information. While every effort was taken to accurately report your
benefits, discrepancies, or errors are always possible. In case of discrepancy between the Guide and the actual
plan documents the actual plan documents will prevail. All information is confidential, pursuant to the Health
Insurance Portability and Accountability Act of 1996. If you have any questions about your Guide, contact
Human Resources.
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QUESTIONS & ANSWERS
Changes that can be made effective January 1, 2012?









Enroll in the Medical plan.
Add or drop dependents in the Medical plan
Enroll in the Dental plan.
Add or drop dependents in the Dental plan.
Enroll yourself, spouse and dependent children in the Voluntary Life insurance plan.
Update Beneficiary
Complete Benefits Enrollment Worksheet. Make sure the emergency contact
information is updated on this form.
Re-enroll in the flexible spending account. All employees have to re-enroll if you
wish to participate in the flexible spending account.
This Guide is intended to be a Summary of Material Modification (SMM) for your
Benefit Plans. It explains changes being made to the plan effective January 1, 2012.
This is important information, so please keep this document with your Summary Plan
Description (SPD) and other benefits information.
How do I enroll?






You only need to fill out an Anthem form if you are enrolling for the first time
or making a change.
You only need to fill out a Delta Dental form if you are enrolling for the first
time or making a change.
If you are increasing voluntary life coverage by more than $40,000 (up to
the guarantee issue) or if you choose to enroll now and did not do so
when first eligible, you will need to submit evidence of insurability to
Aetna.
Everyone who chooses to participate in the flexible spending account will
have to re enroll and specify what amount is to come out of their
paycheck
Benefits Enrollment Worksheet - everyone needs to fill out
All forms are available on the Luna Innovations portal with the
exception of the Benefits Enrollment Worksheet.
What is the deadline to enroll in the benefits ?

All paperwork is due to HR by close of business on December 2 nd, 2011.
I am not enrolling in the benefits. Is there anything
that I need to do?


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You must still fill out the benefit enrollment worksheet. This form also has a
place to waive coverage and update emergency contact information.
If you are opting out of coverage, you need to complete the Opt Out Insurance
Form which can be found out on the portal.
Who do I contact with questions?
Contact Gail Sterner in Human Resources.
******* PLEASE NOTE: IT IS THE EMPLOYEE’S RESPONSIBILITY TO
REPORT ANY CHANGES TO HUMAN RESOURCES. EXAMPLES OF CHANGES
ARE; MARRIAGE, DIVORCE, ADDRESS CHANGE, PHONE NUMBER CHANGE,
ETC. THESE CHANGES MUST BE REPORTED TO HUMAN RESOURCES WITHIN
30 DAYS OF THE CHANGE.
Special Enrollment Notice
This notice is being provided to ensure that you understand your right to apply for
group health insurance coverage. You should read this notice even if you plan to
waive coverage at this time.
Loss of Other Coverage
If you are declining coverage for yourself or your dependents (including your
spouse) because of other health insurance or group health plan coverage, you
may be able to enroll yourself and your dependents in this plan if you or your
dependents lose eligibility for that other coverage (or if the employer stops
contributing toward you or your dependents’ other coverage). However, you
must request enrollment within 30 days after you or your dependents’ other
coverage ends (or after the employer stops contributing toward the other
coverage). There is a 60 day special enrollment period for employees and
their dependents if their Medicaid or CHIP coverage is terminated due to
loss of eligibility. Please note that program information about the
Medicaid and the Children’s Health Insurance program(CHIP) is located
out on the Luna Portal.
Example
You waived coverage because you were covered under a plan offered by your
spouse’s employer. Your spouse terminates his/her employment. If you notify your
employer within 30 days of the date coverage ends, you and your eligible
dependents may apply for coverage under our health plan.
Marriage, Birth, or Adoption
If you have a new dependent as a result of a marriage, birth, adoption or placement
for adoption, you may be able to enroll yourself and your dependents. However, you
must request enrollment within 30 days after the marriage, birth, or placement for
adoption.
Example
When you were hired by us, you were single and chose not to elect health insurance
benefits. One year later, you marry. You and your eligible dependents are entitled
to enroll in this group health plan. However, you must apply within 30 days from the
date of your marriage.
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For More Information or Assistance
To request special enrollment or obtain more information, please contact:
Name:
Human Resources
If you and your eligible dependents enroll during a special enrollment period, as
described above, you are not considered a late enrollee. Therefore, your group
health plan may not require you to serve a pre-existing condition waiting period of
more than 12 months. Any pre-existing condition waiting period will be reduced by
the time served in a qualified plan.
The Women’s Health and Cancer Rights Act of
1998
Important Notice
In October 1998, Congress enacted the Women’s Health and Cancer Rights
Act of 1998. This notice explains some important provisions of the Act.
Please review this information carefully.
As specified in the Women’s Health and Cancer Rights Act, a plan participant or
beneficiary who elects breast reconstruction in connection with a mastectomy is
also entitled to the following benefits:
1. Reconstruction of the breast on which the mastectomy has been
performed;
2. Surgery and reconstruction of the other breast to produce a symmetrical
appearance; and
3. Prosthesis and treatment of physical complications in all stages of
mastectomy, including lymphedemas.
Health plans must determine the manner of coverage in consultation with
the attending physician and the patient. Coverage for breast
reconstruction and related services may be subject to deductibles and
coinsurance amounts that are consistent with those that apply to other
benefits under the plan.
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