Employee Benefits Guide - Hurst-Euless

Transcription

2016-2017
Employee Benefits Guide
Plan Year
September 1, 2016 – August 31, 2017
1849 Central Drive
Bedford, TX 76022
Phone (817) 399-2056
Fax (817) 864-0617
[email protected]
www.hebisd.edu
Benefit
Contact Information
Contact Name
HEB ISD Benefits Office
Maria Ortiz
403b
The Omni Group
457b
Cancer
Contact #
Website or Email Address
817-399-2056
[email protected]
Fax 817-864-0617
877-544-6664
www.omni403b.com
TCG Administrators
800-943-9179
http://tcgservices.com/documents/#/255/457b
Allstate - Terry Barber
817-479-0065
www.allstatebenefits.com/mybenefits
Fax 817-605-0084
Group# 982
Group# 2489
DHMO
888-877-7828
www.ldc.lfg.com
800-423-2765
www.lincolnfinancial.com
800-368-1135
www.standard.com
888-293-6948
www.eapbda.com
800-422-4661
www.tasconline.com
GAP Plan
Group# 4102-8123-4032
Special Insurance Serv.
Group#27158
800-767-6811
www.specialinc.com
Health Savings Account
HSA Bank
800-357-6246
www.hsabank.com
Accidental Death &
Dismemberment Life
800-423-2765
Term Life Insurance
800-423-2765
Aetna – Medical
Caremark – Pharmacy
Teladoc
24 Hour Nurse Line
Beginning Right
Maternity Program
Scott & White Health
800-222-9205
800-222-9205
855-TELADOC
800-556-1555
www.trsactivecareaetna.com
24 Hour Nurse Line
877-505-7947
LegalEase
Superior Vision
888-416-4313
www.legaleaseplan.com/content/heb
800-923-6766
www.superiorvision.com
Dental
(Lincoln Financial)
Group# 40-D026226
PPO
Low - Group#01-D026217
High- Group# 01-D026225
Disability
The Standard
Employee Assistance
Program (EAP)
The Standard
Flexible Spending
(TASC)
Life Insurance
(Lincoln Financial)
Group# 00-648769-0001
BDA – Bensinger, DuPont
& Assoc.
Dependent Day Care
& Medical
Reimbursement
Group# 40-3002157
Group# 000400175244
Medical ActiveCare
1-HD, 2 or Select
Medical HMO
PrePaid Legal Services
Vision
www.caremark.com/trsactivecare
www.teladoc.com
800-272-3531
800-321-7947
Group# 30978
www.trs.swhp.org
Disclosure
This booklet is intended to only be an overview of the benefits plans offered by Hurst Euless Bedford ISD. Complete details
about how the plans work are included in the plan documents. If there are any inconsistencies between the booklet and the
plan documents, the plan documents will govern. The District reserves the right to change benefits plans at any time. Please
visit www.hebisd.edu and click on Benefits for more detailed documents.
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Benefit Enrollment Instructions
HOWDOIENROLLONLINE?
You will sign up for all benefits through our online enrollment system, www.in‐roll.com ESTABLISH YOUR SECURE PASSWORD To change your password you must enter a new one that is case sensitive, requires at least one number, between 5 and 20 characters. User Name Your user name will be the first initial of your first name, followed by your entire last name, followed by the last 4 digits of your SS# (no spaces and all lower case). Example: Robert Smith SS# 123‐45‐6789 User Name: rsmith6789 Be sure to change your password to something that is easy to remember, yet secure, as you will be the only one with access to it. Once you have successfully changed your password you will be directed to a Welcome Page where you will be able to continue with the enrollment process. Password Your default password for the initial log in will be hebisd 3
Annual Benefit Enrollment
HEB ISD OPEN ENROLLMENT IS JULY 25, 2016 – AUGUST 19, 2016
During your annual enrollment period, you have the opportunity to review, change, add or continue benefit
elections each year. You may also add or drop your spouse and/ or dependent children. You must verify your
address is correct and that we have the social security number for every dependent. This is also a great time
to update your beneficiary information. Login to www.in-roll.com to complete your enrollment.
Benefit elections will become effective September 1, 2016.
PRESENTATION SCHEDULE & ENROLLMENT ASSISTANCE
Below are the dates the Benefits Office will conduct presentations of all the benefits available. Each of these
presentations will last approximately one hour and will touch on all the benefits we offer at HEB ISD. We will
also focus on any changes we plan to make for the 2016-2017 school year. Immediately following the
presentation, we will have an open computer lab for you to login and enroll for benefits. This is a perfect
opportunity to get individual assistance if you have many questions.
If you are not able to attend a summer presentation/enrollment session, we will visit every campus during the
Professional Development week in August. We will spend two hours at each campus and help you login to the
enrollment website and select your benefits for the 2016-2017 school year.
Date
Wednesday, July 27
Presentation
2:00 pm
Enrollment Assistance
3:00 pm
10:00 am
1:00 pm
9:00 am
2:00 pm
10:00 am
11:00 am
2:00 pm
10:00 am
3:00 pm
11:00 am
Monday, August 1
Wednesday, August 3
Thursday, August 4
Monday, August 8
Tuesday, August 9
Location
Pat May Center
Buinger CTE Academy
Buinger CTE Academy
Buinger CTE Academy
Door prizes
will be given
away at each
presentation!
Buinger CTE Academy
Buinger CTE Academy
OPEN ENROLLMENT CAMPUS SCHEDULE
We will visit each campus for approximately two hours to help employees enroll online. If you have many questions, we
would encourage you to visit with us during our late July/early August enrollment.
Date
Time
Location
Location
Thursday, August 11th
10:30 am - 12:30 pm
BCTEA
Harrison Lane
2:00 pm - 4:00 pm
Meadow Creek
Hurst Jr.
Friday, August 12th
2:00 pm - 4:00 pm
Bell Manor
Bedford Jr.
Monday, August 15th
2:00 pm - 4:00 pm
Keys
Harwood Jr.
Tuesday, August 16th
8:00 am - 10:00 am
10:30 am - 12:30 pm
2:00 pm - 4:00 pm
Viridian
Spring Garden
LD Bell
Shady Brook
Oakwood Terrace
Wednesday, August 17th
8:00 am - 10:00 am
10:30 am - 12:30 pm
2:00 pm - 4:00 pm
Bellaire
Wilshire
Hurst Hills
Donna Park
Thursday, August 18th
8:00 am - 10:00 am
10:30 am - 12:30 pm
2:00 pm - 4:00 pm
River Trails
Shady Oaks
Trinity
West Hurst
S. Euless
Friday, August 19th
8:00 am - 10:00 am
10:30 am - 12:30 pm
2:00 pm - 4:00 pm
Lakewood
Midway Park
Central Jr.
Stonegate
N. Euless
Euless Jr.
4
Bedford Heights
Annual Benefit Enrollment Continued…
BENEFIT UPDATES – WHAT’S NEW OR CHANGING
HEALTH INSURANCE – PREMIUM & BENEFIT CHANGES
ActiveCare 1 - HD
Current Rates
New Rates
Difference
Plan Design Changes
Old
$6,450
$12,900
New
$6,550
$13,100
Difference
Current Rates
New Rates
Difference
Employee Only
Employee & Spouse
Employee & Child(ren)
Employee & Family
Individual Out of Pocket Maximum
Family Out of Pocket Maximum
ActiveCare Select
Employee Only
Employee & Spouse
Employee & Family
Plan Design Changes
Retail Maintenance Prescriptions
Generic
Preferred Brand
Non-Preferred Brand
ActiveCare 2
Employee Only
Employee & Spouse
Employee & Family
Plan Design Changes
Retail Maintenance Prescriptions
Generic
Preferred Brand
Non-Preferred Brand
$116
$689
$390
$1,006
$248
$897
$537
$1,106
Old
$116
$689
$390
$1,006
$259
$922
$554
$1,136
$0
$0
$0
$0
$100
$200
$11
$25
$17
$30
$6,600
$13,200
$6,850
$13,700
New
Difference
Old
New
Difference
Current Rates
New Rates
Difference
$25
$50
50%
$389
$1,253
$767
$1,296
Old
$35
$60
50%
$420
$1,327
$817
$1,372
$250
$500
$10
$10
0%
$31
$74
$50
$76
$6,600
$13,200
$6,850
$13,700
New
Difference
Old
New
Difference
$25
$50
$80
5
$35
$60
$90
$250
$500
$10
$10
$10
Scott & White HMO
Employee Only
Employee & Spouse
Employee & Family
Plan Design Changes
Individual Deductible
Family Deductible
Current Rates
$278.60
$910.62
$573.30
$1,034.76
Old
$800
$2,400
Primary Care Office Visit Copay
$20
Durable Medical Equipment
50%
Manipulative Therapy
n/a
Prescription Drugs - Specialty Medications
10%, 20%, 30% & 50%
New Rates
Difference
New
Difference
$305.16
$967.82
$614.16
$1,097.98
$1,000
$3,000
$20; first visit copay for
illness waived
20%
New benefit; 20%
without office visit, $40
plus 20% with office
visit
20%
$26.56
$57.20
$40.86
$63.22
$200
$600
-30%
ACTIVECARE 1-HD GENERIC PREVENTIVE DRUG COVERAGE
Certain generic preventive drugs are available at no cost to participants. The deductible and coinsurance do
not apply to these generic medications. Particular generic medications for coronary artery disease,
diabetes, hypertension, antidepressants, osteoporosis and more are available at no cost to members
on 1-HD. Visit www.trsactivecareaetna.com/coverage for a complete list. Please note this list may change
from time to time based upon the interpretation of the Internal Revenue Service regulations.
ACTIVECARE 1-HD OUT OF POCKET MAXIMUM
ActiveCare 1-HD out-of-pocket maximum will work the same as the maximum in the other plan options. That
is, it will apply to each covered person individually, up to the maximum per family. The individual out-of-pocket
maximum only includes covered expenses incurred by that individual. After each covered person meets his or
her individual out-of-pocket maximum, the plan pays 100 percent of the benefits for that person.
MEET ALEX
ALEX is an online tool you can use to learn more about TRS-ActiveCare plan options (not HMO). ALEX collects
some simple information and walks you through benefits, features and costs – without all the insurance jargon.
ALEX can:
•
•
•
•
Help you understand and compare plan options
Explain health benefits terms
Show you how different plan features work – deductibles, coinsurance, out-of-pocket maximums
Walk you through estimating tax savings with a health savings account (if you are considering the
ActiveCare 1-HD plan)
ALEX will summarize his recommendations on your own personal benefits web page. Just click the link to
restart the conversation any time.
To use the tool, visit https://www.myalex.com/trsactivecare/2016#intro
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GROUP TERM LIFE INSURANCE
The plan offers you and your dependents an excellent opportunity to purchase affordable term life insurance
on a payroll deduction basis. Employees must be enrolled in the voluntary term life in order to enroll
dependents on the plan. This plan is age banded.
 Employees can increase and/or elect up to an additional $20,000 with no medical questions
 Spouses can increase and/or elect up to an additional $10,000 with no medical questions
HEALTH SAVINGS ACCOUNT (HSA)
The maximum contribution per year for family coverage increased by $100.
Individual
Family
Under 55
$3,350
$6,750
Age 55+
$4,350
$7,750
FLEXIBLE SPENDING PLANS
If you currently have the Flexible Spending Plan (Medical Reimbursement and/or Dependent Care
Reimbursement) you must re-enroll every year. Failure to re-enroll will result in your plan being cancelled as
of August 31, 2016.
OPEN ENROLLMENT DOCUMENTS
For more information about open enrollment and enrollment documents, please visit www.hebisd.edu.
Click on Employees Corner then choose Employee Benefits on the left hand menu. Click on Forms, Plans
& Resources and then choose the Open Enrollment folder.
NOTE
If you plan to have a life event (i.e. surgery, baby, medical leave, etc.) during the next plan year, please
contact Karen Rose in the Benefits Office for assistance with plan changes. We want to make sure the changes
you make to your insurance will not have a negative impact on you.
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New Hires
PLAN YEAR
The plan year for all benefits is September 1st through August 31st.
EFFECTIVE DATES FOR INSURANCE
•
•
Health Insurance can begin your 1st day of employment or the 1st of the following month.
All other benefits will automatically begin the 1st of the monthly following your 1st day of
employment.
NEW HIRES
New hires must enroll in benefits within 30 days of their hire date. Failure to complete elections
during this timeframe will result in the forfeiture of coverage.
ANNUAL ENROLLMENT
During our annual enrollment period (typically held in mid-July through mid-August), you have the
opportunity to review, change or continue benefit elections each year. Changes are not permitted
during the plan year unless a Section 125 qualifying event occurs.
TEACHER RETIREMENT SYSTEM OF TEXAS (TRS)
HEB ISD requires all employees to participate in TRS instead of Social Security. The membership
contribution rate is 7.7% of your annual salary. You may contact TRS by calling 1-800-223-8778 or
www.trs.state.tx.us to learn more about TRS Retirement.
TRS INSURANCE (TRS INS)
Mandatory active member contribution to TRS-Care (Health Insurance for retirees) is .65% of your
annual salary.
EMPLOYEE ELIGIBILITY REQUIREMENTS
Eligible employees must work 20 or more regularly scheduled hours each work week.
ELIGIBLE DEPENDENTS
• Spouse (including common law spouse)
• Child under the age of 26
• Disabled dependent children over the age of
•
documentation of their disability.
26 are eligible for benefits if you can provide
Grandchildren are eligible for benefits if you can provide documentation that you are their
legal guardian or that you claimed them as a dependent on your tax return.
The em ployee is responsible for notifying the B enefits Office w hen their child no longer m eets
the dependent child qualifications.
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PAYCHECKS
•
•
Professional and paraprofessional employees receive a paycheck on the 20th of each month.
Auxiliary employees receive a paycheck on the 5th and 20th of each month. One half of your
monthly premium will be taken out of each paycheck.
ABSENCES
•
•
•
•
•
See Policy DEC (Local & Regulation)
All full time employees in eligible positions receive 5 local sick leave days and 5 state
personal leave days per school year and may accumulate without limit.
Personal and local sick leave days are prorated based on the actual time employed.
Medical certification (doctor’s note) must be provided if:
 The employee is absent more than 4 consecutive work days because of
personal illness or illness in the immediate family
 There is a questionable pattern of absences
 The employee requests FMLA leave
If you need to be out for more than 4 consecutive work days or want to request FMLA,
please contact:
Karen Rose
Benefits & Risk Manager
(817) 399-2056
[email protected]
LONG TERM CARE
•
•
•
TRS offers a Long Term Care plan through Genworth Life Insurance Co.
Long Term Care is insurance that will help pay for services provided by Assisted Living
Facilities, Nursing Homes, etc.
If you are interested in enrolling in the Long Term Care plan or have questions, please call
866-659-1970 or visit www.genworth.com/trsactivemember
EMPLOYEE ACCESS CENTER
From the Employee Benefits website, you can log on to the Employee Access Center to change your
address, view your paycheck stubs, see your current salary and benefit information and much
more! Your login is your 6 digit unique HEB ID number and your default password is your Social
Security Number without the dashes.
You may also download the app for your phone by searching for eFinance Plus Employee in your
app store. Type in “Hurst” as the employer name and then select “Hurst-Euless-Bedford
Independent SD”. Follow the login instructions to view your account.
EMPLOYEE BENEFITS WEBSITE
You can find the most current information and claim forms on the HEB website. Visit
www.hebisd.edu. Click on the Careers link at the top of the page, then choose Employee Benefits
on the left hand column.
EMPLOYEE BENEFITS FACEBOOK
We have created a HEB ISD Employee Benefits Facebook account. Please visit
http://www.facebook.com/hebbenefits and “Like” our page.
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Changing Your Benefits
SECTION 125 CAFETERIA PLAN GUIDELINES/FAMILY STATUS CHANGES
A cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance
premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this
benefit. Elections made during annual enrollment will become effective on the plan effective date
and will remain in effect during the entire plan year.
Changes in benefit elections can occur only if you experience a qualifying event. You must:
1. Present proof of a qualifying event to the Benefits Office within 30 days of the qualifying
event and
2. Meet with the Benefits Office to complete and sign necessary paperwork in order to make a
benefit election change.
3. Once your paperwork is received and processed you will receive a confirmation statement
from the Benefits Office. If you do not receive a confirmation statement within 3 days,
contact the Benefits Office immediately!
Benefit changes must be consistent with the qualifying event. As an example, adding or dropping
medical plan dependents is common in the case of birth, marriage, or divorce.
Qualifying events include:
Event
Documentation Needed
Marriage
Marriage License
Divorce
Divorce Decree
Death of spouse/child
Death Certificate
Birth or Adoption of a child
Birth Certificate/Adoption Paperwork
Spouse changes employment resulting in
the gain of employer provided coverage
Written letter on company letterhead
indicating the hire date and the effective
date of your insurance
You, your spouse or child involuntarily
loses health insurance coverage
Documentation from the insurance
company or previous employer indicating
the date the insurance ended
Eligible/ineligible for Medicare/Medicaid
Documentation from Medicare/Medicaid
Change in eligibility status of a dependent
(age, employment, or tax dependent)
Note indicating the change in eligibility
status
Judgment/decree/order for coverage of
children
Court order
If you do not request a change in benefits within the 30-day period following your qualifying
event, you cannot make changes until the next open enrollment period.
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Workers Compensation
Employee Notice of Alliance Requirements
IMPORTANT CONTACT INFORMATION
To locate a provider, go to www.pswca.org.
To contact your adjuster at the TASB Risk Management Fund, visit www.tasbrmf.org or call (800) 482-7276.
INFORMATION, INSTRUCTIONS, RIGHTS, AND OBLIGATIONS
If you are injured at work, tell your supervisor or employer immediately. The information in this notice will help you to seek medical
treatment for your injury. Your employer will also help with any questions about how to get treatment. You may also contact your
adjuster at the TASB Risk Management Fund (the Fund) for any questions about treatment for a work related injury. The Fund is
your employer’s workers’ compensation coverage provider and they are working with your employer to ensure you receive timely
and appropriate health care. The goal is to return you to work as soon as it is safe to do so.
HOW DO I CHOOSE A TREATING DOCTOR?
If you are hurt at work and you live in the Alliance service area, you are required to choose a treating doctor from the provider
list. This is required for you to receive coverage of healthcare costs for your work related injury. A provider listing is available
through the Alliance website at www.pswca.org and a link to that site is also contained on the Fund’s website at www.tasbrmf.org.
It identifies providers who are taking new patients.
HOW DO I CHANGE TREATING DOCTORS?
Within the first 60 days of beginning treatment, if you become dissatisfied with your first choice of a treating doctor, you can select
an alternate treating doctor from the list of Alliance treating doctors in your service area. The Fund will not deny a choice of an
alternate treating doctor. However, before you can change treating doctors a second time, you must obtain permission
from your adjuster.
WHO PAYS FOR THE HEALTHCARE?
Alliance providers have agreed to seek payment from the Fund for your health care. They should not request payment from you.
If you obtain health care from a doctor who is not in the Alliance without prior approval from your adjuster, you may have to pay
for the cost of that care and your income benefits may be disputed. You may treat with medical providers that are not contracted
with the Alliance only if one of the following situations occurs:
- Emergencies: You should go to the nearest hospital or emergency care facility.
- You do not live within an Alliance service area.
- Your treating doctor refers you to a provider or facility outside of the Alliance. This referral must be approved by your
adjuster.
WHAT TO DO WHEN YOU ARE INJURED ON THE JOB
If you are injured while on the job, tell your employer as soon as possible. A list of Alliance treating doctors in your service area
may be available from your employer. A complete list of Alliance treating doctors is also available online at www.pswca.org. Or,
you may contact us directly at the following address and/or toll-free telephone number:
TASB Risk Management Fund
P.O. Box 2010
Austin, TX 78768
(800) 482-7276
IN CASE OF AN EMERGENCY…
If you are hurt at work and it is a life threatening emergency, you should go to the nearest emergency room. If you are injured at
work after normal business hours or while working outside your service area, you should go to the nearest care facility. After you
receive emergency care, you may need ongoing care. You will need to select a treating doctor from the Alliance provider list. This
list is available online at www.pswca.org. If you do not have internet access call (800) 482-7276 or contact your employer for a
list. The doctor you choose will oversee the care you receive for your work related injury. Except for emergency care you must
obtain all health care and specialist referrals through your treating doctor.
NON-EMERGENCY CARE…
Report your injury to your employer as soon as you can. Select a treating doctor from the Alliance provider list. This list is available
online at www.pswca.org. If you do not have internet access, call (800) 482-7276 or contact your employer for a list.
11
Sick Leave Bank Summary
P LEASE R EFER TO P OLI CY D EC (L OCAL & R EG ULATI ON ). BELOW IS ONLY A GENERAL SUMMARY OF THE POLICY.
•
The purpose of the sick leave bank is to provide additional sick leave days for members of the bank who
have exhausted all available paid leave because of the catastrophic injury or illness of the employee or the
employee’s immediate family member
•
In order to become a member of the sick leave bank, an employee must donate 3 days of local leave.
This is a one-time donation. Additional days may be needed, please see the policy for more details
•
All local sick, state personal, old state and vacation days must be exhausted before days from the sick
leave bank may be used
•
Sick leave bank days are available to use for an employee, spouse, or child’s illness or injury or for a
parent receiving hospice or end-of-life care
•
Employee must be absent for no fewer than 20 workdays in order to be eligible to request days from
the sick leave bank
•
Applications for sick leave bank must be submitted within 15 workdays from the first date of missed work
or 15 days prior to the exhaustion of all available leave days
•
Maximum # of days that can be used:
1. Employee’s illness – 30 days per school year
2. Spouse or child’s illness – 30 days per school year; 60 days lifetime maximum
3. Parent -10 days per school year; 20 days lifetime maximum
•
A committee will determine whether the request for sick leave days is approved or denied
•
Qualifying Illness/Injury
1. Catastrophic illness or injury is a severe condition or combination of conditions affecting the mental
or physical health of the employee or a member of the employee’s immediate family that requires
the services of a licensed practitioner for a prolonged period of time and that forces the employee
to exhaust all leave time earned by that employee and to lose compensation from the District. Such
conditions typically require prolonged hospitalization or recovery; not a passing disorder or
temporary ailment; or are expected to result in disability or death.
2. Complications of pregnancy and childbirth that pose an immediate medical threat
3. Cancer-related intermittent treatment (i.e. chemo, radiation)
•
Members of the bank who, during the previous school year, found it necessary to use the benefits of the
bank must donate three days or the actual number of days used, whichever is less, at the beginning of the
next school year.
Not Covered:
1. Procedure that could be scheduled, without detriment to the employee’s health, at a time more
compatible with the member’s work responsibilities (i.e. Spring Break, Summer, Christmas Break)
2. Pre-existing Conditions – Absences caused by conditions existing at the time of application for bank
membership will not be covered for one year from the date of enrollment in the bank
3. Examples of conditions that are not covered – Hysterectomy, joint replacement (hip, knee, shoulder,
etc.), general illness (flu, cold, etc.), non-complicated pregnancy, broken bone, general surgery, etc.
12
Employee Assistance Program (EAP)
Employee Assistance Program
Pointing You In The Right Direction
Free/No Cost
We all experience times when we need a little help managing our personal
lives. Your employer understands this and is providing the Employee
Assistance Program (EAP) to covered employees in connection with
your group insurance from The Standard‡, to offer support, guidance and
resources to help you and your family find the right balance between
your work and home life.
What Can The EAP Do For Me?
Experienced master’s-degreed clinicians will confidentially consult with you
over the telephone and direct you to the solutions and resources you need.
You may also receive referrals to support groups, community resources,
a network counselor or your health plan. These services are available for
covered employees, their dependents, including children to age 26, and all
household members.
The EAP Services Can Help With:
•
Child care and elder care
•
Alcohol and drug abuse
•
Life improvement
•
Difficulties in relationships
•
Stress and anxiety with work or family
•
Depression
•
Goal-setting
•
Emotional well-being
•
Financial and legal concerns
•
Grief and loss
•
Identity theft and fraud resolution
•
Online will preparation
Call 888.293.6948 or visit
www.eapbda.com.
The EAP is always ready to
assist you. We’ve also
provided a handy reference
card for your wallet.
How To Access EAP Online
1. Enter this address in your Web browser:
www.eapbda.com
2. Enter standard as the login ID (in all lowercase letters)
when prompted.
3. Enter eap4u as the password (in all lowercase letters)
when prompted.
Note: It is a violation of your company’s contract to share
this information with individuals who are not eligible for
this service.
Fold
EAP For Policyholders of The Standard
Call this toll-free number for access
to EAP services.
888.293.6948
TDD 800.327.1833
Available 24 hours a day, 365 days a year.
How Do I Access EAP Services?
Follow the directions on the wallet card on this page.
Is It Confidential?
Your calls and all counseling services are confidential. Information will be
released only with your permission or as required by law.
continued on reverse
Standard Insurance Company
The Standard Life Insurance
Company of New York
This EAP service is not affiliated with The Standard. The EAP service is not an insurance product.
‡ The Standard is a marketing name for StanCorp Financial Group, Inc. and subsidiaries. Insurance products are
offered by Standard Insurance Company of 1100 SW Sixth Avenue, Portland, Ore., in all states except New York,
where insurance products are offered by The Standard Life Insurance Company of New York of 360 Hamilton
Avenue, Suite 210, White Plains, NY. Product features and availability vary by state and company, and are solely
the responsibility of each subsidiary. Each company is solely responsible for its own financial condition. Standard
Insurance Company is licensed to solicit insurance business in all states except New York. The Standard Life
Insurance Company of New York is licensed to solicit insurance business in only the state of New York.
13
www.standard.com
Employee Assistance Program-3
17201 (5/14) SI/SNY EE
When Is The EAP Available?
Over-the-phone consultation and online access to EAP services
are always available. Simply call the toll-free number or log on to
www.eapbda.com. In emergency situations, you may call the toll-free
number to speak with a master’s-degreed clinician who can also connect
you to emergency services.
Your program also includes up to three face-to-face assessment and
consultative sessions per issue. A clinician will work with you to schedule
appointments according to your needs.
What Can WorkLife Services Do For Me?
WorkLife services can save you countless hours by researching and
providing referrals for important needs like:
•
Child care and elder care
•
Education
•
Adoption
•
Pet care
•
Daily living
•
Travel
A broad range of educational materials and guide books on dependent
care topics are also available.
How Much Does It Cost?
The EAP and WorkLife services are provided to you in connection with your
employer-sponsored group insurance from The Standard. If you accept a
referral to services that are not a part of your EAP program, you may be
responsible for the costs associated with those services.
All The Help You Need Online
The EAP provides the following online services:
•
Informative guides and articles
•
Monthly webinars and bulletins
•
Ability to search on your own for:
−
Child care or elder care services
−
Pet care
−
Adoption resources
•
Detailed maps for every search
•
Self-assessments
•
Healthy lifestyle guidance, from tools for diet and fitness to smoking cessation
•
Videos and articles on topics like understanding depression, nutrition
advice and preparing for childbirth
•
Financial and legal information, including a program for completing a
simple will and identity theft consultation recovery and prevention services
•
Detailed calculators used to help solve common financial concerns, such
as computing college finances
14
Health Insurance
ActiveCare 1-HD, 2 & Select – Aetna
800-222-9205
HMO – Scott & White
800-321-7947
www.trsactivecareaetna.com
In Network Benefits
ActiveCare 1-HD$
Medical Benefits
Deduct ible m ust be m et
before ben efits are paid
(Participant Pays)
$2,500 employee only
$5,000 family
Deductible
Maximum Out of Pocket
(Includes medical &
prescription deductibles,
coinsurance & copays)
$6,550 individual
$13,100 family
Coinsurance
ActiveCare 2
(Participant Pays)
$1,000 individual
$3,000 family
20%
Preventive Care
(after deductible)
Plan pays 100%
ActiveCare Select+
(Participant Pays)
Scott & White
HMO#
No out of netw ork
benefits
No out of netw ork
benefits
$1,200 individual
$3,600 family
$1,000 individual
$3,000 family
(Participant Pays)
$6,850 individual
$13,700 family
$6,850 individual
$13,700 family
20%
20%
20%
$30 copay - primary
$50 copay - specialist
$30 copay - primary
$20 copay - primary
Plan pays 100%
Plan pays 100%
Plan pays 100%
20%
Participant pays (after deductible)
Office Visit Copay
www.trs.swhp.org
$5,000 individual
$10,000 family
Quest Facility-plan pays Quest Facility-plan pays
100% (deductible waived) 100% (deductible waived)
Other Facility-20%*
Other Facility-20%*
Diagnostic Lab
20%
(after deductible)
High-tech Radiology
20%
(after deductible)
$100 copay & 20%*
$100 copay & 20%*
20%*
Outpatient Surgery
20%
(after deductible)
$150 copay & 20%*
$150 copay & 20%*
$150 copay & 20%*
Emergency Room
20%
(after deductible)
$150 copay & 20%*
$150 copay & 20%*
$150 copay & 20%*
Inpatient Hospitalization
20%
(after deductible)
$150 copay/day & 20%*
$150 copay/day & 20%*
$150 copay/day & 20%*
$40 consultation fee
Plan pays 100%
Plan pays 100%
Not covered
Subject to medical
deductible
$0 for generic drugs
$200 per person
$200 per person
$100 per person
Retail
Retail
Teladoc
Prescription Drugs
Drug Deductible
Generic
Brand (preferred list)
Brand (non-preferred list)
Specialty Drugs
Certain generic preventive
drugs are available at no cost
20%
20%
20%
(after deductible)
20%
(after deductible)
(after deductible)
(after deductible)
Mainte
nance
$20
$40
$65
$35
$60
$90
90Days
$45
$105
$180
31-day supply: $200
32-90 day supply: $450
Monthly
Sem iM onthly
$20
$40
50%
Mainte
nance
90-Days
$35
$60
50%
$45
$105
50%
20%
20%*
Retail
90-Days
$3
30%
50%
$6
30%
50%
20%
Premiums
Monthly
Sem iM onthly
Monthly
Sem iM onthly
Monthly
Sem iM onthly
Employee Only
$116.00
$58.00
$420.00
$210.00
$259.00
$129.50
$305.16
$152.58
Employee & Spouse
$689.00
$344.50
$1327.00
$663.50
$922.00
$461.00
$967.82
$483.91
$390.00
$195.00
$817.00
$408.50
$554.00
$277.00
$614.16
$307.08
Employee & Family
$1006.00
$503.00
$1372.00
$686.00
$1136.00
$568.00
$1097.98
$548.99
*After the deductible has been met
$
Qualifies as a high deductible health plan; therefore, you may enroll in a Health Savings Account
+
#
Visit www.trsactivecareaetna.com to search for providers. Choose the Baylor Scott & White Quality Alliance (DFW Area)
option to search for providers in the Select plan
Visit www.trs.swhp.org to search for providers in the Baylor Scott & White HMO plan
Visit w w w .trsactivecareaetna.com to dow nload the Enrollm ent Guide
15
2016 – 2017 TRS-ActiveCare Plan Highlights
Effective September 1, 2016 through August 31, 2017 | In-Network Level of Benefits*
ActiveCare 1-HD
Type of Service
ActiveCare Select or ActiveCare
Select Whole Health
ActiveCare 2
(Baptist Health System and HealthTexas
Medical Group; Baylor Scott & White Quality
Alliance; Memorial Hermann Accountable
Care Network; Seton Health Alliance)
Deductible
(per plan year)
$2,500 employee only
$5,000 family
$1,200 individual
$3,600 family
$1,000 individual
$3,000 family
Out-of-Pocket Maximum
(per plan year; does include medical deductible/
any medical copays/coinsurance/any
prescription drug deductible and applicable
copays/coinsurance)
$6,550 individual
$13,100 family
(the individual out-of-pocket maximum
only includes covered expenses incurred
by that individual)
$6,850 individual
$13,700 family
$6,850 individual
$13,700 family
Coinsurance
Plan pays (up to allowable amount)
Participant pays (after deductible)
80%
20%
80%
20%
80%
20%
Office Visit Copay
Participant pays
20% after deductible
$30 copay for primary
$60 copay for specialist
Diagnostic Lab
Participant pays
Plan pays 100% (deductible waived) if
performed at a Quest facility; 20% after
deductible at other facility
Plan pays 100% (deductible waived) if
performed at a Quest facility; 20% after
deductible at other facility
Preventive Care
See reverse side for a list of services
Plan pays 100%
Plan pays 100%
Plan pays 100%
Teladoc® Physician Services
$40 consultation fee (applies to
Plan pays 100%
deductible and out-of-pocket maximum)
Plan pays 100%
High-Tech Radiology
(CT scan, MRI, nuclear medicine)
Participant pays
$100 copay plus 20% after deductible
Inpatient Hospital
(preauthorization required)
(facility charges)
Participant pays
$150 copay per day plus 20% after deductible
($750 maximum copay per admission)
$150 copay per day plus 20% after deductible
($750 maximum copay per admission;
$2,250 maximum copay per plan year)
Emergency Room (true emergency use)
Participant pays
(copay waived if admitted)
(copay waived if admitted)
Outpatient Surgery
Participant pays
$150 copay per visit plus 20% after
deductible
$150 copay per visit plus 20% after
deductible
Bariatric Surgery
Physician charges (only covered if performed
at an IOQ facility)
Participant pays
$5,000 copay plus 20% after deductible
Not covered
$5,000 copay (does not apply to outof-pocket maximum) plus 20% after
deductible
Prescription Drugs
Drug deductible (per plan year)
Subject to plan year deductible
$200 per person for brand-name drugs
$200 per person for brand-name drugs
Retail Short-Term
(up to a 31-day supply)
Participant pays
• Generic copay
• Brand copay (preferred list)
• Brand copay (non-preferred list)
(deductible and coinsurance waived
for certain generic preventive drugs.
Go to www.trsactivecareaetna.com/
coverage to view the list).
$20
$40**
50% coinsurance**
$20
$40**
$65**
Retail Maintenance
(after first fill; up to a 31-day supply)
Participant pays
• Generic copay
$35
$60**
50% coinsurance**
$35
$60**
$90**
Mail Order and Retail-Plus
Participant pays
• Generic copay
$45
$105**
50% coinsurance**
$45
$105**
$180**
Specialty Drugs
Participant pays
20% coinsurance per fill
$200 per fill (up to 31-day supply)
$450 per fill (32- to 90-day supply)
A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available;
there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts
exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. **If the patient obtains a brand-name drug when a generic equivalent
is available, the patient will be responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug.
16
2016 – 2017 TRS-ActiveCare Plan Highlights
TRS-ActiveCare Plans – Preventive Care
In-Network Benefits
When Using In-Network Providers
(Provider must bill services as “preventive care”)
Preventive Care Services
ActiveCare 1-HD
ActiveCare Select or
ActiveCare Select
Whole Health
ActiveCare 2 Network
(Baptist Health System and
HealthTexas Medical Group; Baylor
Scott & White Quality Alliance;
Memorial Hermann Accountable
Care Network; Seton Health Alliance)
Plan pays 100% (deductible
waived)
waived; no copay required)
waived; no copay required)
Some examples of preventive care
frequency and services:
• Routine physicals – annually age
12 and over
• Well-child care – unlimited up to
age 12
• Well woman exam & pap smear –
annually age 18 and over
• Mammograms – 1 every year age
35 and over
• Colonoscopy – 1 every 10 years
age 50 and over
• Prostate cancer screening –
1 per year age 50 and over
• Smoking cessation counseling –
8 visits per 12 months
• Healthy diet/obesity counseling –
unlimited to age 22; age 22 and
over-26 visits per 12 months
• Breastfeeding support –
6 lactation counseling visits per
12 months
12 and over
age 12
35 and over
age 50 and over
12 months
12 and over
age 12
35 and over
age 50 and over
12 months
Annual Vision Examination
(one per plan year; performed by an opthalmologist or optometrist
using calibrated instruments)
Participant pays
After deductible, plan pays 80%;
participant pays 20%
Annual Hearing Examination
Participant pays
After deductible, plan pays 80%;
participant pays 20%
Evidence−based items or services that have in effect a rating
of “A” or “B” in the current recommendations of the United
States Preventive Services Task Force (USPSTF) http://www.
uspreventiveservicestaskforce.org/Page/Name/uspstf-a-andb-recommendations.
Immunizations recommended by the Advisory Committee on
Immunization Practices of the Centers for Disease Control and
Prevention (CDC) with respect to the individual involved.
Evidence−informed preventive care and screenings provided for in
the comprehensive guidelines supported by the Health Resources
and Services Administration (HRSA) for infants, children and
adolescents. Additional preventive care and screenings for women,
not described above, as provided for in comprehensive guidelines
supported by the HRSA http://www.hhs.gov/healthcare/factsand-features/fact-sheets/preventive-services-covered-underaca/index.html#CoveredPreventiveServicesforAdults.
For purposes of this benefit, the current recommendations of the
USPSTF regarding breast cancer screening and mammography
and prevention will be considered the most current (other than
those issued in or around November 2009).
The preventive care services described above may change as
USPSTF, CDC and HRSA guidelines are modified.
Examples of covered services included are:
Routine annual physicals (one per year); immunizations;
well-child care; breastfeeding support, services and supplies;
cancer screening mammograms; bone density test; screening
for prostate cancer and colorectal cancer (including routine
colonoscopies); smoking cessation counseling services and
healthy diet counseling; and obesity screening/counseling.
Examples of covered services for women with reproductive
capacity are:
Female sterilization procedures and specified FDA-approved
contraception methods with a written prescription by a
health care practitioner, including cervical caps, diaphragms,
implantable contraceptives, intra-uterine devices, injectables,
transdermal contraceptives and vaginal contraceptive devices.
Prescription contraceptives for women are covered under the
pharmacy benefits administered by Caremark.
To determine if a specific contraceptive drug or device is included
in this benefit, contact Customer Service at 1-800-222-9205. The
list may change as FDA guidelines are modified.
Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider,
you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. Non-network preventive care is not paid
at 100%. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select Whole Health.
17
Scott & White Health Plan
Summary of Benefits for TRS-ActiveCare
Fully Covered Health Care Services
Copay
Home Health Services
Copay
$50 copay
Preventive Services
No Charge
Home Health Care Visit
Standard Lab and X-ray
No Charge
Worldwide Emergency Care
Disease Management and
Complex Case Management
No Charge
Nurse Advice Line
1-877-505-7947
Well Child Care Annual Exams
No Charge
Online Services
No Charge — go to
trs.swhp.org
Immunizations (age appropriate)
No Charge
After Hours Primary Care Clinics
Plan Provisions
Annual Deductible
Annual out-of-pocket
maximum (including medical and
prescription opays and coinsurance)
$1,000 Individual/
$3,000 Family
$40 copay and 20% of charges
after deductible
Emergency Room6
$5,000 Individual/
$10,000 Family
$150 copay and 20% of charges
after deductible
Urgent Care Facility
(includes combined Medical
and RX copays, deductibles
and coinsurance)
None
Outpatie t Services
Copay
Rx Deductible
$50 copay
Other Outpatient Services
Diagnostic/Radiology
Procedures
Prenatal Care
Ask an SWHP
Pharmacy
representati e how to
save money on your
prescriptions
3
Preferred Generic7
Inpatie t Services
Overnight hospital stay: includes
all medical services including
semi-private room or intensive care
Diagnostic
Therapeutic Se vices
Physical and Speech Therapy
Manipulati e Therapy5
Equipment and Supplies
Maintenance Quantit
Retail Quantit
BSWH Pharmacies Only
(Up to a 90-day supply)
(Up to a 30-day supply)
$3 copay
$6 copay
Preferred Brand
30% after Rx deductible
Non-Preferred
Non-Formulary
Greater of $50 or
Not available
$150 copay and 20% of
charges after deductible
Mail Order
Copay
No Charge
Specialty Medication
$150 per day and
20% of charges
after deductible
Copay
$150 per day4 and
20% of charges
after deductible
Copay
1-800-707-3477
Copay
Including all services billed with office visit
1
Does not apply to wellness or preventive visits
2
Includes other services, treatments, or procedures received at time of office visit
3
$750 maximum copay per admission and 20% after deductible
4
5 visits max per month, 35 max visit per year
5
Copay waived if admitted within 24 hours
6
If a brand name drug is dispensed when a generic is available, 50% copay applies
7
$50 copay
20% without office vis
$40 plus 20% with
office vis
Copay
Preferred Diabetic Supplies
and Equipment
$3 copay; no deductible
Non-Preferred Diabetic Supplies
and Equipment
Durable Medical Equipment/
Prosthetics
$100
No Charge
4
Inpatient Delivery
Unlimited
Does not apply to preferred generic drugs
Specialty Care
Maternity Care
Prescription Drug
$20 Copay
(First Primary Care Visit for
Illness $0 Copay2)
Outpatient Surgery
$55 copay
Annual Benefit Maximum
Primary Care1
Allergy Serum & Injections
$20 copay
Ambulance and Helicopter
Copay
Lifetime Paid Benefit Maximum
Eye Exam (one annually)
Copay
18
trs.swhp.org
How to Search for Health Care Providers in
TR S A c t i v e C a r e 1 - H D , 2 , o r S e l e c t
To locate an in network provider for a medical plan go to: www.trsactivecareaetna.com
Click on:
In the search bar you
may search by name,
specialty, procedure or
condition.
Choose your health plan:
ActiveCare Select – Make sure you
choose Baylor Scott & White
Quality Alliance (DFW Region)
NOT ActiveCare Select
ActiveCare 1-HD
ActiveCare 2
19
How to Search for Health Care Providers in
Scott & W hite HM O
To locate an in network provider for a medical plan go to: www.trs.swhp.org
Click on Provider Information:
Click on Browse providers online:
Choose the TRS – Active Care Participants Network then you may search by doctor, facility or specialty.
20
Maximum Annual Costs 2016-2017
Hurst Euless Bedford ISD
For Illustration Purposes Only
EMPLOYEE ONLY
Deductible (Medical)
Deductible (Prescription)
Maximum Out of Pocket (co-ins & copays)
Subtotal Medical & Prescription Costs
Annual Premium
Total Premium, Medical & Prescription
Expenses
EMPLOYEE & SPOUSE
Annual Premium
Expenses
EMPLOYEE & CHILD(REN)
ASSUMES 2 CHILDREN
Annual Premium
Expenses
EMPLOYEE & FAMILY
ASSUMES 4 FAMILY MEMBERS
Annual Premium
Expenses
ActiveCare
1 - HD
$2,500
$0
$4,050
$6,550
$1,392
ActiveCare
2
$1,000
$200
$5,650
$6,850
$5,040
ActiveCare
Select
$1,200
$200
$5,450
$6,850
$3,108
Scott &
White HMO
$1,000
$100
$3,900
$5,000
$3,662
$7,942
$11,890
$9,958
$8,662
ActiveCare
1 - HD
$5,000
$0
$8,100
$13,100
$8,268
ActiveCare
2
$2,000
$400
$11,300
$13,700
$15,924
ActiveCare
Select
$2,400
$400
$10,900
$13,700
$11,064
Scott &
White HMO
$2,000
$200
$7,800
$10,000
$11,614
$21,368
$29,624
$24,764
$21,614
ActiveCare
1 - HD
ActiveCare
2
ActiveCare
Select
Scott &
White HMO
$5,000
$0
$8,100
$13,100
$4,680
$3,000
$600
$10,100
$13,700
$9,804
$3,600
$600
$9,500
$13,700
$6,648
$3,000
$300
$6,700
$10,000
$7,370
$17,780
$23,504
$20,348
$17,370
ActiveCare
1 - HD
ActiveCare
2
ActiveCare
Select
Scott &
White HMO
$5,000
$0
$8,100
$13,100
$12,072
$3,000
$800
$9,900
$13,700
$16,464
$3,600
$800
$9,300
$13,700
$13,632
$3,000
$400
$6,600
$10,000
$13,176
$25,172
$30,164
$27,332
$23,176
21
Split Premiums/Pooling Funds Comparison
TRS ActiveCare
 Married couples working for different participating entities
OR
 Married couples both working for HEB ISD
 Family coverage and all want the same plan; One employee will decline coverage
and the other employee will elect Family coverage
 May “pool” their funds
 Requires an Application to Split Premium form to be completed by both
employees and both employers
Employee & Family
Standard Funding
Employee Only Premium
Employee & Child(ren) Premium
Pooling Funds
Employee & Family Total Premium
HEB Contribution for Employee A
HEB Contribution for Employee B
Total Premium due
Each employee pays
Monthly Savings or (additional cost)
Annual Savings or (additional cost)
TRS ActiveCare
1 -HD
$116.00
$390.00
$506.00
TRS ActiveCare
Select
$259.00
$554.00
$813.00
Scott & White
HMO
$305.16
$614.16
$919.32
TRS ActiveCare
2
$420.00
$817.00
$1,237.00
TRS ActiveCare
1-HD
$1,231.00
-$225.00
-$225.00
$781.00
÷2
$390.50
TRS ActiveCare
Select
$1,361.00
-$225.00
-$225.00
$911.00
÷2
$455.50
Scott & White
HMO
$1,322.98
-$225.00
-$225.00
$872.98
÷2
$436.49
TRS ActiveCare
2
$1,597.00
-$225.00
-$225.00
$1,147.00
÷2
$573.50
($275.00)
($3,300.00)
($98.00)
($1,176.00)
$46.34
$556.08
$90.00
$1,080.00
22
TRS-ActiveCare Health and Wellness Tools & Resources
You can get Aetna Navigator on the go with Aetna Mobile. Pull up your secure memberwebsitetofindnetwork
doctors,viewandshowyourIDcard,checkonclaims, contact Member Services, and more. The Aetna Mobile app
works with Apple® and Android™ digital devices.*
GET IT: Text “Apps” to 23862** or visit www.aetna.com/mobile.
iTriage helps you make sense of your health care options. Check a symptom, look upconditionsandprocedures,
findtherightdoctororfacility,lookupERwaittimes, and much more.
GET IT: The app is free on Google PlayTM or the App StoreSM;* youcan also visit www.itriagehealth.com.
The Caremark app gives you real-time, secure access to your prescriptions and pharmacy information.
Look up pharmacies near you. Order prescriptions using the mail service, then check on the status of your
order. Check your prescription history. You can use the app on your iPhone® or Android phone.*
GET IT: Visit www.caremark.com. On the home page, look for the CVS/Caremark app link to “Download it now.”
Teladoc givesyou24/7/365accesstoboard-certifieddoctorsbyphonewhocantreat conditions like colds,
allergies, ear infections and much more.
GET IT: Download the app at www.teladoc.com/mobile or text “Get Started” to 469-804-9918.**
You can schedule appointments, check your results, share information and more using the MyQuest mobile app.
GET IT: Download the app at www.questdiagnostics.com/myquest.
Telehealth services
Your TRS-ActiveCare plan provides telephone resources that let you talk with health care professionals when you have a
question, concern or problem.
Aetna Health Concierge
The Aetna Health Conciergeisasinglepointofcontactformedicalbenefitsandwellnessinformation.Callwitha
problemorquestion,gethelptofindtherightcare,learnhowaclaimwaspaid,findoutaboutprogramsthatcanhelp
withspecificconditionsandneeds–andmuch more.
CALL TRS-ActiveCare Customer Service at 1-800-222-9205 to talk with a Concierge.
Teladoc
Teladocisaservicethatgivesyou24/7/365phoneaccesstoboard-certifiedprimarycarephysicians (including
pediatricians). Teladoc doctors can diagnose, treat and prescribe
fornon-emergencyproblems,suchascoldsandflu,allergies,sinusinfections,andothers.Consultationsarecovered
100%forActiveCareSelectandActiveCare2plans.For ActiveCare 1-HD, the fee is $40 per consult.
CALL 1-855-TELADOC (1-855-835-2362).
24-Hour Nurse Information Line
The 24-Hour Nurse Information Line lets you talk with a registered nurse when you have a health-related question or
concern. The nurse can provide answers and information, help you know where to seek care and suggest things you can
do until you are able to see a doctor.
CALL 1-800-556-1555.
23
GAP Plan
Special Insurance Services, Inc.
800-767-6811
…the solution to your benefit
problems
Benefit Connection is a low-cost program designed to help you pay for covered out-of-pocket
expenses you may incur while you are either confined in a hospital or being treated as an
out-patient for an injury or an illness.
Please note this plan cannot be used in conjunction with a Health Savings Account (HSA).
Basic Plan Benefits offered to employees of HEB ISD
Hospital Confinement Benefit* - This benefit is designed to offset the cost you incur as an in-patient in the
hospital when your primary comprehensive major medical policy applies such expenses to your deductible or
coinsurance maximum, up to the $1,500 calendar year maximum per insured person.
Out-Patient Benefit* - This benefit offsets the cost you incur for out-patient treatment when your primary
major medical policy applies such expenses to your deductible or coinsurance maximum, up to the $1,500
benefit limit, and up to a maximum of three out-patient occurrences per family per calendar year. An
“occurrence” is the treatment, or the series of treatments, for a specific injury or illness within a calendar
year. Expenses related to physician office visits are not included in this benefit. Covered expenses include:
•
•
•
•
•
Surgery in an Out-Patient Facility or a Physician’s Office
Emergency Room visits
Diagnostic testing, MRI’s, CT scans, Lab & X-ray at a diagnostic or hospital out-patient facility or at a
Physician’s office if the cost is not included in the global office visit fee and is not part of
wellness/preventive care
Physical therapy
Chiropractic care
*For expenses to be eligible under this plan they must be medically necessary for the treatment of an injury or illness. Expenses
not covered by your group major medical plan are not covered.
How to File a Claim
When you enroll in the Benefit Connection plan, you will receive an ID card, along with specific instructions on how
to file a claim. This form outlines the procedures you should follow to obtain a claim form, what you need to file a
claim, and where you should send your claim. Simply stated, you will need to submit a completed claim form, itemized
bills (NOT balance due statements), and EOB’s that correspond to the itemized bills.
Claims may be filed at any time, but must be filed no longer than 12 months from the date of service in order to be
eligible for coverage.
Premiums
Under Age 40
Employee Only
Employee & Spouse
Employee & Family
Ages 40 - 49
Ages 50 & Above
Monthly
Semi-Monthly
Monthly
Semi-Monthly
Monthly
Semi-Monthly
$26.89
$49.44
$64.64
$86.57
$13.45
$24.72
$32.32
$43.29
$35.41
$65.05
$69.58
$98.44
$17.71
$32.53
$34.79
$49.22
$74.37
$136.65
$128.15
$188.80
$37.19
$68.33
$64.08
$94.40
This information sheet highlights the important features of the product. The policy has limitations and exclusions. The exact provisions governing
the insurance are contained in the master policy issued to each group on form number GAPP-4200, policy series G4200. Your carrier representative
can supply you with costs and complete details of coverage.
24
Dental Plans
Lincoln Financial Group
PPO
800-423-2765
DHMO 888-877-7828
www.ldc.lfg.com
The district offers a choice of three different dental plans. A summary of the respective plans follows.
DHMO
Preventive Services
PPO
High
PPO
Low
Fixed Co-Pays
Plan Pays 100%
Plan Pays 100%
Basic
Fixed Co-Pays
Plan Pays 80%
Plan Pays 70%
Major
Fixed Co-Pays
Plan Pays 50%
Plan Pays 50%
Orthodontics (Children under 19)
Fixed Co-Pays
Plan Pays 50%
Not Covered
Ortho. Lifetime Maximum
N/A
$1,000
Not Covered
Out of Network Benefits
No
Yes
Out of Network Reimbursement
None
90th Percentile
Yes
Based on
Contracted Fee
Schedule
Deductible (Per Calendar Year)
None
$50 Person
$150 Family
$25 Person
$75 Family
None
$1,000
$750
Yes – See the next 2
pages for list of dentists
No
No
$1 - $600
$1 - $300
$250 per year
$150 per year
$350 per year
$200 per year
$1,000
$750
(Cleanings, Exams, X-Rays, etc.)
(Fillings, Extractions, etc.)
(Crowns, Bridges, Dentures, etc.)
Annual Maximum Benefit
(Maximum amount the insurance company will
pay during a calendar year)
Primary Care Dentist Required
Deductible Applies
Deductible Applies
Deductible Applies
Deductible Applies
MaxRewards
Eligible Range (Claim Threshold)
Rollover Amount
Rollover Amount with Preferred
Provider
Not Applicable
Maximum Rollover Account Balance
Premiums
Monthly
SemiM onthly
Monthly
SemiM onthly
Monthly
SemiM onthly
Employee Only
$13.91
$6.96
$38.00
$19.00
$25.00
$12.50
Employee + 1
$26.42
$13.21
$75.50
$37.75
$51.50
$25.75
Employee + Family
$41.72
$20.86
$114.50
$57.25
$69.50
$34.75
*Note: Please refer to the plan booklets for specific fixed co-pays for DHMO.
25
Dental Providers for the DHMO Plan
TARRANT COUNTY
ARLINGTON
BRIDENT DENTAL
(682)-560-4468
3779 S COOPER ST
ARLINGTON, TX 76015
-KUNG, ANDREW
Prov. No.: 000002298542
-PATEL, TANVIBEN J.
Prov. No.: 000002450929
-SEN, SOUMAVA
Prov. No.: 000002299254
BRIDENT DENTAL
(682) 999-3116
2142 N COLLINS ST.
ARLINGTON, TX 7611
-CHANG, SZU-WEI
Prov. No.: 11551878
-GADE, ANURADHA
Prov. No.: 11551895
-NGUYEN, DAVID
Prov. No.: 12005055
DIAMOND DENTAL
(817)-563-1111
4050 W I 20
ARLINGTON, TX 76017
-TURNER, CECIL
Prov. No.: 22949
IDEAL DENTAL
(972) 820-6453
2150 E. LAMAR BLVD
STE 106
ARLINGTON, TX 76006
-ANTONISSE, JORDAN
Prov. No.: 12181045
-BRAY, ELIZABETH
Prov. No.: 12158537
-HERRERA, CHRISTOPHER
Prov. No.: 12180180
-HOLMES, MICHAEL
Prov. No.: 12202519
-JAMES, AMBER
Prov. No.: 12195076
IDEAL DENTAL
(817) 274-9999
1250 E. LAMAR BLVD
ARLINGTON, TX 76011
-CASTLE, MICHAEL
Prov. No.: 12098476
-COVINO, JULIE
Prov. No.: 12098483
-HATTAWAY, RICHARD
Prov. No.: 12098485
-HERMAN, SARAH
Prov. No.: 12099866
-JACKSON, ASHLEY
Prov. No.: 12099867
MILESTONE DENTAL
(817) 635-6453
5005 S COOPER ST.
SUITE 173
ARLINGTON, TX 76017
MONARCH DENTAL
(817)-540-2223
1717 AIRPORT FWY
BEDFORD, TX 76021
-AMIN, AWESTA
Prov. No.: 12005330
-COUGHLIN, CHRISTINE
-AHMED, SULLMAN
Prov. No.: 4474714
-ANDERSON, RYAN
Prov. No.: 2782425
-CASSIDY, CHRISTOPHER
Prov. No.: 8359036
-CASTLE, MICHAEL
Prov. No.: 3915219
Prov. No.: 6299207
-EDWARDS, CHRISTOPHER
Prov. No.: 11773599
-MUKHERJI, PARTHA
Prov. No.: 000001548246
-CHAUDHARI, REKHA
Prov. No.: 12108012
-RHOADS, STANLEY
Prov. No.: 3913713
-WORLTON, SCOTT
Prov. No.: 12017399
-WILLIAMS, KIMBERLY
Prov. No.: 11774011
MONARCH DENTAL
(817)-795-4044
1005 N COLLINS ST
STE 100
ARLINGTON, TX 76011
-ARRECHEA, VANINA C.
Prov. No.: 000002020063
-COLEMAN, DEBRA Y.
Prov. No.: 000000213995
-MEHTA, SALIL
Prov. No.: 000002088546
-MOORE, MICHAEL B.
Prov. No.: 000001121691
-MOORE, ROLAND E.
Prov. No.: 000001121689
COLLEYVILLE
IDEAL DENTAL
(817) 428-5111
4712 COLLEYVILLE
BLVD #110
COLLEYVILLE, TX 76034
-BRAY, ELIZABETH
Prov. No.: 12158560
-MOON, SPENCER
Prov. No.: 12227672
-MUELLER, VERONICA
Prov. No.: 12173718
-NGUYEN, SCOTTIE
Prov. No.: 12185676
-VILLARREAL, MARCOS
Prov. No.: 12170549
MONARCH DENTAL
(817)-561-9199
5760 W PLEASANT
RIDGE RD STE 110
ARLINGTON, TX 76016
-CARMICHAEL, BRYAN
Prov. No.: 7194445
Prov. No.: 6299204
-JEMELKA, JOE F.
Prov. No.: 000000031309
-KRYSIAK, AMANDA
Prov. No.: 11551469
-MEHTA, SALIL
Prov. No.: 000002018052
EULESS
BRIDENT DENTAL
(817)-786-3941
1101 N MAIN ST
EULESS, TX 76039
-AHIR, DHIREN
Prov. No.: 10902896
-BHADESHIYA, HARDIK
Prov. No.: 11998836
-CHANG, SZU-WEI
Prov. No.: 000002298613
Prov. No.: 10903409
-HAENDEL, JACLYN
Prov. No.: 1657056
-JAFFER, SALMAN
Prov. No.: 2298908
-SHYAM, SONYA
Prov. No.: 12103626
-TRUONG, PETER
Prov. No.: 2299484
BEDFORD
BRANSON DENTAL
Prov. No.: 35325
(817)-285-8825
1220 F AIRPORT FWY
BEDFORD, TX 76022
26
IDEAL DENTAL
(817) 571-3368
3010 STATE HWY 121
SUITE 300
EULESS, TX 76039
-ADAMS, JAMES
Prov. No.: 2539250
-DAY, MARTHA
Prov. No.: 12149470
-IGLINSKY, PATRICK
Prov. No.: 12191533
-MANRIQUE, ALEX
Prov. No.: 6964017
-O’BRIEN, RACHAEL
Prov. No.: 12028787
-VAELLO, CHRISTIN
Prov. No.: 1926428
MONARCH DENTAL
(817)-540-2552
2721 STATE HWY 121
SUITE 300
EULESS, TX 76039
-COLEMAN, DEBRA
Prov. No.: 12179081
-HORNER, SANDRA
Prov. No.: 12162692
-PATEL, SHITALBEN
Prov. No.: 12203250
FORT WORTH
ACCESS DENTAL
(817)-446-0800
6302 MEADOWBROOK
#112
FORT WORTH, TX 76112
-PHAN,TIEN D.
Prov. No.: 000000438383
ACCESS DENTAL
(214)-391-1900
6901 MCCART AVE
STE 175
-PHAN, TIEN D.
Prov. No.: 000000459791
BRIDENT DENTAL
(817) 344-7159
3411 SYCAMORE
SCHOOL RD
-AHIR, DHIREN
Prov. No.: 6963871
-GADE, ANURADHA
Prov. No.: 11116050
-PARK, YOUNA
Prov. No.: 10404193
-PATEL, DEVANG R.
Prov. No.: 6511158
FORT WORTH
BRIDENT DENTAL
(817)-585-2475
6000 CAMP BOWIE BLVD
#120
-CHANG, SZU-WEI
Prov. No.: 000002298618
-KUNG, ANDREW
Prov. No.: 000002298541
-PATEL, DEVANG R.
Prov. No.: 000002373531
BRIDENT DENTAL
(817) 918-3295
4511 WESTERN CENTER
BLVD.
-AHIR, DHIREN
Prov. No.: 10902898
-KIM, MIN
Prov. No.: 7193084
-KOO, BONHEE
Prov. No.: 5917382
-NAIR, BRINDA
Prov. No.: 12200947
DRAKE, LEIGH G.
(817)-877-4600
Prov. No.: 000000070924
1120 S HENDERSON
FLETCHER, CRISTI
(817) 348-0910
Prov. No.: 11551351
4420 HERITAGE TRACE
PKWY, SUITE 300
IDEAL DENTAL
(817) 337-0021
12584 N BEACH ST.
STE 150
-ACOSTA, NICHOLAS
Prov. No.: 12029143
-ADAMS, JAMES
Prov. No.: 2539266
-COVINO, JULIE
Prov. No.: 3641942
-KOPECKY, BRITTANY
Prov. No.: 12127073
-PHAM, HENRY
Prov. No.: 12049691
-STRUMWASSER, BRETT
Prov. No.: 12007830
I SMILE DENTAL PA
(817) 253-6169
5824 S HULEN ST
-TRUONG, THANH N.
Prov. No.: 000000328244
GRAPEVINE
MITCHELL, EARL A.
Prov. No.: 000000087948
1511 E BERRY ST
(817)-924-7171
MONARCH DENTAL
(817)-251-0057
306 S PARK BLVD
STE 120
GRAPEVINE, TX 76051
MONARCH DENTAL
(817)-921-1544
4200 S FWY STE 15
-EDWARDS,
CHRISTOPHER
Prov. No.: 11773601
-XU, JEAN J.
Prov. No.: 000001215657
-WILLIAMS, KIMBERLY
Prov. No.: 11774012
-ADAMS, JAN
Prov. No.: 12147072
-BALDWIN, DOUGLAS
Prov. No.: 12159841
-BARRETT, GILBERT
Prov. No.: 12205590
-DAVILA, MICHELLE
Prov. No.: 10904059
-HOLLAR, GAIL
Prov. No.: 12182559
-KRYSIAK, AMANDA
Prov. No.: 12000837
-MEHTA, SALIL
Prov. No.: 6811880
HURST
BRIDENT DENTAL
(682) 253-3146
1460 PRECINCT LINE RD
STE 300
HURST, TX 76054
-AHIR, DHIREN
Prov. No.: 8359268
-JAYSWAL, NIKI
Prov. No.: 12116299
-KUNG, ANDREW
Prov. No.: 6510725
-NGUYEN, DAVID
Prov. No.: 12005049
-SHYAM, SONYA
Prov. No.: 12103663
MONARCH DENTAL
(817) 256-9823
1900 MALL CIRCLE
-BEMIS, NATHANIEL
Prov. No.: 1499498
-DAVILA, MICHELLE
Prov. No.: 3913730
-ELAM, MAEGAN
Prov. No.: 6811275
-REEVES, WILLIAM
Prov. No.: 12148903
-STRICKLAND, JOHN
Prov. No.: 31283
CASTLE DENTAL
(817)-268-4867
1101 MELBOURNE ST
#7002
HURST, TX 76053
-COLEMAN, DEBRA
Prov. No.: 12046713
-WILLIAMS, KIMBERLY
Prov. No.: 11774005
-WORLTON, SCOTT
Prov. No.: 12017403
MONARCH DENTAL
(817)-346-9040
6261 GRANBURY RD
-CARR, TONI
Prov. No.: 16909
-CHRISTENSEN, MARK
Prov. No.: 11994625
-POQUIZ, JANE
Prov. No.: 000000031319
-STEWART, KANIKA S.
Prov. No.: 000001822252
KELLER
IDEAL DENTAL
(817) 431-5599
1431 KELLER PARKWAY
STE 300
KELLER, TX 76248
-ANDERSEN, ERIC
Prov. No.: 12228081
-FONVILLE, DOUGLAS
Prov. No.: 12228056
-SHUMAN, RICHARD
Prov. No.: 12228094
-VOISSEM, PHILIP
Prov. No.: 12228101
WEST TEXAS DENTAL
(817) 457-4141
6600 BRENTWOOD
STAIR ROAD
-DEZHAM, HOSSAIN
Prov. No.: 418623
This is not a complete list and is subject to change.
For the most current list, please visit Lincoln
Financial’s website and search for DHMO Dentists.
27
MILESTONE DENTAL
(817) 581-6453
5800 N TARRANT PKWY
STE 102
FT. WORTH (KELLER),
TX 76244
-AGUILAR, JONATHAN
Prov. No.: 12120019
-ANDERSON, RYAN
Prov. No.: 2782427
-GEIGER, COURTNEY
Prov. No.: 2782997
-HERMAN, SARAH
Prov. No.: 12007836
-REAGAN, JAMES
Prov. No.: 12110315
-ZERBY, WILLIAM
Prov. No.: 6964077
NRH
MONARCH DENTAL
(817) 605-8067
8528 DAVIS BLVD
STE 100
NRH, TX 76180
-HORNER, SANDRA T.
Prov. No.: 000000364767
-KRYSIAK, AMANDA
Prov. No.: 12000506
-MCCARTNEY, COLIN
Prov. No.: 2700727
-PETERSON, SCOTT
Prov. No.: 1193555
MONARCH DENTAL
(817) 577-3433
6455 HILLTOP DR #114
NRH, TX 76180
-JAMES, LEON D.
Prov. No.: 000001265557
-KENNEY, DANIEL
Prov. No.: 4029982
-WORLTON, SCOTT
Prov. No.: 12017402
SOUTHLAKE
IDEAL DENTAL
(817) 421-9999
2645 E SOUTHLAKE
BLVD, SUITE 150
SOUTHLAKE, TX 76092
-JACKSON, ASHLEY
Prov. No.: 11331671
-LOVING, DAN
Prov. No.: 12029053
-MCCAMMON, DUSTIN
Prov. No.: 12004893
-MINOR, LINDSAY
Prov. No.: 12029052
-REAGAN, JAMES
Prov. No.: 12110102
-VILLARREAL, MARCOS
Prov. No.: 12119868
Schedule of Benefits for DHMO Plan
Code
Service
Diagnostic Treatment
D0120
Periodic Oral Evaluation
D0150
Comprehensive Oral Evaluation - New Or Established Patient
D0210
X-Rays Intraoral - Complete Series - Including Bitewings
D0274
X-Rays Bitewings - Four Films
D0330
Panoramic Film
Preventive Services
D1110/D1120 Prophylaxis - Adult and Child
D1351
Sealant per tooth
Restorative Services
D2140
Amalgam - One Surface, Primary Or Permanent
D2330
Resin-Based Composite - One Surface, Anterior
D2391
Composite (White) Filling - One Surface - Posterior Tooth
Crowns
D2740
Crown Porcelain/Ceramic Substrate
D2751
Crown Porcelain Fused To Predominantly Base Metal
Endodontics
D3220
Therapeutic Pulpotomy
D3330
Root Canal - Molar - Per Tooth
Periodontics
D4260
D4341
Osseous Surgery (Inc Flap Entry) - Four Or More Contiguous Teeth Or Bounded Teeth
Spaces - Per Quadrant
Periodontal Scaling And Root Planning - Four Or More Contiguous Teeth Or Bounded
Teeth - Per Quadrant
D4381
Localized Delivery Of Antimicrobial Agents
D4910
Periodontal Maintenance
Prosthodontics
D5110/D5120 Complete Denture - Maxillary / Mandibular
D5211/D5212 Partial Denture - Resin Base - Maxillary / Mandibular
Crowns / Fixed Bridges
D6241
Pontic - Porcelain Fused To Predominantly Base Metal
D6750
Porcelain Crown Fused To High Noble Metal
Oral Surgery
Extraction, Erupted Tooth Or Exposed Root (Elevation And / Or Forceps
D7140
Removal)
D7210
Surgical Removal Of Erupted Tooth
D7220
Removal Of Impacted Tooth - Soft Tissue
D7240
Extraction - Removal Of Impacted Tooth - Completely Bony
Orthodontic
D8070,
Comprehensive Orthodontic Treatment Of The Transitional, Adolescent Or
D8080,
Adult Dentition
D8090
Start-up fee (Including exam, beginning records, x-rays, tracing, photos, &
D8999
models)
Adjunctive General Services
D9110
Palliative (Emergency) Treatment Of Dental Pain - Minor Procedure
D9220
DP Sedation/Gen Anesthesia – 1st 30 Minutes
D9310
Consultation
D9972
External Bleaching – Per Arch
D0999
Office Visit Fee - Per Visit
Copayment
$0
$0
$0
$0
$0
$0
$5
$0
$0
$35
$210
$150
$0
$225
$275
$35
$55
$25
$215
$250
$150
$150
$0
$15
$35
$75
$1,895
$250
$10
$145
$0
$125
$5
***This benefit comparison is for illustration purposes only. See schedule of benefits for details.
28
DENTAL PPO Plans
•
•
•
•
•
You may choose any dentist. However, using contracting dentists should lower your out-of-pocket
expenses. * You do not need a referral to see a specialist. A list of participating dentists may be
accessed at www.LincolnFinancial.com.
By enrolling in the dental plan you and your enrolled family members will have access to Lincoln
DentalConnectSM, our free on-line dental health information Web site.
If you incur dental expenses, the plan pays the following percentage of allowable expenses in excess
of the deductible up to the maximum benefit.
Covered dental expenses include only those services listed in your certificate.
Covered expenses outside the panel service area will not exceed the policy’s usual and
customary allowances.
Preventive
Basic
Major
Orthodontics
Deductible
Maximum
Ortho Maximums
Exclusions
•
•
•
•
•
•
•
•
•
•
•
•
•
•
PPO High Plan
Routine Oral Exams
Routine Cleanings
Fluoride Treatments
Sealants
X-Rays
Space Maintainers
Fillings
Simple Extractions
Surgical Extractions
Denture Repair
Non-surgical Periodontal Therapy
Periodontal Surgery
Oral Surgery
Anesthesia
• Full & Partial Dentures
• Endodontics (including Root Canal
Treatment)
• Crowns, Inlays, Onlays & related services
• Orthodontic Treatment – including
Orthodontic Exams, X-rays, Extractions,
Study Models & Appliances
Calendar year deductible. Waived for
Preventive Services
Calendar year maximum for Preventive, Basic
& Major Services
Lifetime Ortho Maximum for Children
PPO Low Plan
Routine Oral Exams
Routine Cleanings
Fluoride Treatments
Sealants
X-Rays
Space Maintainers
Fillings
Simple Extractions
Surgical Extractions
Denture Repair
Non-surgical Periodontal Therapy
Periodontal Surgery
Oral Surgery
Anesthesia
Endodontics (including Root Canal
Treatment)
• Full & Partial Dentures
• Crowns, Inlays, Onlays & related services
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Not Covered
Calendar year deductible. Waived for
Preventive Services
Calendar year maximum for Preventive, Basic &
Major Services
Not Covered
This is a summary of policy exclusions. The policy contains other, more specific, exclusions and limitations not fully
explained in this benefit summary.
•
•
Plan benefits are not payable for a condition for which the claimant is eligible for benefits under worker’s
compensation or a similar law; or for a condition attributed to employment or military service. Coverage is not
available for dental conditions caused by an act of war, self-inflicted injury, involvement in an illegal occupation;
attempt to commit a felony, or active participation in a riot.
If benefits for orthodontia are included, the plan does not cover any treatment plan started before coverage begins
or during the benefit waiting period unless the member was receiving orthodontia benefits from this employer’s
previous group dental policy. In that case, Lincoln Financial will continue orthodontia benefits until the combined
benefit paid by the two policies is equal to this policy’s lifetime orthodontia.
29
PPO Dental M a x R e w a r d s Program
M ax im ize your Lincoln DentalConnect plan benefits
The MaxRewards maximum rollover feature allows covered members to roll over a portion of their
unused annual maximum into a MaxRewards Account Balance. This flexibility lets members save for
more expensive dental treatment down the road.
How the M axR ew ards feature w orks
To qualify for a rollover, a covered member must meet the following qualifications during the year:
• Submit at least one claim for covered services
• Keep benefit payments during the year below the threshold amount
If eligible, the rollover amount is moved into the member’s MaxRewards Account Balance. The member
can use the MaxRewards Account for future covered services when the plan’s annual maximum is
exhausted.
M axR ew ards benefits
Promotes better oral health by requiring an annual treatment to be eligible for rollovers
Empowers members to manage benefit dollars they would lose under a traditional plan
Allows members to build up their MaxRewards Account Balance in order to cover large claims
Rewards long-term members by allowing the rollover account to accumulate over time
Includes a bonus amount when members seek care from in-network providers, with the
option to remove the in-network bonus amount
 Offers high threshold amounts with the option to remove threshold and claim requirements





The M ax Rew ards feature in action
Plan specifications and hypothetical scenario
Annual
maximum
$1,000
Threshold
$600
Claim
required?
Yes
Out of network rollover
In-network
rollover
MaxRewards Account
$250
$350
$1,000
Balance limit
YEAR 1 Member uses $300 toward the $1,000 annual maximum and sees an out-of-network dentist at least once.
• The $300 benefit is less than the $600 threshold, so the member is eligible for a rollover.
• Since the member saw an out-of-network dentist at least once, the out-of-network rollover amount of $250 is
deposited into the MaxRewards Account Balance.
YEAR 2 Member has $1,000 annual maximum and $250 in her MaxRewards Account Balance, and uses zero dollars
toward the annual maximum (she didn’t see the dentist).
• The plan design requires at least one claim in the calendar year for any rollover amount to be applied.
• Since no claims were incurred this year, the plan applies no rollover amount.
• The member still has $250 in her MaxRewards Account Balance from the prior year rollover.
YEAR 3 Member has $1,000 annual maximum and $250 in her MaxRewards Account Balance, and incurs $1,100 in
claims from an in-network dentist.
• The $1,100 claim cost is above the $1,000 maximum, so $100 of the MaxRewards Account Balance is applied to cover
the remaining cost.
• Since the annual claim costs are above the $600 threshold, the claimant is not eligible for a rollover benefit.
• $150 remains in the member’s MaxRewards Account Balance for future use.
30
Vision Plan
Superior Vision
800-923-6766
Copays
Eye Exam Copay
Material Copay (lenses & frames only, not contact lenses)
Contact Lens Fitting
Benefits (In Network)
www.superiorvision.com
$10
$25
$0 (Standard) / $50 retail allowance (Specialty)
Frames
Contact Lenses
$130 retail allowance; 20% off amount over allowance
Single Vision, Bifocal & Trifocal Lenses
Covered in full
$150 retail allowance
(in lieu of eyeglass lenses & frames benefit)
Covered to provider’s in-office standard retail lined trifocal amount; member
pays difference between progressive & standard retail lined trifocal, plus
applicable co-pay
Progressive Lens upgrade
Factory scratch coat
Covered in full
Services/Frequency (Based on date of service)
Exam
Frames
Contact Lens Fitting
Lenses
Contact Lenses
12
24
12
12
12
months
months
months
months
months
Discount Features
Discounts on Covered Materials
The following options have out-of-pocket maximums on Standard (no premium, brand, or progressive) lenses.
Maximum Member Out-of-Pocket
Single Vision
Bifocal & Trifocal
$13
$13
$15
$15
$25
$25
$50
$50
$40
20% off retail
$55
20% off
$80
20% off
Scratch coat
Ultraviolet coat
Tints, solid or gradients
Anti-reflective coat
Polycarbonate
High index 1.6
Photochromic
Discounts on Non-Covered Exam & Material
Exams, frames & prescription lenses
Lens options, contacts, other prescription materials
Disposable contact lenses
Refractive Surgery
30% off
20% off
10% off
Superior Vision has a nationwide network of refractive surgeons and
leading LASIK networks who offer members a discount. These
discounts range from 5% - 50%, and are the best possible discounts
available to Superior Vision.
Premiums
Employee Only
Employee + 1
Employee + Family
Monthly
$6.10
$11.84
$17.39
31
Semi-M onthly
$3.05
$5.92
$8.70
The Standard
Disability Insurance
800-368-1135
www.standard.com
What if you weren’t getting a paycheck?
Chances are work plays an important role in your life. So what if a disabling illness or injury kept
you from the workplace? How long would your savings hold out?
Certainly, there’s a lot depending on your paycheck. That’s why HEB ISD has teamed up with
The Standard to offer disability income protection insurance. Should a disability prevent you from
working and earning a living, this insurance can help you meet your expenses.
What is Disability Income?
It replaces a portion of your income when you are sick or injured and cannot work.
1st Step: Select a Benefit Amount –
You may purchase any monthly benefit amount in $100 increments up to 2/3rds of your monthly
earnings.
2nd Step: Choose a Benefit Waiting Period that meets your needs –
Benefit waiting period is the period of time that you must be continuously disabled before benefits
become payable. Benefits are N OT payable during the benefit w aiting period. Options:
7, 14, 30, 60, 90, 180 days
First Day Hospital Benefit:
With this benefit, if an insured employee is admitted as a hospital inpatient for at least four hours
during the Benefit Waiting Period, the Benefit Waiting Period will be satisfied. Benefits become
payable on the date of the hospitalization. This feature is included only on plans w ith a
Benefit W aiting P eriod of 30 days or less.
Preexisting Condition Exclusion:
Any condition you had 90 days prior to the effective date of your insurance will be considered
preexisting. The exclusion period is 12 months.
Preexisting Condition Waiver:
For the first 45 days of disability, The Standard will pay full benefits even if you have a preexisting
condition.
Other Features:
Employee Assistance Program (EAP) - This program offers support, guidance and resources that
can help an employee resolve personal issues and meet life’s challenges.
32
Disability Rates
Annual
Earnings
3,600
5,400
7,200
9,000
10,800
12,600
14,400
16,200
18,000
19,800
21,600
23,400
25,200
27,000
28,800
30,600
32,400
34,200
36,000
37,800
39,600
41,400
43,200
45,000
46,800
48,600
50,400
52,200
54,000
55,800
57,600
59,400
61,200
63,000
64,800
66,600
68,400
Monthly
Earnings
300
450
600
750
900
1,050
1,200
1,350
1,500
1,650
1,800
1,950
2,100
2,250
2,400
2,550
2,700
2,850
3,000
3,150
3,300
3,450
3,600
3,750
3,900
4,050
4,200
4,350
4,500
4,650
4,800
4,950
5,100
5,250
5,400
5,550
5,700
Monthly
Disability
Benefit
200
300
400
500
600
700
800
900
1,000
1,100
1,200
1,300
1,400
1,500
1,600
1,700
1,800
1,900
2,000
2,100
2,200
2,300
2,400
2,500
2,600
2,700
2,800
2,900
3,000
3,100
3,200
3,300
3,400
3,500
3,600
3,700
3,800
Accidental Injury/Sickness Benefit Waiting Period
Cost Per Month
7 days
14 days
30 days
60 days
90 days
180 days
9.74
14.61
19.48
24.35
29.22
34.09
38.96
43.83
48.70
53.57
58.44
63.31
68.18
73.05
77.92
82.79
87.66
92.53
97.40
102.27
107.14
112.01
116.88
121.75
126.62
131.49
136.36
141.23
146.10
150.97
155.84
160.71
165.58
170.45
175.32
180.19
185.06
7.78
11.67
15.56
19.45
23.34
27.23
31.12
35.01
38.90
42.79
46.68
50.57
54.46
58.35
62.24
66.13
70.02
73.91
77.80
81.69
85.58
89.47
93.36
97.25
101.14
105.03
108.92
112.81
116.70
120.59
124.48
128.37
132.26
136.15
140.04
143.93
147.82
6.42
9.63
12.84
16.05
19.26
22.47
25.68
28.89
32.10
35.31
38.52
41.73
44.94
48.15
51.36
54.57
57.78
60.99
64.20
67.41
70.62
73.83
77.04
80.25
83.46
86.67
89.88
93.09
96.30
99.51
102.72
105.93
109.14
112.35
115.56
118.77
121.98
4.38
6.57
8.76
10.95
13.14
15.33
17.52
19.71
21.90
24.09
26.28
28.47
30.66
32.85
35.04
37.23
39.42
41.61
43.80
45.99
48.18
50.37
52.56
54.75
56.94
59.13
61.32
63.51
65.70
67.89
70.08
72.27
74.46
76.65
78.84
81.03
83.22
3.80
5.70
7.60
9.50
11.40
13.30
15.20
17.10
19.00
20.90
22.80
24.70
26.60
28.50
30.40
32.30
34.20
36.10
38.00
39.90
41.80
43.70
45.60
47.50
49.40
51.30
53.20
55.10
57.00
58.90
60.80
62.70
64.60
66.50
68.40
70.30
72.20
2.94
4.41
5.88
7.35
8.82
10.29
11.76
13.23
14.70
16.17
17.64
19.11
20.58
22.05
23.52
24.99
26.46
27.93
29.40
30.87
32.34
33.81
35.28
36.75
38.22
39.69
41.16
42.63
44.10
45.57
47.04
48.51
49.98
51.45
52.92
54.39
55.86
33
la
TheStandard�·
Educator Options Voluntary Long Term Disability
Coverage Highlights -Texas
Hurst Euless Bedford Independent School District
Voluntary Long Term Disability Insurance
Standard Insurance Company has developed this document to provide you with information about the optional
insurance coverage you may select through the Hurst Euless Bedford Independent School District. Written in non
technical language, this is not intended as a complete description of the coverage. lf you have additional questions,
please check with your human resources representative.
Employer Plan Effective Date
The group policy effective date is September I, 2011.
Eligibility
To become insured, you must be:
• A regular employee of the Hurst Euless Bedford Independent School District, excluding temporary or seasonal
employees, full-time members of the armed forces, leased employees or independent contractors
• Actively at work at least 20 hours each week
• A citizen or resident of the United States or Canada
Employee Coverage Effective Date
Please contact your human resources representative for more information regarding the following requirements that
must be satisfied for your insurance to become effective. You must satisfy:
• Eligibility requirements
• An eligibility waiting period of the first day of the month that follows the date you become an eligible employee
• An evidence of insurability requirement, if applicable
• An active work requirement. This means that if you are not actively at work on the day before the scheduled
effective date of insurance, your insurance will not become effective until the day after you complete one full day
of active work as an eligible employee.
Benefit Amount
You may select a monthly benefit amount in $100 increments from $200 to $8,000; based on the tables and
guidelines presented in the Rates section of these Coverage Highlights. The monthly benefit amount must not
exceed 66 2/3 percent of your monthly earnings.
Benefits are payable for non-occupational disabilities only. Occupational disabilities are not covered.
Plan Maximum Monthly Benefit: 66 2/3 percent of predisability earnings
Plan Minimum Monthly Benefit: l O percent of your LTD benefit before reduction by deductible income
SI 14494-648769
(2/16)
34
Coverage Highlights - Texas
Benefit Waiting Period and Maximum Benefit Period
The benefit waiting period is the period of time that you must be continuously disabled before benefits become
payable. Benefits are not payable during the benefit waiting period. The maximum benefit period is the period for
which benefits are payable. The benefit waiting period and maximum benefit period associated with your plan
options are shown below:
012tion
1
2
3
4
5
6
Accidental Injury
0 days
14 days
30 days
60 days
90 days
180 days
Other Disability
7 days
14 days
30 days
60 days
90 days
180 days
Maximum Benefit Period
To Age 65 for both Sickness and Accident
Options 1-6: Maximum Benefit Period To Age 65 for Sickness and Accident
If you become disabled before age 62, LTD benefits may continue during disability until you reach age 65. If you
become disabled at age 62 or older, the benefit duration is determined by your age when disability begins:
Age
62
63
64
65
66
67
68
69+
3 years 6 months
3 years
2 years 6 months
2 years
1 year 9 months
I year 6 months
1 year 3 months
1 year
First Day Hospital Benefit
With this benefit, if an insured employee is admitted as a hospital inpatient for at least four hours during the Benefit
Waiting Period, the Benefit Waiting Period will be satisfied. Benefits become payable on the date of
hospitalization; the maximum benefit period also begins on that date. This feature is included only on LTD plans
with Benefit Waiting Periods of 30 days or less.
Preexisting Condition Exclusion
A general description of the preexisting condition exclusion is included in the Group Voluntary Long Term
Disability Insurance for Educators and Administrators brochure. If you have questions, please check with your
human resources representative.
Preexisting Condition Period: The 90-day period just before your insurance becomes effective
Exclusion Period: 12 months
Preexisting Condition Waiver
For the first 45 days of disability, The Standard will pay full benefits even if you have a preexisting condition. After
45 days, The Standard will continue benefits only if the preexisting condition exclusion does not apply.
Own Occupation Period
For the plan's definition of disability, as described in your brochure, the own occupation period is the first
12 months for which LTD benefits are paid.
Any Occupation Period
The any occupation period begins at the end of the own occupation period and continues until the end of the
maximum benefit period.
SI 14494-648769
35
(2/16)
Coverage Highlights - Texas
Other LTD Features
• Employee Assistance Program (EAP) -This program offers support, guidance and resources that can help an
employee resolve personal issues and meet life's challenges.
• Special Dismemberment Provision - If an employee suffers a lost as a result of an accident, the employee will
be considered disabled for the applicable Minimum Benefit Period and can extend beyond the end of the
• Reasonable Accommodation Expense Benefit- Subject to The Standard's prior approval, this benefit allows us
to pay up to$25,000 of an employer's expenses toward work-site modifications that result in a disabled
employee's return to work.
• Survivor Benefit - A Survivor Benefit may also be payable. This benefit can help to address a family's financial
need in the event of the employee's death.
• Return to Work (RTW) Incentive -The Standard's RTW Incentive is one of the most comprehensive in the
employee benefits history. For the first 12 months after returning to work, the employee's LTD benefit will not
be reduced by work earnings until work earnings plus the LTD benefit exceed 100 percent of predisability
earnings. After that period, only 50 percent of work earnings are deducted.
• Rehabilitation Plan Provision - Subject to The Standard's prior approval, rehabilitation incentives may include
training and education expense, family (child and elder) care expenses, and job-related and job search expenses.
When Benefits End
LTD benefits end automatically on the earliest of:
• The date you are no longer disabled
• The date your maximum benefit period ends
• The date you die
• The date benefits become payable under any other LTD plan under which you become insured through
employment during a period of temporary recovery
• The date you fail to provide proof of continued disability and entitlement to benefits
Rates
Employees can select a monthly LTD benefit ranging from a minimum of$200 to a maximum amount based on
how much they earn. Referencing the appropriate attached charts, follow these steps to find the monthly cost for
your desired level of monthly LTD benefit and benefit waiting period:
1. Find the maximum LTD benefit by locating the amount of your earnings in either the Annual Earnings or
Monthly Earnings column. The LTD benefit amount shown associated with these earnings is the maximum
amount you can receive. If your earnings fall between two amounts, you must select the lower amount.
2. Select the desired monthly LTD benefit between the minimum of$200 and the determined maximum amount,
making sure not to exceed the maximum for your earnings.
3. In the same row, select the desired benefit waiting period to see the monthly cost for that selection.
If you have questions regarding how to determine your monthly LTD benefit, the benefit waiting period, or the
premium payment of your desired benefit, please contact your human resources representative.
Group Insurance Certificate
If you become insured, you will receive a group insurance certificate containing a detailed description of the
insurance coverage. The information presented above is controlled by the group policy and does not modify it in
any way. The controlling provisions are in the group policy issued by Standard Insurance Company.
SI 14494-648769
(2/16)
36
Allstate – Terry
Barber
Cancer Insurance
817-479-0065
www.allstatebenefits.com/mybenefits
Group Voluntary Cancer Insurance
If you suddenly become diagnosed with cancer, it can be difficult on your family’s financial and emotional
stability. Having the right coverage to help when you are sick and undergoing treatment or when you
cannot work is important. Our cancer insurance can help provide security when you need it most.
Meeting Your Needs
Our cancer coverage can help offer you and your family members’ financial support during a period
of unexpected illness.
•
•
•
•
•
Benefits will be paid directly to you unless otherwise assigned
Coverage can be purchased for you or your entire family
Waiver of premium after 90 days of disability due to cancer as long as your disability lasts
Portable coverage
Includes coverage for 29 other specified diseases:
Low Plan High Plan
Benefits (see next page for complete list)
Ambulance
Per confinement
$100
$100
Cancer Initial Diagnosis
One-time benefit
$2,000
$5,000
Continuous Hospital Confinement
Daily
$200
$200
Intensive Care Confinement
Daily
$600
$600
Non-Local Transportation
Per trip per mile
Radiation/Chemotherapy for Cancer
Every 12 months
Surgery
Based on procedure up to
maximum shown
Payable once/covered person/
calendar year
Wellness
Premiums
Coach Fare or $.40
Low Plan
$10,000
$20,000
$3,000
$3,000
$100
$100
High Plan
Monthly
Semi-Monthly
Monthly
Semi-Monthly
Employee Only
$26.41
$13.21
$40.33
$20.17
Employee & Spouse
$41.87
$20.94
$63.24
$31.62
$37.28
$18.64
$57.55
$28.78
Employee & Family
$52.72
$26.36
$80.44
$40.22
37
Group benefit coverage for:
Hurst Euless Bedford ISD
group voluntary cancer
HOSPITAL AND RELATED BENEFITS
LOW
HIGH
Continuous Hospital Confinement (daily)
$200
Government or Charity Hospital (daily)
$200
$200
Private Duty Nursing Services (daily)
$200
$200
Extended Care Facility (daily)
$200
$200
At Home Nursing (daily)
$200
$200
1. $200
2. $200
1. $200
2. $200
Radiation/Chemotherapy for Cancer (every 12 mos.)
$10,000*
$20,000*
Blood, Plasma, and Platelets (every 12 mos.)
$10,000'
$20,000*
$500*'
$1,000*'
$200*
$400*
$3,000''
$3,000*'
Hospice Care Center (daily) or
Hospice Care Team (per visit)
$200
RADIATION, CHEMOTHERAPY AND RELATED BENEFITS
Medical Imaging (yearly)
Hematological Drugs (yearly)
SURGERY AND RELATED BENEFITS
Surgery
Anesthesia (% of surgery)
Ambulatory Surgical Center (daily)
Second Opinion
Bone Marrow or Stem Cell Transplant
1. Autologous
2. Non-autologous
3. Non-autologous for leukemia
25%
25%
$500
$500
$400
$400
1. $1,000'
2. $2,500'
3. $5,000'
1. $1,000'
2. $2,500'
3. $5,000'
$25
$25
MISC ELLANEOUS BENEFITS
Inpatient Drugs and Medicine (daily)
Physician's Attendance (daily)
$50
$50
Ambulance (per confinement)
$100
$100
Coach Fare
or $0.40
Coach Fare
or $0.40
$50''
$50*'
$50'
Coach Fare
or $0.40
$50'
Coach Fare
or $0.40
$50
$50
Non-Local Transportation (per trip or mile)
Outpatient Lodging (daily)
Family Member Lodging (daily)
and Transportation (per trip or mile)
Physical or Speech Therapy (daily)
New or Experimental Treatment (every 12 mos.)
$5,000*
$5,000*
Prosthesis
$2,000'3
$2,000*3
Hair Prosthesis (every 2 years)
Nonsurgical External Breast Prosthesis
Anti-Nausea Benefit (yearly)
Waiver of Premium (primary insured only)
ADDITIONAL BENEFITS
Cancer Initial Diagnosis
Wellness (yearly)
Intensive Care
1. Intensive Care Confinement (daily)
2. Step-down Confinement (daily)
3. Air/Surface Ambulance
$25
$25
$50'
$50*
$200*
$200*
Yes
Yes
$2,0005
$5,0005
$100'
$100'
1. $600
2. $300
3. Charges
1. $600
2. $300
3. Charges
Listed to the
left are benefit
amounts
associated with
the benefits
described in
the brochure.
• Benefit pays for
charges/costs up
to amount listed
' Limit $2,000/ 12
mo. period
Based on
procedure up to
maximum shown
2
1
Per amputation
'Payable once/
covered person/
calendar year
5
One-time benefit
.Allstate
BENEFITS
ABJ30082X-lnsert-HEBISD
38
itJAllstate
BENEFITS
cancer and specified disease
Receiving a diagnosis of cancer or a specified disease can be difficult on anyone, both emotionally and financially. Having the
right coverage to help when undergoing treatments for cancer or a specified disease is important. Our coverage can help
provide added financial support when it is needed most.
Our coverage helps offer peace of mind when a diagnosis of cancer or a specified disease occurs. Below is an example of
how benefits might be paid.*
Jane chooses benefit
coverage under her
Employer
Approved Plan
Jane undergoes her
annual wellness test and
is diagnosed with cancer.
Jane's doctor recommends pre-op testing
and provides her with the location of the
hospital. Jane must travel 200 miles to
have pre-op testing (medical imaging) and
is admitted to the hospital for surgery.
Jane undergoes surgery, anesthesia,
radiation/chemo, and is visited by a
doc tor during a 3-day hospital stay.
And every 2 weeks she has radiation/
chemotherapy at a local facility, is given
anti-nausea medication, and sees her
doctor during her follow-up visits.
Our cancer insurance policy paid Jane the following:
Wellness Exam
$
100
Hospital Confinement
$ 600
Cancer Initial Diagnosis�$�2,_
00_0
_____
Non-Local Transportation $
160
Surgery --$ 3,000
$
750
Anesth�
$10,000
Radiation/Chemo
Medical Imaging
$
500
Inpatient Mec:i1cTne
$
75
Physician Visits
$
------;so
$
200
Anti-Nausea
Total Benefits:
$17,535
*The example shown may vary from the plan your employer is offering. Your individual experience may also vary.
meeting your needs
benefit coverage highlights
Our Cancer coverage can help offer you
and your family financial support.
Cancer and specified disease benefits can help cover the costs of
specific treatments and expenses as they happen. Terms and conditions
for each benefit will vary.
• Benefits paid directly to you unless
otherwise assigned
• Waiver of premium after 90 days of
disability due to cancer for as long as
your disability lasts**
Specified Diseases - Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease),
Muscular Dystrophy, Poliomyelitis, Multiple Sclerosis, Encephalitis,
Rabies, Tetanus, Tuberculosis, Osteomyelitis, Diphtheria, Scarlet Fever,
Cerebrospinal Meningitis, Brucellosis, Sickle Cell Anemia, T halassemia,
Rocky Mountain Spotted Fever, Legionnaires' Disease, Addison's Disease,
Hansen's Disease, Tularemia, Hepatitis (Chronic B or C), Typhoid Fever,
Myasthenia Gravis, Reye's Syndrome, Primary Sclerosing Cholangitis
(Walter Payton's Disease), Lyme Disease, Systemic Lupus Erythematosus,
Cystic Fibrosis, and Primary Biliary Cirrhosis.
• Portable
HOSPITAL AND RELATED BENEFITS
• Coverage for you or your entire family
• No evidence of insurability required
at initial enrollmentt
1 Enrolling after your initial enrollment period
requires evidence of insurability.
** Primary insured only.
Continuous Hospital Confinement - Pays a benefit for each day of
inpatient confinement.
Government or Charity Hospital - Pays a benefit for each day of
inpatient confinement to a U.S. government hospital or a hospital that
does not charge for its services. In lieu of all other benefits.
Private Duty Nursing Se_rvices - Pays a daily benefit when receiving
physician-authorized inpatient private nursing services.
Extended Care Facility - Pays a daily benefit for physician-authorized
inpatient confinement (within 14 days of a hospital stay).
At Home Nursing - Pays a daily benefit for physician-authorized
private nursing care (up to the number of days of the previous
hospital stay).
ABJ30082X
39
Wellness tests
annually
.II
II
October
18
Tests are run and
results received
A doctor visit
is scheduled
Hospice Care - Pays a benefit when a physician determines
terminal illness and approves hospice care at home (1 visit
per day) or in a freestanding hospice care center.
RADIATION, CHEMOTHERAPY AND RELATED BENEFITS
You get
paid cash
Family Member Lodging and Transportation - Pays a
benefit for one adult family member when confined at a
non-local hospital for specialized treatment (more than
100 miles from family member's home).
Radiation/Chemotherapy for Cancer - Pays a benefit for
covered treatment to destroy or modify cancerous tissue.
Physical or Speech T h erapy - Pays a daily benefit for
physical or speech therapy to restore normal body function.
Blood, Plasma, and Platelets - Pays a benefit for blood,
plasma, and platelets. Includes charges for transfusions,
administration, processing, procurement and cross-matching.
Does not include donor replaced blood or immunoglobulins.
New or Experimental Treatment - Pays a benefit for
physician-approved new or experimental treatments not
paid under other benefits.
Prosthesis - Pays a benefit for a prosthetic device that
requires surgical implanting.
Medical Imaging - Pays a benefit for an initial diagnosis
or follow-up evaluation.
Hematological Drugs - Pays a benefit for drugs to boost cell lines
when
Radiation/Chemotherapy
for
Cancer
benefit
is paid.
SURGERY AND RELATED BENEFITS
Surgery*- Pays a benefit for an inpatient or outpatient
operation listed in the Schedule of Surgical Procedures.
Nonsurgical External Breast Prosthesis - Pays a benefit
for the initial nonsurgical breast prosthesis after a
covered mastectomy.
Anti-Nausea Benefit - Pays a benefit for prescribed anti
nausea medication administered on an outpatient basis.
Anesthesia - Pays 25% of surgery benefit.
Waiver of Premium (primary insured only) - Pays premiums
after disabled 90 days in a row due to cancer, for as long
as disability lasts.
Ambulatory Surgical Center - Pays a benefit for surgery
at an ambulatory surgical center.
Second Opinion - Pays a benefit for a second surgical
opinion.
ADDIT ION AL B ENEFIT S
Cancer Initial Diagnosis - Pays a one-time benefit if
diagnosed for the first time with cancer (except skin cancer)
Bone Marrow or Stem Cell Transplant - Pays a benefit
for transplants.
Wellness - Pays a benefit each calendar year for one of the
following: Biopsy for skin cancer; Blood tests for triglycerides,
CA15 -3 (breast cancer), CA125 (ovarian cancer), CEA
(colon cancer) and PSA (prostate cancer); Bone Marrow
Testing; Chest X-ray; Colonoscopy; Doppler screening for
carotids or peripheral vascular disease; Echocardiogram;
EKG; Flexible sigmoidoscopy; Hemoccult stool analysis;
HPV (Human Papillomavirus) Vaccination; Lipid panel
(total cholesterol count); Mammography, including Breast
Ultrasound; Pap Smear, including T hin Prep Pap Test; Serum
Protein Electrophoresis (test for myeloma); Stress test on
bike or treadmill; T hermography; and Ultrasound screening
for abdominal aortic aneurysms
MISCELLANE OU S BENEFITS
Inpatient Drugs and Medicine - Pays a daily benefit for
inpatient drugs and medicine.
Physician's Attendance - Pays a daily benefit for one
inpatient visit.
Ambulance - Pays a benefit for transfer by ambulance
service to or from a hospital.
Non-Local Transportation - Pays a benefit for transportation
for treatment not available locally (up to 700 miles)
Outpatient Lodging - Pays a daily benefit for lodging when
receiving radiation or chemotherapy on an outpatient basis
non-locally (more than 100 miles from home).
'Two or more surgeries done at the same time are considered one
operation. The operation with the largest benefit will be paid. Outpatient is
paid at 150% of the amount listed in the Schedule of Surgical Procedures.
Hair Prosthesis - Pays a benefit for a wig or hairpiece when
hair loss is experienced.
40
Intensive Care - Pays a daily benefit for Intensive Care Unit
Confinements for any illness or accident (up to 45 days for
each stay), Step-down Intensive Care Unit Confinements
(up to 45 days for each stay) and air or surface ambulance
to a hospital intensive care unit.
ABJ30082X
Intensive Care Benefits Exclusions and Limitations Ca) Benefits are not paid for: Cl) attempted suicide or
intentional self-inflicted injury; C2) intoxication or being
under the influence of drugs not prescribed by a
physician; or C3) alcoholism or drug addiction. Cb) Benefits
are not paid for confinements to a care unit that does not
qualify as a hospital intensive care unit including
progressive care, subacute intensive-care, intermediate
care, private rooms with monitoring, step-down and
other lesser care units. Cc) Benefits are not paid for stepdown confinements in the following units: telemetry or
surgical recovery rooms; post-anesthesia care; progressive
care; intermediate care; private monitored rooms;
observation units in emergency rooms or outpatient
surgery units; beds, wards, or private or semi-private
rooms; emergency, labor or delivery rooms; or other
facilities that do not meet the standards for a step-down
hospital intensive-care unit. Cd) Benefits are not paid for
confinements occurring during a hospitalization prior to
the effective date. Ce) Children born within 10 months of the
effective date are not covered for confinement
occurring or beginning during the first 30 days of the
child's life. Cf) We do not pay for ambulance if paid under
the cancer and specified disease ambulance benefit.
CERTIFICATE SPECIFICATIONS
Eligibility - Coverage may include you, your spouse or
domestic partner and children under age 26.
Termination of Coverage - Ca) Coverage under the policy
ends on the date the policy is canceled; the last day
premium payments were made; the last day of active
employment, unless coverage is continued due to
Temporary Layoff, Leave of Absence or Family and
Medical Leave of Absence; the date you or your class is
no longer eligible. Cb) Spouse/domestic partner coverage
ends upon divorce/termination of partnership or your
death. Cc) Coverage for children ends when the child
reaches age 26, unless he or she continues to meet the
requirements of an eligible dependent.
Portability Privilege - Coverage may be continued under the
Portability Provision when coverage under the policy ends.
LIMITS, EXCLUSIONS AND EXCEPTIONS
Pre-Existing Condition - Ca) Allstate Benefits does not pay
benefits for a pre-existing condition during the 12-month
period beginning on the date that person's coverage
starts. Cb) A pre-existing condition is a disease or
condition for which symptoms existed within the
12-month period prior to the effective date; or Cc)
medical advice or treatment was recommended or
received from a medical professional within the 12-month
period prior to the effective date. Cd) A pre-existing
condition can exist even though a diagnosis has not yet
been made.
Cancer and Specified Disease Benefits Exclusions and
Limitations - Ca) Allstate Benefits does not pay for any loss,
except for losses due to cancer or a specified disease.
Cb) Benefits are not paid for conditions caused or aggravated
by cancer or a specified disease.
Treatment and services must be needed due to cancer or
a specified disease and be received in the United States
or its territories.
For the Surgery, New o r Experimental Treatment and
Prosthesis benefits, Allstate Benefits pays 50% of the
applicable maximum when specific charges are not
obtainable as proof of loss.
For the Radiation/Chemotherapy for Cancer benefit,
Allstate Benefits does not pay for: Ca) any other chemical
substance which may be administered with or in conjunction
with radiation/chemotherapy; or Cb) treatment planning
consultation; management; or the design and construction
of treatment devices; or basic radiation dosimetry calculation;
or any type of laboratory tests; X-ray or other imaging
used for diagnosis or monitoring; or the diagnostic tests
related to these treatments; or Cc) any devices or supplies
including intravenous solutions and needles related to
these treatments.
41
ABJ30082X
Lincoln Financial
Term Life Insurance
800-423-2765
Build your benefit with Lincoln Financial‘s Voluntary Life Insurance. Your employer gives you the
opportunity to buy valuable life insurance coverage for yourself or your family – all at affordable group
rates.
Insurance
Schedules
Employee
Basic Life
and AD&D
Employee
Spouse
Child
$10,000
Increments
$5,000 Increments
Day 1 to 6 months:
$500
$5,000
5 x Salary to
$500,000
Employee
Contribution
50% of employee’s
Benefit up to
$75,000
0%
100%
100%
100%
Rate per $1,000
No charge
See Step Rates
Below
$.120
Guarantee Issue
as a New Hire
$5,000
See Step Rates
Below
3 times salary to
$300,000
Maximum
Benefit
$30,000
$5,000 or $10,000
All Guaranteed
Issue
Age
Employee Rate per $1,000
Spouse Rate per $1,000
<20
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
$0.024
$0.038
$0.040
$0.053
$0.075
$0.095
$0.136
$0.224
$0.396
$0.572
$1.009
$0.024
$0.038
$0.040
$0.053
$0.075
$0.095
$0.136
$0.224
$0.396
$0.572
$1.009
•
If your spouse works for HEB ISD, your spouse cannot be listed as a dependent on Lincoln Financial’s
supplemental life insurance policy. Both employees have to enroll in his/her own Life Insurance policy.
Children/dependents-only one employee may enroll the dependents under his/her life policy.
•
Coverage is portable. You can take this coverage with you upon retirement or termination.
•
TravelConnect program offers a wealth of travel, medical and safety-related services when you travel more
than 100 miles from home.
42
Employee Monthly Premium
Voluntary Life Premium for sample benefit amounts
Employee and Spouse premiums are calculated separately.
Spouse premiums will be calculated based on the Employee’s age.
Refer to Program Specifications for your maximum benefit amounts.
AGE
Monthly
Rate per
$1,000
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
<20
$0.024
$0.24
$0.48
$0.72
$0.96
$1.20
$1.44
$1.68
$1.92
$2.16
$2.40
20 - 24
$0.038
$0.38
$0.76
$1.14
$1.52
$1.90
$2.28
$2.66
$3.04
$3.42
$3.80
25 - 29
$0.040
$0.40
$0.80
$1.20
$1.60
$2.00
$2.40
$2.80
$3.20
$3.60
$4.00
30 - 34
$0.053
$0.53
$1.06
$1.59
$2.12
$2.65
$3.18
$3.71
$4.24
$4.77
$5.30
35 - 39
$0.075
$0.75
$1.50
$2.25
$3.00
$3.75
$4.50
$5.25
$6.00
$6.75
$7.50
40 - 44
$0.095
$0.95
$1.90
$2.85
$3.80
$4.75
$5.70
$6.65
$7.60
$8.55
$9.50
45 - 49
$0.136
$1.36
$2.72
$4.08
$5.44
$6.80
$8.16
$9.52
$10.88
$12.24
$13.60
50 - 54
$0.224
$2.24
$4.48
$6.72
$8.96
$11.20
$13.44
$15.68
$17.92
$20.16
$22.40
55 - 59
$0.396
$3.96
$7.92
$11.88
$15.84
$19.80
$23.76
$27.72
$31.68
$35.64
$39.60
60 - 64
$0.572
$5.72
$11.44
$17.16
$22.88
$28.60
$34.32
$40.04
$45.76
$51.48
$57.20
65 - 69
$1.009
$10.09
$20.18
$30.27
$40.36
$50.45
$60.54
$70.63
$80.72
$90.81
$100.90
70 - 74
$1.615
$16.15
$32.30
$48.45
$64.60
$80.75
$96.90
$113.05
$129.20
$145.35
$161.50
75 - 79
$1.544
$15.44
$30.88
$46.32
$61.76
$77.20
$92.64
$108.08
$123.52
$138.96
$154.40
80 - 84
$1.544
$15.44
$30.88
$46.32
$61.76
$77.20
$92.64
$108.08
$123.52
$138.96
$154.40
Spouse Monthly Premium
Voluntary Life Premium for sample benefit amounts
AGE
Monthly
Rate per
$1,000
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
< 20
$0.024
$0.12
$0.24
$0.36
$0.48
$0.60
$0.72
$0.84
$0.96
$1.08
$1.20
20 - 24
$0.038
$0.19
$0.38
$0.57
$0.76
$0.95
$1.14
$1.33
$1.52
$1.71
$1.90
25 - 29
$0.040
$0.20
$0.40
$0.60
$0.80
$1.00
$1.20
$1.40
$1.60
$1.80
$2.00
30 - 34
$0.053
$0.27
$0.53
$0.80
$1.06
$1.33
$1.59
$1.86
$2.12
$2.39
$2.65
35 - 39
$0.075
$0.38
$0.75
$1.13
$1.50
$1.88
$2.25
$2.63
$3.00
$3.38
$3.75
40 - 44
$0.095
$0.48
$0.95
$1.43
$1.90
$2.38
$2.85
$3.33
$3.80
$4.28
$4.75
45 - 49
$0.136
$0.68
$1.36
$2.04
$2.72
$3.40
$4.08
$4.76
$5.44
$6.12
$6.80
50 - 54
$0.224
$1.12
$2.24
$3.36
$4.48
$5.60
$6.72
$7.84
$8.96
$10.08
$11.20
55 - 59
$0.396
$1.98
$3.96
$5.94
$7.92
$9.90
$11.88
$13.86
$15.84
$17.82
$19.80
60 - 64
$0.572
$2.86
$5.72
$8.58
$11.44
$14.30
$17.16
$20.02
$22.88
$25.74
$28.60
65 - 69
$1.009
$5.05
$10.09
$15.14
$20.18
$25.23
$30.27
$35.32
$40.36
$45.41
$50.45
70 - 74
$1.615
$8.08
$16.15
$24.23
$32.30
$40.38
$48.45
$56.53
$64.60
$72.68
$80.75
75+
See Plan Administrator for premiums.
Dependent Children Monthly Rate = $0.60 per $5,000 and $1.20 per $10,000
Premium covers all dependent children regardless of the number of children.
43
Voluntary Life Insurance
SUMMARY OF BENEFITS
Sponsored by:
Hurst-Euless-Bedford ISD
Effective date:
September 01, 2013
All Active Full-time Employees
Life Benefit
Employee
Spouse
Amount
Choice of $10,000 increments
Choice of $5,000
increments
Not to exceed 5 times your salary.
Dependent
Choice of $5,000 or
$10,000 child(ren) age 6
months to 26 years.
Day 1 to 6 months: $500
Employee must elect
coverage for spouse to be
eligible. Not to exceed
Employee must elect
50% of employee elected coverage for dependent to
amount.
be eligible.
Minimum Amount
$10,000
$5,000
$500
Maximum Amount
$500,000
$75,000
$10,000
Guarantee Issue
Newly Eligible Employees: The lesser
of $300,000 or 300% of salary of
coverage is available on a guaranteed
acceptance basis.
Current Eligible Employees: Up to 2
Increments are available on a
guaranteed acceptance basis.
Newly eligible spouses:
$30,000 of coverage is
available on a guaranteed
acceptance basis.
Current eligible spouses:
Up to 2 Increments are
available on a guaranteed
acceptance basis.
$10,000
Benefit Reduction
Employee
Spouse
Benefits will reduce: Coverage will terminate upon
retirement.
Benefits will terminate
upon employee retirement.
Additional Benefits
See Definition:
Accelerated Death Benefit
Conversion
Portability
Eligibility
Employee
Spouse and Dependents
All full-time active employees working Cannot be in a period of
20 or more hours per week in an
limited activity on the day
eligible class are eligible for coverage coverage takes effect.
on the policy effective date. A delayed
effective date will apply if the employee
is not actively at work.
ROADURBI
HRST
HRA1D656NA20130304
1.00
44
2013/03/04
Definitions
Accelerated Death Benefit
Accelerated Death Benefit provides an option to withdraw a percentage of your life
insurance when diagnosed as terminally ill (as defined in the policy). The death
benefit will be reduced by the amount withdrawn. To qualify, you have satisfied
the Active Work rule and have been covered under this policy for the required
amount of time as defined by the policy. Check with your tax advisor or attorney
before exercising this option.
Conversion
If you terminate your employment or become ineligible for this coverage, you have
the option to convert all or part of the amount of coverage in force to an individual
life policy on the date of termination without Evidence of Insurability. Conversion
election must be made within 31 days of your date of termination.
Guarantee Issue
For timely entrants enrolled within 31 days of becoming eligible, the Guarantee
Issue amount is available without any Evidence of Insurability requirement.
Evidence of Insurability will be required for any amounts above this, for late
enrollees or increase in insurance, and it will be provided at your own expense.
Limited Activity
A period when a spouse or dependent is confined in a health care facility; or,
whether confined or not, is unable to perform the regular and usual activities of a
healthy person of the same age and sex.
Portability
If coverage has been in force for at least 12 months, you may continue coverage
for a specified period of time after your employment by paying the required
premium. Portability is available if you cease employment for a reason other than
total disability. A written application must be made within 31 days of your
termination.
Term Life
Coverage provided to the designated beneficiary upon the death of the insured.
Coverage is provided for the time period that you are eligible and premium is paid.
There is no cash value associated with this product.
Exclusion: Suicide
Benefits will not be paid if the death results from suicide within 2 years after
coverage is effective. May apply if employee contributes toward the premium.
Additional Benefits
BeneficiaryConnectSM
Support services for beneficiaries who have experienced a loss.
TravelConnectSM
Travel assistance services for employees and eligible dependents traveling more
For assistance or additional information
Contact Lincoln Financial Group at (800) 423-2765 or log on to www.LincolnFinancial.com
NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does
not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the
benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern.
©2008 Lincoln National Corporation
Group Insurance products are issued by The Lincoln National Life Insurance Company (Ft. Wayne, IN), which is not licensed and does not solicit business
in New York. In New York, group insurance products are issued by Lincoln Life & Annuity Company of New York (Syracuse, NY). Both are Lincoln Financial
Group companies. Product availability and/or features may vary by state. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its
affiliates. Each affiliate is solely responsible for its own financial and contractual obligations.
ROADURBI
HRST
HRA1D656NA20130304
1.00
45
2013/03/04
Accidental Death & Dismemberment Life
Insurance
Lincoln Financial
800-423-2765
Build your benefit with Lincoln Financial's Voluntary AD&D Insurance. Accidental Death &
Dismemberment is Life Insurance that is payable if a death is ruled an accident. This policy
also pays benefits for dismemberment of a limb, etc. You have the opportunity to buy valuable
life insurance coverage for yourself or your family – all at affordable group rates.
Benefit
Amount
Employee Only Plan
1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 times annual
salary, rounded to the next higher
$1,000.
Family Plan
Spouse:
50% of the employee benefit, not to
exceed $250,000
(Spouse and employee covered)
Each Child:
15% of employee benefit, not to exceed
$30,000
(Children and employee covered)
Spouse + Each Child:
Spouse 40% and Child 10% of the
employee benefit, not to exceed $30,000
(Spouse, children and employee covered)
Minimum Amount
Maximum Amount
$10,000
$500,000
$5,000
$250,000
Rate per $1,000
$.024
$.033
Benefit
Reduction
Employee
Spouse
Benefits terminate at retirement.
Benefits will terminate at employee
retirement.
Benefits will reduce:
Additional Benefits
Safe Driver, Education, Spouse Training, Felonious Assault, Alternate, Child Care, Coma, Common Disaster,
Exposure Disappearance Common Carrier
46
Hurst-Euless-Bedford ISD
Employee Monthly Premium
Accidental Death and Dismemberment premium for sample benefit amounts
AGE
Monthly
Rate per $25,000
$1,000
< 99
0.024
$50,000
$0.60
$1.20
$75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000
$1.80
$2.40
$3.00
$3.60
$4.20
$4.80
$5.40
$6.00
This is an estimate of premium cost. Actual deductions may vary slightly due to rounding and payroll frequency.
Example: Use this formula to calculate premium for benefit amounts over $250,000.
Example:
Age
Monthly Rate Per $1,000
X
Benefit In $1,000’s
=
Monthly Cost
35
0.024
X
300
=
$7.20
X
=
Family Monthly Premium
Accidental Death and Dismemberment premium for sample benefit amounts
AGE
Monthly
Rate per $25,000
$1,000
<99
0.033
$50,000
$0.83
$1.65
$75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000
$2.48
$3.30
$4.13
$4.95
$5.78
$6.60
$7.43
$8.25
This is an estimate of premium cost. Actual deductions may vary slightly due to rounding and payroll frequency.
Example: Use this formula to calculate premium for benefit amounts over $250,000.
Example:
Age
Monthly Rate Per $1,000
X
Benefit In $1,000’s
=
Monthly Cost
35
0.033
X
300
=
$9.90
X
=
Definitions
AD&D
Accidental Death and Dismemberment (AD&D) insurance provides specified benefits
for a covered accidental bodily injury that directly causes dismemberment (e.g., the
loss of a hand, foot, or eye). In the event that death occurs from a covered accident,
both the life and the AD&D benefit would be payable. This insurance is optional and
can be purchased by you and your spouse.
Limited Activity
A period when a spouse or dependent is confined in a health care facility; or,
whether confined or not, is unable to perform the regular and usual activities of a
healthy person of the same age and sex.
Exclusion: Suicide
Benefits will not be paid if the death results from suicide within 2 years after
coverage is effective. May apply if employee contributes toward the premium.
Additional Benefits
BeneficiaryConnectSM
Support services for beneficiaries who have experienced a loss.
TravelConnectSM
Travel assistance services for employees and eligible dependents traveling more
47
LegalEase
PrePaid Legal Services
Enrollment Questions: 800-248-9000
Member Services: 888-416-4313
www.legaleaseplan.com/content/heb
LegalGUARD® can ease one of the biggest stresses – finding the right
lawyer.
LegalEASE offers employees a customized legal assistance plan called
LegalGUARD. It’s a plan that provides support and protection from
unexpected personal legal issues.
•
•
•
•
•
•
•
•
•
•
•
What employees get with a LegalGUARD Plan:
An attorney with expertise specific to your personal legal matter
Access to a national network of attorneys with exceptional experience that are matched to meet
your needs.
Coverage for in- and out-of-network
Flexible benefit levels, permitting you to use your own attorney
Concierge help navigating common individual or family legal issues
Up to 10 hours of financial counseling per year
The value of a LegalGUARD Plan.
Being a LegalGUARD member saves you time and costly legal fees. But most importantly, it gives
you confidence and provides coverage for:
Home & Residential: Purchase, Sale, Refinancing, Tenant disputes
Financial & Consumer: Consume dispute, Document preparation, Debts
Estate Planning & Wills: Will/codicil, Living trust document, Health Care Power of Attorney
Auto & Traffic: Traffic defense, Administrative proceedings, Misdemeanor defense*
Family: Name change, Divorce*, Adoptions*, Guardianship/Conservatorship*
* Limitations apply
Premium:
Employee Only
Family Coverage
Monthly
$16.91
$18.88
Semi-Monthly
$8.46
$9.44
We’re here for you.
To learn more about LegalGUARD and the benefits you receive:
Call: 1(800) 248-9000
Visit: https://www.legaleaseplan.com/content/heb
Limitations and exclusions apply. This benefit summary is intended only to highlight benefits and should not be relied upon to fully
determine coverage. More complete descriptions of benefits and the terms under which they are provided are received upon
enrolling in the plan. Group legal plans are administered by LegalEASE or The LegalEASE Group, Houston, Texas.
Product available in all states. Underwritten by Virginia Surety Company, Inc. Please contact LegalEASE for complete details.
© 2015 The LegalEASE Group. All rights reserved.
48
Why do you need legal coverage?
Never have to worry if it’s worth calling an attorney again.
You never know when a legal matter may affect you or your family, and there are times in life when it is a
good idea to consult an attorney. Legal issues are complicated and disorienting. As many as 7 out of 10 of
people you know will have the need for an attorney this year, according to the American Bar Association.
This means that each year, only 30% of us will be lucky enough not to deal with the stress of a legal issue.
And without the right help, legal matters are tough. Without legal benefits, issues can average anywhere
from $500.00 to $7,000.00 per issue. The LegalGUARD Plan helps protect you, your family and your
savings from unexpected legal costs for many issues.
We understand that when you have a legal need, it is the most important event in your life at that moment.
We also know that finding the right attorney on your own can be stressful and dominate much of your time
and attention. Protect yourself and your family with the great value of the LegalGUARD Plan.
We have been putting people in touch with quality local attorneys and helping them solve problems since
1971. Our processes are designed to help you save time and to make things less stressful. Also, the
providers in our network must meet the most rigorous credentials standards in the market today.
How does the plan work?
The right help when you need it the most.
Finding the right type of attorney when a need arises can be one of the more stressful tasks when dealing
with a legal matter. The right help is essential. There are many types of attorneys depending upon what
type of issue someone may be facing. We help with this first step. We use our experience and relationships
with our network providers to match you to the right type of attorney you need in the right location, with
availability to set up a consultation with you. We see this step as a way to save you time, so you can get
back to your busy schedule of work, kids or whatever may be just as important. This step alone can save
you hours. If you use an In Network attorney, you don’t have to hassle with forms. LegalEASE works
directly with the provider to provide your benefits.
We also always follow up to ensure everything is going well and to see how else we can be of assistance.
We believe that quality service is essential, especially in a world today where quality service can be scarce.
So if you have a legal, financial, or identity need, to start getting the help you need, just give us a call. It’s
that easy. We will guide you through the steps and be right with you the entire way.
49
LegalGUARD Plan Benefits
Benefits are designed to meet the typical needs of an employee and their family. There are no deductibles to
worry about for covered services. Benefits cover the attorney’s time. Other costs, such as filing fees, are not
covered by legal benefits. Listed below are the types of matters that are covered by the new LegalGUARD Plan.
The LegalGUARD plan offers convenience of In Network and Out of Network benefits. Many of the below areas
are fully covered, unless noted.
Consultation
Home
Office Consultation*
Telephone Advice
Purchase of Primary Residence
Sale of Primary Residence
Refinancing of Primary Residence
Landlord/Tenant Dispute*
Consumer
Consumer Dispute
Small Claims Court Representation*
Document Preparation:
Simple Deed
Promissory Note
Consumer Dispute Correspondence
Installment Sales Agreement
Simple Affidavit
General Power of Attorney
Lease Agreement – Tenant Only
Time Share Agreement
Civil
Civil Litigation Defense*
Family
Uncontested Separation*
Consent/default Divorce*
Uncontested Divorce*
Contested Divorce*
Name Change
Guardianship/Conservatorship*
Governmental Agency Adoptions*
Stepparent Adoptions*
Juvenile Court Proceedings
Estate Planning and Wills
Simple Will or Codicil*
Living Will
Health Care Power of Attorney
Living Trust Document
Probate of Small Estate*
Criminal
Traffic Defense (resulting in suspension or
revocation of license)
Administrative Proceeding (regarding suspension or
revocation of license)
Misdemeanor Defense*
Financial
Debt Collection Defense
Pre-litigation defense activities
Trial defense*
Bankruptcy (chapter 7 or 13)*
Tax Audit*
Foreclosure*
Financial Planning*
Savings Coaching*
Budgeting Coaching*
Credit Coaching*
Savings Coaching*
Debt Management Programs*
Elder/Parents
Consultation
Review Documents*
Standard Wills Prepared*
Codicil*
Amendment to a single document*
Amendment(s) to spousal document*
Living Will*
Powers of Attorney*
*Some limitations apply
Enrollment Questions Call:
1(800) 248-9000
More Information at:
https://www.legaleaseplan.com/content/heb
50
Meet LegalEASEsm
We believe people deserve to have a sense of safety and
security, a peace of mind, when it comes to being protected
in legal matters. How we do it is by providing an in-depth
pool of resources to accommodate your legal needs. The
LegalGUARD plan is underwritten by Virginia Surety
Company, Inc.
LegalEASE Corporate Headquarters
5850 San Felipe, Suite 600
Houston, Texas 77057
Member Services: 1(888) 416-4313
We’re here when you need us.
Enrollment Questions Call:
1(800) 248-9000
More Information at:
https://www.legaleaseplan.com/content/heb
Plan Proudly
Offered to
HEB ISD Employees
Plan Cost:
The LegalGUARD Plan is only $16.91 per month, via payroll deduction.
The LegalGUARD Plan + Family Coverage is only $18.88 per month, via payroll deduction.
LegalGUARD Covered Family Member Definition:
The Member’s lawful spouse and children. Eligible Family Members are the Member’s spouse and Member’s
unmarried dependent children, including stepchild, legally adopted child, child placed in the home for adoption
and foster child, up to age 19, and from age 19 up to 26 years if they are enrolled in an accredited school or
college as full-time student(s) and are primarily dependent upon the Member for support.
Limitations and Exclusions Apply.
This benefit summary is intended only to highlight benefits and should not be relied upon to fully determine
coverage. More complete descriptions of benefits and the terms under which they are provided are received
upon enrolling in the plan. Group legal plans are administered by LegalEASE or The LegalEASE Group,
Houston, Texas.
Product available in all states. Underwritten by Virginia Surety Company, Inc. Please contact LegalEASE for
complete details.
© 2015 The LegalEASE Group. All rights reserved.
HurstEulessBedfordIndependentSchoolDistrict_2015
51
Health Savings Accounts (HSA)
HSA Bank
800-357-6246
www.hsabank.com
What is a Health Savings Account (HSA)?
An HSA, or health savings account, is a unique tax-advantaged account that you can use to pay for
current or future healthcare expenses. With an HSA, you’ll have:
• A tax-advantaged savings account that you use to pay for eligible medical expenses as well as
deductibles, co-insurance, prescriptions, vision and dental care.
• Unused funds that will roll over year to year. There’s no “use or lose it” penalty.
• Potential to build more savings through investing. You can choose from a variety of HSA selfdirected investment options with no minimum balance required.
• Additional retirement savings. After age 65, funds can be withdrawn for any purpose without
penalty.
• Money in your account is accessible as it is contributed. You do not have access upfront to all
of the money you are supposed to contribute to the account for the entire year like a Flexible
Spending Account.
Eligibility
•
•
•
•
•
•
To be eligible for a Health Savings Account, you must be covered by a HSA-qualified High
Deductible Health Plan (HDHP). The plan that qualifies as a HDHP is TRS Active Care
Plan 1-HD.
You cannot be enrolled in the GAP Plan
You cannot be enrolled in Medicare
You cannot be covered by other health insurance that is not a HDHP
You cannot be considered a dependent on someone else’s tax return
You cannot have a Flexible Spending Account
Maximum Contribution per Year
Individual
Family
Under 55
$3,350
$6,750
Age 55+
$4,350
$7,750
Eligible Medical Expenses
You can use your HSA to pay for a wide range of eligible medical expenses for yourself, your spouse or
tax dependents. HSA funds can be used to reimburse yourself for past medical expenses if the expense
was incurred after your HSA was established. While you do not need to submit any receipts to HSA
Bank, it is a good idea to save your bills and receipts for tax purposes.
An eligible medical expense is an expense that pays for healthcare services, equipment or medications
as described in IRS Publication 502*. In general, your HSA can be used for:
• Expenses applied to your health plan deductible
• Dental care services
• Vision care services
• Prescription drugs and medicines
• Certain medical equipment
52
HSA Bank
Welcomes You!
Your employer has presented you with a
great opportunity by offering you a Health
Savings Account (HSA) through HSA Bank.
We’d like to introduce ourselves and show
you why HSA Bank is a trusted financial
healthcare partner.
What is an HSA?
HSAs work together with HSA-compatible health plans. The health plan is used to cover serious illness or injury, while the HSA is used
for current or future expenses that are not paid by the health plan. Try our online calculating tools located at
www.hsabank.com/calculators, to learn more about HSAs and if one is right for you.
What are the advantages of an HSA?
• Funds Roll Over Annually
There is no “use it or lose it” philosophy. If you don’t use it, save it for next year. Or better yet, for retirement.
• Tax Advantages*
Contributions can be made pre-tax or post-tax, distributions for eligible expenses are tax-free and earnings grow
tax-deferred.
• You Own the Account
Even if your HSA-compatible coverage ends, you can still use your HSA funds tax-free for eligible medical expenses.
• Long-term Investment Opportunities**
We offer two investment platforms (www.hsabank.com/investments) that give you a wide variety of stocks, bonds and
mutual funds to choose from.
• You’re in Charge
You choose when to use your HSA or pay out-of-pocket.
HSA Bank is here for you.
HSA Bank is here for you even before you sign up with us. Our Client Assistance Center representatives are HSA experts and will help
show you the way to a healthy future. They provide live assistance Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. – 1 p.m., CT,
at 800-357-6246 and are available via email at [email protected]. Once enrolled, you’ll receive 24/7 access to your account balance
and transaction history with our toll-free automated Bankline system, (800) 565-3515. You can also set up online access at
www.hsabank.com/member and perform all of your regular banking tasks just by logging in. We’ll help you manage your account by
keeping you up-to-date with emails and other alerts. Plus, we’ll provide you with the tax forms and instructions you’ll need for your
HSA-related tax filing.
*HSA Bank does not provide tax advice. Consult your tax professional for tax-related questions.
** Investment accounts are not FDIC insured and they are not bank guaranteed. Investment accounts are not a deposit account, or an obligation of HSA Bank, and they
may lose value. They are not guaranteed by any federal government agency.
For assistance, please contact the Client Assistance Center
800-357-6246
Monday – Friday, 7 a.m. – 9 p.m., and Saturday 9 a.m. - 1:00 p.m., CT
www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081
53
How to use your HSA
It’s easy to manage your Health Savings Account (HSA) online.
Access real-time account balances, transaction history and statements, as well as track your expenses online. Sign up for online
banking today.
Mobile App – Use your iOS (iPhone, iPod Touch, iPad) or Android-powered device to check available balances in your account and
view HSA transaction details, save and store receipts using your device’s camera, receive account balances and configurable
alerts via text message on any mobile device, and access customer service contact information.
myHealth Portfolio – Use this tool to track your healthcare expenses, submit and retain receipts and claims from multiple
insurance and financial account providers. Also view expenses by provider, category, and more.
How to deposit funds into your HSA.
To maximize HSA tax and savings benefits, begin funding your account as soon as you can. HSA Bank offers several convenient
methods for making contributions to your HSA.
Payroll Deductions – If your employer offers this option, HSA Bank will facilitate recurring pre-tax payroll deductions. Contact
your employer to complete the appropriate paperwork.
Online Transfers – On HSA Bank’s member website, you can transfer funds from an external bank account, such as a personal
checking or savings account, to your HSA.
Check – Mail your personal check and completed Contribution Form to:
HSA Bank, PO Box 939, Sheboygan, WI 53082
How to pay for healthcare expenses from your HSA.
Whether you want to reimburse yourself for an expense paid out-of-pocket or you want to pay directly from your HSA,
HSA Bank offers multiple options for accessing your funds.
Health Benefits Debit Card – Your HSA Bank debit card from Visa® provides access to your HSA funds at point-of-sale with
signature or PIN and at ATMs for withdrawals. Transaction fees may apply when used with a PIN*.
Checks – A book of 50 checks can be ordered upon request for an additional fee*. You can use these checks to pay providers or
reimburse yourself for expenses already incurred.
Online Transfers – On HSA Bank’s member website, you can reimburse yourself for out-of-pocket expenses by making a one-time
or reoccurring online transfer from your HSA to your personal checking or savings account.
Online Bill Pay – Use this feature to pay medical providers directly from your HSA.
*For applicable fees, see your HSA Bank Interest and Fee Schedule.
HSA Bank’s Health Benefits Debit Card can be used for point-of-sale transactions in two ways, signature or PIN. For signature, swipe
card, press credit on the keypad, and sign the receipt. To pay using a PIN (fee per PIN transaction may apply*), swipe your card,
select debit on the keypad, and enter your PIN. To withdraw HSA funds from an ATM (fee per ATM withdrawal may apply*), be sure
to select the “checking” option (not savings) when asked the type of account you are withdrawing from. HSA Bank limits pointof-sale debit card transactions to medical merchants. As a mechanism for fraud protection, HSA Bank has set limits on debit card
transactions. You can withdraw $2,000 per day when a signature is used and $300 per day for PIN-based transactions. Debit card
transactions are also limited to your current daily balance. You are able to make five debit card transactions per day. Any additional
transactions will be denied.
For assistance, please contact the Client Assistance Center:
800-357-6246
Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. - 1 p.m., CT
www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081
54
TASC
Flexible Spending Account
800-422-4661
Maximum Contribution
$2,400 per year or $200 per month
55
www.tasconline.com
56
HSA/FSA Comparison Chart
Questions
Who qualifies as a participant?
Health Savings Account
(HSA)
All individuals under 65 who are
participants in a qualified High
Deductible Health Plan (HDHP).
A HDHP is TRS ActiveCare plan 1-HD
Flexible Spending
Account (FSA)
All employees (not required to be
on District insurance to
participate)
Non-Medicare enrolled persons
What is the maximum
contribution per year?
Individual - $3,350; over 55 - $4,350
Family - $6,750; over 55 - $7,750
$2,400
Can I access the entire account at No, money is available as it is
contributed to the account
the start of the plan year?
Yes, the total amount elected for
the year is available to the
employee on day one
Employee tax savings?
Contributions are tax-free
Contributions are tax-free
Does interest accrue on the
account?
Interest can be accrued
Interest is NOT accrued
Can I roll unused dollars to next
year?
Yes. Funds may be carried over
indefinitely throughout an account
holder’s lifetime. Upon death, an
account may be passed on to a
surviving spouse.
No
What are qualified medical
expenses on the plan?
Deductibles, coinsurance,
prescriptions, includes dental and
vision
Deductibles, coinsurance,
prescriptions, includes dental and
vision
Are claims substantiated?
Only upon audit
Yes. Receipts may be required.
Can I use the money on nonmedical qualified expenses?
Yes. The expense is subject to taxes
and 10% tax penalty. (After age 65,
no 10% penalty)
No
Is there a “catch up” provision?
Yes, individuals 55 and older may
make additional contributions up to
$1,000 per year.
No
Portability
Yes. It is owned by the account
holder
No
Subject to Cobra?
No
Yes
• 800-422-4661 •
Fax: 608-245-3623
57
Dependent Care Flexible Spending Account
TASC
800-422-4661
www.tasconline.com
Dependent Care
Qualifications
FSA eligibility criteria for Dependent Care expenses
A) The dependent care expenses must be work related. The care must be necessary for the employee and
the employee’s spouse to work, to look for work, or to attend school full-time, or if they are physically
unable to care for their children.
B) The dependent care expenses provided during a calendar year cannot exceed $5,000. In the case of a
separate return by a married individual, the limit is $2,500. This amount may be less if the employee’s
earned income or spouse’s earned income is less than $5,000.
The dependent care expenses must be for the care of one or more qualifying persons. A
qualifying person is one of the following:
A) A dependent who was under age 13 when the care was provided and for whom an exemption can be
claimed.
B) A spouse who was physically or mentally not able to care for himself or herself, and lived with you for more
than half the year.
C) A dependent who was physically or mentally not able to care for himself or herself and for whom an
exemption can be claimed, and lived with you for more than half the year.
To receive the dependent care benefit, one must follow these procedures:
A) All persons and organizations that provide dependent care for a qualified person must be identified. This
information is requested on Form 2441. The name, address, and taxpayer identification number of the
provider must be included. Under certain circumstances, the taxpayer identification number will be a social
security number.
B) If the care is being provided by a center that cares for more than six persons, the center must comply with
all state and local regulations.
C) Payments made to relatives who are not dependents can be included. However, do not include amounts paid
to a dependent for whom you can claim an exemption or for your child who is under age 19 at the end of the
year, regardless of whether he or she is your dependent.
D) Use Form W-10 to request the required information from the care provider.
TASC • 2302 International Lane • Madison, WI 53704-3140 • 800-422-4661 • Fax: 608-245-3623 • www.tasconline.com
58
Special rules apply to children of divorced or separated parents:
Even if you cannot claim your child as a dependent, he or she is treated as your qualifying person if all of
the following are true:
•
•
The child was under age 13 or was not physically or mentally able to care for himself or herself.
One or both parents provided more than half of the child’s support for the year and are divorced,
legally separated, or lived apart at all times during the last 6 months of the calendar year.
One or both parents had custody of the child for more than half of the year.
• You were the child’s custodial parent. The custodial parent is the parent having custody for the
greater portion of the calendar year. If the child was with both parents for an equal number of
nights, the parent with the higher adjusted gross income is the custodial parent.
A non-custodial parent that is entitled to claim the child as a dependent on their tax return may not treat
the child as a qualifying individual for the dependent care benefit even when that parent is financially
responsible for providing the care. Only one parent (the custodial parent) may qualify for the dependent
care benefit for a taxable year. The regulations do not provide any relief for a non-custodial parent that
incurs dependent care expenses for the portion of the year in which they have custody of the child to
enable the non-custodial parent to work.
•
Eligible and Ineligible Expenses for FSA Dependent Care (partial list):
Eligible Expenses (must be employment related)
• FICA/FUTA taxes of dependent care provider
• Nanny expenses attributed to dependent care
• Nursery school (preschool)
• Late pick up fees
• Day Camp – primary purpose must be custodial care and not educational in nature
• Day care when one parent is working and the other is sleeping during daytime hours
Ineligible Expenses
• Kindergarten
• Activity fees/supplies
• Late payment charges
• Overnight camp
• Transportation
• Fees paid to a provider not reporting the income to the IRS
For more information regarding dependent care expenses, please review IRS Publication 503.
59
Retirement Planning
Enrollm ent in a 403(b) and/ or 457 m ay be done anytime during the year!
403(b) Plan
457 Plan
TCG Administrators
800-943-9179
http://tcgservices.com/documents/
#/255/457b
The Omni Group
877-544-6664
www.omni403b.com
What is a 403(b)?
A 403(b) plan is a retirement savings plan
available for public education organizations.
It has tax treatment similar to a 401(k)
plan. Employee salary deferrals into a
403(b) plan are made before income tax is
paid an allowed to grow tax-deferred until
the money is taxed as income when
withdrawn from the plan. 403(b) plans are
also referred to as tax-sheltered annuity.
What is a 457?
The 457 plan is a type of deferredcompensation retirement plan that is
available for governmental employers. The
employer provides the plan and the
employee defers compensation into it on a
pre-tax basis. For the most part the plan
operates similarly to a 401(k) or 403(b)
plan. The key difference is that there is no
penalty for withdrawal before the age of
59½ (but subject to income tax).
You have 20 + companies to choose from
with a variety of investment options
available – Please visit www.trs.state.tx.us
and select 403b Certification and click on
View 403(b) Products List to see the list of fees
charged by each company/product.
HEB ISD has selected 1 company to provide
our employees with the 457b plan. RAMS
offers several investment options
How to Enroll:
Step 1: Set up your 403b account with an
approved vendor (see the link
above)
Step 2: Complete the Salary Reduction
Agreement with The Omni Group
(see the following pages for login
instructions)
How to Enroll:
Complete the Salary Reduction Agreement
with TCG Administrators (see the
following pages for login instructions)
There is a 10% tax penalty on any funds
withdrawn prior to retirement age
No penalty for early withdrawal (upon
separation of service)
Maximum Contributions:
Annual Maximum - $18,000
Over age 50 Catch-up - $6,000
Maximum Contributions:
Annual Maximum - $18,000
Over age 50 Catch-up - $6,000
60
403(b)
61
457(b)
The 457(b) Retirement Savings Plan is a voluntary savings program designed to allow
employees to defer a portion of their compensation through payroll deductions. These deferrals are
made on a pre-tax basis and allow employees the opportunity to save for retirement. Roth accounts
are also available, at the option of the District. The 457(b) Retirement Savings Plan is an attractive
alternative to traditional 403(b) “tax sheltered annuity” programs.
The Retirement Savings Plan is set up under Section 457(b) of the Internal Revenue Code. The
plan is offered through the ESC Region 10 457 Cooperative and Master Plan by means of an
interlocal agreement with each participating District. The Plan works for the most part like a 401(k) plan.
•
•
Employees can enroll in the plan online or with forms without the need to meet with a
sales person.
Educational meetings are offered to the District by salaried representatives of the
companies providing the plan services. No commissions are paid to any individuals or
companies from the plan.
A 457(b) plan has the same basic features and advantages of 403(b) and 401(k) plans. However,
funds paid out of a 457(b) plan are not subject to an early withdrawal excise tax (unlike 403(b), IRAs
or 401(k) plans).
457(b) Plan Enrollment Instructions
1. Go to www.tcgservices.com/login/ to set up your salary deferral (contribution amount ) and allocation
a. Click on "Group Retirement Plan Login"
b. Click on "New User"
c. Enter the Plan Password from the Summary Plan Description
d. Enter Social Security Number without dashes
e. Select “Next”
2. Upon entering the site, you will move through several steps:
a.
b.
c.
d.
e.
f.
Establish username and password
Create security questions and answers
Enter your personal information
Beneficiaries
Contributions
Investment Elections
g. Confirmation
Congratulations, your Account has been created. Additionally, the contribution amount to be deducted from
your pay check will be communicated with the District.
Please call TCG Administrators at (800)943-9179 with any questions or concerns.
62
Hurst-Euless-Bedford
ISD
Summary Plan Description
Plan Type
Internal Revenue Code
Section 457(b)
Plan Administrator
TCG Administrators
Excluded Employees
Independent Contractors
Plan Password for Enrolling Online
hurst457
Plan Effective Date
05/01/2014
Plan Year End
8/31
Contribution Tax Treatment
Pre-Tax
Contribution Sources
Employee Only
Contribution Limit
$18,000 per year
Catch-Up Contribution Limit
$6,000 for employees age 50+
Rollovers Into Plan
Available from another qualified plan
Rollovers Out of Plan
Available to another qualified plan,
upon termination of service
Distributions
Available for the following:
- Separation of Service
- Death
- Disability
Unforeseeable Emergency
Distributions
Available as defined by the IRS for
this type of plan
Loans
Available, see the Loan Agreement
and Application Form
Beneficiaries
A Designation of Beneficiary Form
is only required if Spouse is not the
Primary Beneficiary
Fees of Service Plan Providers
TCG Administrators, TPA
$18.50 per participant per year
0.25% of assets, paid by the
participant
Matrix Trust,
Custodian/Trustee
0.10%, paid by participant
Inactivity Distributions
Available for accounts with
balances of less than $5,000,
and no activity for 2 years
TCG Advisors, Investment Advisor Other Fees
Sliding Scale (0.45% -0.25%),
$30 Distribution Fee
currently 0.35%, paid by participant $50 Loan Set up
All of the above paid by
ESC Region 10, Plan Coordinator
participant
$0.10 per participant per month,
paid by participant
For more information please contact TCG Adminstrators, the Plan Administrator
This document is designed to inform Participants about the Plan in non-technical language. Every attempt is made to convey the Plan
accurately. If anything in this Summary Plan Description varies from the Plan Documents, Plan Documents govern.
63

Employee Benefits Guide - Hurst-Euless

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